For Dates of Service Before January 1, 2021

Radiographs

ForwardHealth coverage of radiographs includes reimbursement for exposure, developing, mounting, and interpretation of the radiograph.

An intraoral complete series may include either a periapical series plus bitewings or a panorex plus bitewings. Individual panoramic radiographs are covered when another radiograph is insufficient for proper diagnosis.

Full Mouth Radiographs

Dentists may obtain PA for additional full mouth (intraoral complete series) radiographs or panoramic films in cases of trauma or other unusual medical or dental clinical histories, such as cancer or rampant decay.

Panoramic Films (D0330)

Coverage of panoramic films is limited to once per member per DOS, and should be taken only when another type of radiograph is insufficient for diagnosis. Documentation to support the medical necessity of this service must be included in the member's record.

When a panoramic film and bitewings are taken on the same DOS, claims should be submitted with procedure code D0210 (Intraoral; complete series [including bitewings]) only.

Cephalormetric Films and Pre-Orthodontic Visits (D0340, D8660)

Cephalormetric films and pre-orthodontic visit services are limited to members with an orthodontic diagnosis only. Providers may submit claims for these services before submitting a PA request for orthodontia.

Oral/Facial Photographic Images (D0350)

Oral/facial photographic images may be used as a diagnostic tool for oral surgery and orthodontia services only and may be submitted as supporting clinical documentation with a PA request.

Mounting Radiographs for Prior Authorization

When four or more periapical X-rays, four bitewing X-rays, or when a full mouth X-ray must be submitted to BadgerCare Plus to substantiate a PA request, providers should mount the X-rays to allow for proper identification and to speed the review process.

Providers are required to do the following when sending in four or more periapical X-rays, four bitewing X-rays, or a full mouth series:

• Mount the X-rays.
• Label the X-rays (left or right).
• Include the date the X-rays were taken.
• Include the member's name and identification number.
• Include the provider's name and provider number.

When sending in three or fewer periapical or bitewing X-rays:

• Label the X-rays (left or right).
• Include the date the X-rays were taken.
• Include the member's name and identification number.
• Include the provider's name and provider number.
• Place X-rays in an envelope.
• Staple X-ray envelope to designated portion of PA form that states, "Staple X-ray envelope here."

Submitting Claims for Radiographs

Radiographs provided to a member on the same DOS must be submitted on the same claim form. Wisconsin Medicaid denies reimbursement for services performed on the same DOS but submitted on separate claim forms.