The following procedure codes are covered under BadgerCare Plus and Medicaid.
Covered removable prosthodontic services are identified by the allowable CDT procedure codes listed in the following table. Medicaid reimbursement is allowable only for services that meet all program requirements. This includes documenting the medical necessity of services in the member's medical record.
| Code | Description of Service | Prior Authorization? | Limitations and Requirements |
|---|---|---|---|
| Complete Dentures (Including Routine Post-Delivery Care) | |||
| D5110 | Complete denture—maxillary | Yes | Allowed once per five years.1, 2 |
| D5120 | Complete denture—mandibular | Yes | Allowed once per five years.1, 2 |
| Partial Dentures (Including Routine Post-Delivery Care) | |||
| D5211 | Maxillary (upper) partial denture; resin base (including any conventional clasps, rests and teeth) | Yes | Allowed once per five years.1, 2 |
| D5212 | Mandibular (lower) partial denture; resin base (including any conventional clasps, rests and teeth) | Yes | Allowed once per five years.1, 2 |
| D5213 | Maxillary partial denture; cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) | Yes | Allowed once per five years.1, 2 Reimbursement is limited to reimbursement for D5211. Upgraded partial denture. No dentist is obligated to complete this type of partial. |
| D5214 | Mandibular partial denture; cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) | Yes | Allowed once per five years.1, 2 Reimbursement is limited to reimbursement for D5212. Upgraded partial denture. No dentist is obligated to complete this type of partial. |
| D5225 | Maxillary partial denture—flexible base (including any clasps, rests and teeth) | Yes | Allowed once per five years.1, 2 |
| D5226 | Mandibular partial denture—flexible base (including any clasps, rests and teeth) | Yes | Allowed once per five years.1, 2 |
| Repairs to Complete Dentures | |||
| D5511 | Repair broken complete denture base, mandibular | No | Combined maximum reimbursement limit per six months for repairs. |
| D5512 | Repair broken complete denture base, maxillary | No | Combined maximum reimbursement limit per six months for repairs. |
| D5520 | Replace missing or broken teeth—complete denture (each tooth) | No | Combined maximum reimbursement limit per six months for repairs. |
| Repairs to Partial Dentures | |||
| D5611 | Repair resin partial denture base, mandibular | No | Combined maximum reimbursement limit per six months for repairs. |
| D5612 | Repair resin partial denture base, maxillary | No | Combined maximum reimbursement limit per six months for repairs. |
| D5621 | Repair cast partial framework, mandibular | No | Combined maximum reimbursement limit per six months for repairs. |
| D5622 | Repair cast partial framework, maxillary | No | Combined maximum reimbursement limit per six months for repairs. |
| D5630 | Repair or replace broken clasp—per tooth | No | Combined maximum reimbursement limit per six months for repairs. Requires an area of oral cavity code (01=Maxillary or 02=Mandibular) in the appropriate element of the claim form. Requires tooth numbers on claim submission. |
| D5640 | Replace broken teeth—per tooth | No | Combined maximum reimbursement limit per six months for repairs. Requires an area of oral cavity code (01=Maxillary or 02=Mandibular) in the appropriate element of the claim form. |
| D5650 | Add tooth to existing partial denture | No | Combined maximum reimbursement limit per six months for repairs. Requires an area of oral cavity code (01=Maxillary or 02=Mandibular) in the appropriate element of the claim form. |
| D5660 | Add clasp to existing partial denture—per tooth | No | Combined maximum reimbursement limit per six months for repairs. Requires an area of oral cavity code (01=Maxillary or 02=Mandibular) in the appropriate element of the claim form. Requires tooth numbers on claim submission. |
| D5670 | Replace all teeth and acrylic on cast metal framework (maxillary) | Yes | Combined maximum reimbursement limit per six months for repairs. Requires area of oral cavity code 01=Maxillary in the appropriate element of the claim form. |
| D5671 | Replace all teeth and acrylic on cast metal framework (mandibular) | Yes | Combined maximum reimbursement limit per six months for repairs. Requires area of oral cavity code 02=Mandibular in the appropriate element of the claim form. |
| Denture Reline Procedures | |||
| D5750 | Reline complete maxillary denture (laboratory) | No | Allowed once per three years.1 Retain documentation of medical necessity. |
| D5751 | Reline complete mandibular denture (laboratory) | No | Allowed once per three years.1 Retain documentation of medical necessity. |
| D5760 | Reline maxillary partial denture (laboratory) | No | Allowed once per three years.1 Retain documentation of medical necessity. |
| D5761 | Reline mandibular partial denture (laboratory) | No | Allowed once per three years.1 Retain documentation of medical necessity. |
1 Frequency limitation may be exceeded in exceptional circumstances with written justification on PA request.
2 Healing period of six weeks required after last extraction prior to taking impressions for dentures, unless shorter period approved in PA.
Covered maxillofacial prosthetics are identified by the allowable procedure codes listed in the following table. Medicaid reimbursement is allowable only for services that meet all program requirements. This includes documenting the medical necessity of services in the member's medical record.
| Code | Description of Service | Prior Authorization? | Limitations and Requirements |
|---|---|---|---|
| 21076 | Impression and custom preparation; surgical obturator prosthesis | Yes | Allowed once per six months.
Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements. |
| 21077 | Impression and custom preparation; orbital prosthesis | Yes | Allowed once per six months.
Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements. |
| 21079 | Impression and custom preparation; interim obturator prosthesis | Yes | Allowed once per six months.
Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements. |
| 21080 | Impression and custom preparation; definitive obturator prosthesis | Yes | Allowed once per six months.
Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements. |
| 21081 | Impression and custom preparation; mandibular resection prosthesis | Yes | Allowed once per six months.
Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements. |
| 21082 | Impression and custom preparation; palatal augmentation prosthesis | Yes | Allowed once per six months.
Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements. |
| 21083 | Impression and custom preparation; palatal lift prosthesis | Yes | Allowed once per six months.
Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements. |
| 21084 | Impression and custom preparation; speech aid prosthesis | Yes | Allowed once per six months.
Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements. |
| 21085 | Impression and custom preparation; oral surgical splint | Yes | Allowed once per six months.
Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements. |
| 21086 | Impression and custom preparation; auricular prosthesis | Yes | Allowed once per six months.
Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements. |
| 21087 | Impression and custom preparation; nasal prosthesis | Yes | Allowed once per six months.
Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements. |
| 21088 | Impression and custom preparation; facial prosthesis | Yes | Allowed once per six months.
Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements. |
| 21089 | Unlisted maxillofacial prosthetic procedure | Yes | Allowed once per six months.
Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements. |
| D5932 | Obturator prosthesis, definitive | No | Allowed once per six months.1
Retain documentation of medical necessity. |
| D5955 | Palatal lift prosthesis, definitive | No | Allowed once per six months.1 Retain documentation of medical necessity. |
| D5991 | Topical medicament carrier | No | |
| D5999 | Unspecified maxillofacial prosthesis, by report | Yes | For medically necessary removable prosthodontic procedures.
Use this code only if a service is provided that is not accurately described by other HCPCS or CPT procedure codes. |
1 Frequency limitation may be exceeded in exceptional circumstances with written justification on PA request.
Covered fixed prosthodontic services are identified by the allowable CDT procedure codes listed in the following table. Medicaid reimbursement is allowable only for services that meet all program requirements. This includes documenting the medical necessity of services in the member's medical record.
| Code | Description of Service | Prior Authorization? | Limitations and Requirements |
|---|---|---|---|
| Fixed Partial Denture Pontics | |||
| D6211 | Pontic—cast predominantly base metal | Yes | Permanent teeth only (tooth numbers 1–32 and 51–82 only). |
| D6241 | Pontic—porcelain fused to predominantly base metal | Yes | Permanent teeth only (tooth numbers 1–32 and 51–82 only). |
| Fixed Partial Denture Retainers—Inlays/Onlays | |||
| D6545 | Retainer; cast metal for resin bonded fixed prosthesis | Yes | Tooth numbers 1–32, 51–82 only. |
| Fixed Partial Denture Retainers—Crowns | |||
| D6751 | Retainer crown—porcelain fused to predominantly base metal | Yes | Permanent teeth only (tooth numbers 1–32 and 51–82 only). |
| D6791 | Retainer crown—full cast predominantly base metal | Yes | Permanent teeth only (tooth numbers 1–32 and 51–82 only). |
| Other Fixed Partial Denture Services | |||
| D6930 | Recement fixed partial denture | No | |
| D6940 | Stress breaker | Yes | Copy of lab bill required. |
| D6980 | Fixed partial denture repair, by report | Yes | Copy of lab bill required. |
| D6985 | Pediatric partial denture, fixed | No | Allowable up to age 12. Retain documentation of medical necessity. |
Covered oral and maxillofacial surgery services are identified by the allowable CDT procedure codes listed in the following table. Medicaid reimbursement is allowable only for services that meet all program requirements. This includes documenting the medical necessity of services in the member's medical record.
| Code | Description of Service | Prior Authorization? | Limitations and Requirements |
|---|---|---|---|
| Extractions (Includes local anesthesia, suturing, if needed, and routine postoperative care) | |||
| D7111 | Extraction, coronal remnants—primary tooth | No | Allowed only once per tooth. Primary teeth only (tooth letters A–T and AS–TS only). Not payable same DOS as D7250 for same tooth letter. |
| D7140 | Extraction, erupted tooth or exposed root (elevation and/or forceps removal) | No | Allowed only once per tooth (tooth numbers 1–32, A–T, 51–82 and AS–TS). Not payable same DOS as D7250 for same tooth number. |
| Surgical Extractions (Includes local anesthesia, suturing, if needed, and routine postoperative care) | |||
| D7210 | Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated | No | Allowed only once per tooth. Covered when performing an emergency service or for orthodontia (tooth numbers 1–32, A–T, 51–82 and AS–TS).1 Not payable same DOS as D7250 for same tooth number. |
| D7220 | Removal of impacted tooth—soft tissue | No | Allowed only once per tooth. Covered when performing an emergency service or for orthodontia (tooth numbers 1–32, A–T, 51–82 and AS–TS).1 Not payable same DOS as D7250 for the same tooth number. |
| D7230 | Removal of impacted tooth—partially bony | No | Allowed only once per tooth. Covered when performing an emergency service or for orthodontia (tooth numbers 1–32, A–T, 51–82 and AS–TS).1 Not payable same DOS as D7250 for the same tooth number. |
| D7240 | Removal of impacted tooth—completely bony | No | Allowed only once per tooth. Covered when performing an emergency service or for orthodontia (tooth numbers 1–32, A–T, 51–82 and AS–TS).1 Not payable same DOS as D7250 for the same tooth number. |
| D7241 | Removal of impacted tooth—completely bony, with unusual surgical complications | No | Allowed only once per tooth. Covered when performing an emergency service or for orthodontia (tooth numbers 1–32, A–T, 51–82 and AS–TS).1 Not payable same DOS as D7250 for the same tooth number. |
| D7250 | Removal of residual tooth roots (cutting procedure) | No | Emergency only
(tooth numbers 1–32, A–T, 51–82 and AS–TS).1 Allowed only once per tooth. Not allowed on the same DOS as tooth extraction of same tooth number. |
| Other Surgical Procedures | |||
| D7260 or CPT2 | Oroantral fistula closure | No | Operative report required on claim submission. |
| D7261 | Primary closure of a sinus perforation | No | Operative report required on claim submission. |
| D7270 | Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth | No | Emergency only (tooth numbers 1–32, C–H, M–R, 51–82, CS–HS, and MS–RS).1 Operative report required on claim submission. |
| D7280 | Exposure of an unerupted tooth | No | Not allowed for primary or wisdom teeth (tooth numbers 2–15, 18–31, 52–65, and 68–81 only). Allowable for members ages 0–20. Covered for orthodontic reasons. Clinical notes and an operative report must be retained in the member's medical or dental record. |
| D7282 | Mobilization of erupted or malpositioned tooth to aid eruption | No | Not allowed for primary or wisdom teeth (tooth numbers 2–15, 18–31, 52–65, and 68–81 only). Allowable for members ages 0–20. Covered for orthodontic reasons. Clinical notes and an operative report must be retained in the member's medical or dental record. |
| D7283 | Placement of device to facilitate eruption of impacted tooth | No | Not allowed for primary or wisdom teeth (tooth numbers 2–15, 18–31, 52–65, and 68–81 only). Allowable for members ages 0–20. Covered for orthodontic reasons. Clinical notes and an operative report must be retained in the member's medical or dental record. |
| D7285 or CPT2 | Incisional biopsy of oral tissue—hard (bone, tooth) | No | Once per DOS.3 Operative report required on claim submission. |
| D7286 or CPT2 | Incisional biopsy of oral tissue—soft | No | Once per DOS.3 Operative report required on claim submission. |
| D7287 or CPT2 | Exfoliative cytological sample collection | No | Once per DOS.3 Operative report required on claim submission. |
| D7288 | Brush biopsy—transepithelial sample collection | No | Once per DOS.3 Operative report required on claim submission. |
| Alveoloplasty—Surgical Preparation of Ridge for Dentures | |||
| D7310 | Alveoloplasty in conjuction with extractions—per quadrant | No | Allowable area of oral cavity codes: 10 (upper right), 20 (upper left), 30 (lower left), 40 (lower
right). X-ray, treatment notes and treatment plan required. |
| D7311 | Alveoloplasty in conjuction with extractions—one to three teeth or tooth spaces, per quadrant | No | Allowable area of oral cavity codes: 10 (upper right), 20 (upper left), 30 (lower left), 40 (lower right). X-ray, treatment notes and treatment plan required. |
| D7320 | Alveoloplasty not in conjuction with extractions—per quadrant | No | Allowable area of oral
cavity codes: 10 (upper right), 20 (upper left), 30 (lower left), 40 (lower
right). X-ray, treatment notes and treatment plan required. |
| D7321 | Alveoloplasty not in conjuction with extractions—one to three teeth or tooth spaces, per quadrant | No | Allowable area of oral cavity codes: 10 (upper right), 20 (upper left), 30 (lower left), 40 (lower
right). X-ray, treatment notes and treatment plan required. |
| Surgical Excision of Soft Tissue Lesions | |||
| D7410 or CPT2 | Excision of benign lesion up to 1.25 cm | No | Once per DOS.3 Pathology report required. |
| D7411 or CPT2 | Excision of benign lesion greater than 1.25 cm | No | Once per DOS.3 Pathology report required. |
| D7412 or CPT2 | Excision of benign lesion, complicated | No | Once per DOS.3 Pathology report required. |
| D7413 or CPT2 | Excision of malignant lesion up to 1.25 cm | No | Once per DOS.3 Pathology report required. |
| D7414 or CPT2 | Excision of malignant lesion greater than 1.25 cm | No | Once per DOS.3 Pathology report required. |
| D7415 or CPT2 | Excision of malignant lesion, complicated | No | Once per DOS.3 Pathology report required. |
| Surgical Excision of Intra-Osseous Lesions | |||
| D7440 or CPT2 | Excision of malignant tumor—lesion diameter up to 1.25 cm | No | Once per DOS.3 Pathology report required. |
| D7441 or CPT2 | Excision of malignant tumor—lesion diameter greater than 1.25 cm | No | Once per DOS.3 Pathology report required. |
| D7450 or CPT2 | Removal of benign odontogenic cyst or tumor—lesion diameter up to 1.25 cm | No | Once per DOS.3 Pathology report required. |
| D7451 or CPT2 | Removal of benign odontogenic cyst or tumor—lesion diameter greater than 1.25 cm | No | Once per DOS.3 Pathology report required. |
| D7460 or CPT2 | Removal of benign nonodontogenic cyst or tumor—lesion diameter up to 1.25 cm | No | Once per DOS.3 Pathology report required. |
| D7461 or CPT2 | Removal of benign nonodontogenic cyst or tumor—lesion diameter greater than 1.25 cm | No | Once per DOS.3 Pathology report required. |
| Excision of Bone Tissue | |||
| D7471 or CPT2 | Removal of lateral exostosis (maxilla or mandible) | Yes | Oral photographic image or diagnostic cast of arch required for PA. |
| D7472 or CPT2 | Removal of torus palatinus | Yes | Oral photographic image or diagnostic cast of arch required for PA. |
| D7473 or CPT2 | Removal of torus mandibularis | Yes | Oral photographic image or diagnostic cast of arch required for PA. |
| D7485 or CPT2 | Surgical reduction of osseous tuberosity | No | Operative report required on claim submission. |
| D7490 or CPT2 | Radical resection of maxilla or mandible | No | Operative report required on claim submission. Only allowable in hospital or ambulatory surgical center POS. |
| Surgical Incision | |||
| D7510 or CPT2 | Incision and drainage of abscess—intraoral soft tissue | No | Operative report required on claim submission. Not to be used for periodontal abscess—use D9110. |
| D7511 or CPT2 | Incision and drainage of abscess—intraoral soft tissue—complicated (includes drainage of multiple fascial spaces) | No | Operative report required on claim submission. Not to be used for periodontal abscess—use D9110. |
| D7520 or CPT2 | Incision and drainage of abscess—extraoral soft tissue | No | Operative report required on claim submission. |
| D7521 or CPT2 | Incision and drainage of abscess—extraoral soft tissue—complicated (includes drainage of multiple fascial spaces) | No | Operative report required on claim submission. |
| D7530 or CPT2 | Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue | No | Not allowed for removal of root fragments and bone spicules. (Use D7250 instead.) Operative report required on claim submission. |
| D7540 or CPT2 | Removal of reaction producing foreign bodies, musculoskeletal system | No | Not allowed for removal of root fragments and bone spicules. (Use D7250 instead.) Operative report required on claim submission. |
| D7550 or CPT2 | Partial ostectomy/sequestrectomy for removal of non-vital bone | No | Operative report required on claim submission. |
| D7560 or CPT2 | Maxillary sinusotomy for removal of tooth fragment or foreign body | No | Operative report required on claim submission. |
| Treatment of Fractures—Simple | |||
| D7610 or CPT2 | Maxilla—open reduction (teeth immobilized, if present) | No | Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission. |
| D7620 or CPT2 | Maxilla—closed reduction (teeth immobilized, if present) | No | Operative report required on claim submission. |
| D7630 or CPT2 | Mandible—open reduction (teeth immobilized, if present) | No | Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission. |
| D7640 or CPT2 | Mandible—closed reduction (teeth immobilized, if present) | No | Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission. |
| D7650 or CPT2 | Malar and/or zygomatic arch—open reduction | No | Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission. |
| D7660 or CPT2 | Malar and/or zygomatic arch—closed reduction | No | Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission. |
| D7670 or CPT2 | Alveolus—closed reduction, may include stabilization of teeth | No | Operative report required on claim submission. |
| D7671 or CPT2 | Alveolus—open reduction, may include stabilization of teeth | No | Operative report required on claim submission. |
| D7680 or CPT2 | Facial bones—complicated reduction with fixation and multiple surgical approaches | No | Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission. |
| Treatment of Fractures—Compound | |||
| D7710 or CPT2 | Maxilla—open reduction | No | Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission. |
| D7720 or CPT2 | Maxilla—closed reduction | No | Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission. |
| D7730 or CPT2 | Mandible—open reduction | No | Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission. |
| D7740 or CPT2 | Mandible—closed reduction | No | Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission. |
| D7750 or CPT2 | Malar and/or zygomatic arch—open reduction | No | Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission. |
| D7760 or CPT2 | Malar and/or zygomatic arch—closed reduction | No | Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission. |
| D7770 or CPT2 | Alveolus—open reduction stabilization of teeth | No | Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission. |
| D7771 or CPT2 | Alveolus—closed reduction stabilization of teeth | No | Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission. |
| D7780 or CPT2 | Facial bones—complicated reduction with fixation and multiple approaches | No | Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission. |
| Reduction of Dislocation and Management of Other Temporomandibular Joint Dysfunctions | |||
| D7810 or CPT2 | Open reduction of dislocation | No | Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission. |
| D7820 or CPT2 | Closed reduction of dislocation | No | Once per DOS.3 Operative report required on claim submission. |
| D7830 or CPT2 | Manipulation under anesthesia | No | Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission. |
| D7840 or CPT2 | Condylectomy | Yes | Only allowable in hospital, office, or ambulatory surgical center POS. No operative report required on claim submission. |
| D7850 or CPT2 | Surgical discectomy, with/without implant | Yes | Only allowable in hospital, office, or ambulatory surgical center POS. No operative report required on claim submission. |
| D7860 or CPT2 | Arthrotomy | Yes | Only allowable in hospital, office, or ambulatory surgical center POS. No operative report required on claim submission. |
| D7871 or CPT2 | Non-arthroscopic lysis and lavage | Yes | Allowable only once per side (right and left) per three years. |
| D7899 | Unspecified TMD therapy, by report | Yes | Use this code for billing TMJ assistant surgeon. Procedure must be included in PA request for the surgery itself. Only allowable in hospital or ambulatory surgical center POS. |
| Repair of Traumatic Wounds | |||
| D7910 or CPT2 | Suture of recent small wounds up to 5 cm | No | Emergency only1—operative report required on claim submission. Once per DOS.3 |
| Complicated Suturing (Reconstruction requiring delicate handling of tissues and wide undermining for meticulous closure) | |||
| D7911 or CPT2 | Complicated suture—up to 5 cm | No | Covered for trauma (emergency) situations only.1 Once per DOS.3 Operative report required on claim submission. |
| D7912 or CPT2 | Complicated suture—greater than 5 cm | No | Covered for trauma (emergency) situations only.1 Once per DOS.3 Operative report required on claim submission. |
| Other Repair Procedures | |||
| D7940 or CPT2 | Osteoplasty—for orthognathic deformities | Yes | Only allowable in hospital, office, or ambulatory surgical center
POS. No operative report required on claim submission. Allowable age less than 21. |
| D7950 or CPT2 | Osseous, osteoperiosteal, or cartilage graft of the mandible or facial bones—autogeneous or nonautogeneous, by report | Yes | Only allowable in hospital, office, or ambulatory surgical center POS. No operative report required on claim submission. |
| D7951 | Sinus augmentation with bone or bone substitutes | No | |
| D7961 or CPT2 | Buccal/labial frenectomy (frenulectomy) | No | Covered areas of the oral cavity are 01 and 02. The area of the oral cavity is required to be indicated on the claim.
Up to two units of service per area of the oral cavity allowed per DOS. Total of four units per DOS. Note: An image of the obstructed frenum is not required to be submitted with claims but must be available in the medical or dental record. A dentist statement regarding the medical/dental need for the treatment is required to be available upon request. Refer to the Frenulectomy Procedures Online Handbook topic for limitations and requirements. |
| D7962 or CPT2 | Lingual frenectomy (frenulectomy) | No | Covered areas of the oral cavity are 01 and 02. The area of the oral cavity is required to be indicated on the claim.
Up to two units of service per area of the oral cavity allowed per DOS. Total of four units per DOS. Note: An image of the obstructed frenum is not required to be submitted with claims but must be available in the medical or dental record. A dentist statement regarding the medical/dental need for the treatment is required to be available upon request. Refer to the Frenulectomy Procedures Online Handbook topic for limitations and requirements. |
| D7970 or CPT2 | Excision of hyperplastic tissue per arch | Yes | No operative report required on claim submission. |
| D7972 or CPT2 | Surgical reduction of fibrous tuberosity | No | Operative report required on claim submission. |
| D7979 | Non-surgical sialolithotomy | No | No operative report required on claim submission. |
| D7980 or CPT2 | Surgical sialolithotomy | No | Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission. |
| D7991 or CPT2 | Coronoidectomy | Yes | Only allowable in hospital or ambulatory surgical center POS. No operative report required on claim submission. |
| D7997 or CPT2 | Appliance removal (not by dentist who placed appliance), includes removal of archbar | No | Operative report required on claim submission. |
| D7999 or CPT2 | Unspecified oral surgery procedure, by report | Yes | For medically necessary unspecified oral surgery procedure, by report.
Use this code only if a service is provided that is not accurately described by other HCPCS or CPT procedure codes. Note: For occlusal guard use procedure code D9440. |
1 Retain records in member files regarding nature of emergency.
2 Providers who are enrolled in Wisconsin Medicaid as oral surgeons or oral pathologists and who choose CPT billing must use a CPT code to bill for this procedure. Refer to the Dental Maximum Allowable Fee Schedule for allowable CPT procedure codes.
3 Frequency limitation may be exceeded if a narrative on the claim demonstrates medical necessity for additional services.
Covered orthodontic services are identified by the allowable CDT procedure codes listed in the following table. Medicaid reimbursement is allowable only for services that meet all program requirements. This includes documenting the medical necessity of services in the member's medical record.
| Code | Description of Service | Prior Authorization? | Limitations and Requirements |
|---|---|---|---|
| Limited Orthodontic Treatment | |||
| D8010 | Limited orthodontic treatment of the primary dentition | Yes | Allowable age less than 21. |
| D8020 | Limited orthodontic treatment of the transitional dentition | Yes | Allowable age less than 21. |
| D8030 | Limited orthodontic treatment of the adolescent dentition | Yes | Allowable age less than 21. |
| D8040 | Limited orthodontic treatment of the adult dentition | Yes | Allowable age less than 21. |
| Interceptive Orthodontic Treatment | |||
| D8050 | Interceptive orthodontic treatment of the primary dentition | Yes | Allowable age less than 21. |
| D8060 | Interceptive orthodontic treatment of the transitional dentition | Yes | Allowable age less than 21. |
| Comprehensive Orthodontic Treatment | |||
| D8070 | Comprehensive orthodontic treatment of the transitional dentition | Yes | Allowable age less than 21. |
| D8080 | Comprehensive orthodontic treatment of the adolescent dentition | Yes | Allowable age less than 21. |
| D8090 | Comprehensive orthodontic treatment of the adult dentition | Yes | Allowable age less than 21. |
| Minor Treatment to Control Harmful Habits | |||
| D8210 | Removable appliance therapy | Yes | Allowable age less than 21. |
| D8220 | Fixed appliance therapy | Yes | Allowable age less than 21. |
| Other Orthodontic Services | |||
| D8660 | Pre-orthodontic treatment visit | No | Allowable age less than 21. Includes exam, diagnostic tests and consult. |
| D8670 | Periodic orthodontic treatment visit (as part of contract) | Yes | Allowable age less than 21. Used for monthly adjustments. |
| D8680 | Orthodontic retention (removal of appliances, construction and placement of retainer[s]) | Yes | Allowable age less than 21. |
| D8695 | Removal of fixed orthodontic appliances for reasons other than completion of treatment | Yes | Covered for members ages 0 to 20 years. Allowable once per member per provider. Coverage is considered on a case-by-case basis with a review of the following requirements:
|
| D8698 | Re-cement or re-bond fixed retainer—maxillary | No | |
| D8699 | Re-cement or re-bond fixed retainer—mandibular | No | |
| D8703 | Replacement of lost or broken retainer—maxillary | No | Covered for members ages 0 to 20 years. |
| D8704 | Replacement of lost or broken retainer—mandibular | No | Covered for members ages 0 to 20 years. |