For Dates of Service Before January 1, 2009

Standard Plan/Medicaid Diagnostic, Preventive, Restorative, Endodontics, Periodontics, General Codes

The following Procedure codes are covered under the BadgerCare Plus Standard Plan and Medicaid.

D0100-D0999 Diagnostic

Covered diagnostic services are identified by the allowable CDT procedure codes listed in the following tables. 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
Clinical Oral Examinations
D0120	Periodic oral evaluation	No	One per six-month period, per provider, for members under the age of 21.
D0140	Limited oral evaluation - problem focused	No	One per six months, per provider.
D0150	Comprehensive oral evaluation - new or established patient	No	One per three years, per provider.
D0160	Detailed and extensive oral evaluation - problem focused, by report	No	One per three years, per provider.
D0170	Re-evaluation limited, problem focused (established patient; not post-operative visit)	No	Allowed once per year, per provider. Allowable in office or hospital POS.
Radiographs/Diagnostic Imaging (Including Interpretation)
D0210	Intraoral; complete series (including bitewings)	No³	One per three years, per provider. Not billable within six months of other X-rays including D0220, D0230, D0240, D0270, D0272, D0274, and D0330 except in an emergency.¹ Panorex plus bitewings may be billed under D0210.
D0220	periapical first film	No	One per day. Not payable with D0210 on same DOS or up to six months after.²
D0230	periapical each additional film	No	Up to three per day. Must be billed with D0220. Not payable with D0210 on same DOS or up to six months after.²
D0240	occlusal film	No	Up to two per day. Not payable with D0210 on same DOS.
D0250	Extraoral; first film	No	Emergency only, one per day.¹
D0260	each additional film	No	Emergency only, only two per day.¹ Must be billed with D0250.
D0270	Bitewing(s); single film	No	One per day, up to two per six-month period, per provider. Not payable with D0210, D0270, D0272, D0273, or D0274 on same DOS or up to six months after.²
D0272	two films	No	One set of bitewings per six-month period, per provider. Not payable with D0210, D0270, D0272, D0273, or D0274 on same DOS or up to six months after.²
D0273	three films	No	One set of bitewings per six-month period, per provider. Not payable with D0210, D0270, D0272, D0273, or D0274 on same DOS or up to six months after.²
D0274	four films	No	One set of bitewings per six-month period, per provider. Not payable with D0210, D0270, D0272, D0273, or D0274 on same DOS or up to six months after.²
D0330	Panoramic film	No³	One per day when another radiograph is insufficient for proper diagnosis. Not payable with D0210, D0270, D0272, D0273, or D0274.
D0340	Cephalometric film	No	Orthodontia diagnosis only. Allowable for members up to age 20.
D0350	Oral/facial photographic images	No	Allowable for members up to age 20. Allowable for orthodontia or oral surgery.
Tests and Examinations
D0470	Diagnostic casts	No	Orthodontia diagnosis only. Allowed with PA for members ages 21 and over, at BadgerCare Plus's request (e.g., for dentures).
D0486	Accession of brush biopsy sample, microscopic examination, preparation and transmission of written report	No	None.
D0999	Unspecified diagnostic procedure, by report	Yes	HealthCheck "Other Service." Use this code for up to two additional oral exams per year with a HealthCheck referral. Allowable for members ages 13-20.

¹ Retain records in recipient files regarding nature of emergency.
² Six-month limitation may be exceeded in an emergency.
³ The same DOS limitation may not be exceeded in an emergency.

D1000-D1999 Preventive

Covered preventive services are identified by the allowable CDT procedure codes listed in the following table. 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
Dental Prophylaxis
D1110	Prophylaxis; adult	No	One per 12-month period, per provider, for ages 21 and older. One per six-month period, per provider, for ages 13-20. Allowable for members ages 13 or older. Not payable with periodontal scaling and root planing or periodontal maintenance procedure. Special Circumstances: Up to four per 12-month period, per provider, for permanently disabled member. Retain documentation of disability that impairs ability to maintain oral hygiene. Allowable for Medicaid-certified dental hygienists.
D1120	child	No	One per six-month period, per provider. Allowable for members up to age 12. Special Circumstances: Up to four per 12-month period, per provider, for permanently disabled members. Retain documentation of disability that impairs ability to maintain oral hygiene. Allowable for Medicaid-certified dental hygienists.
Topical Fluoride Treatment (Office Procedure)
D1203	Topical application of fluoride (prophylaxis not included); child	No	Two per 12-month period, per provider. Allowable for members up to age 12. Special Circumstances: Up to four per 12-month period, per provider, for cases of demonstrated high need, or for permanently disabled members. Retain documentation of disability that impairs ability to maintain oral hygiene or demonstrated high need. Allowable for Medicaid-certified dental hygienists, physicians, and nurses.
D1204	adult	No	Two per 12-month period, per provider, for ages 13-20. Covered only in special circumstances for ages 21 and older: Up to four per 12-month period, per provider, for permanently disabled members. Retain documentation of disability that impairs ability to maintain oral hygiene. Allowable for members age 13 or older. Allowable for Medicaid-certified dental hygienists.
D1206	Topical fluoride varnish; therapeutic application for moderate to high caries risk patients	No	Up to four per 12-month period, per provider, for at risk children ages 0-20. Up to two per 12-month period, per provider, for children up to age 12. Up to four per 12-month period, per provider, for children up to age 12 for cases of demonstrated high need or permanently disabled members. Covered only in special circumstances for ages 21 and older: Up to four per 12-month period, per provider, for permanently disabled members. Retain documentation of disability that impairs ability to maintain oral hygiene. Not payable with periodontal scaling and root planing. Allowable for Medicaid-certified dental hygienists. Per CDT, not used for desensitization.
Other Preventive Services
D1351	Sealant - per tooth	No	Retain documentation regarding medical necessity of sealants placed on teeth other than permanent molars (1, 4-13, 16, 17, 20-29, 32, 51-82, A-T, AS-TS). Allowable for members up to age 20. Narrative required in order to exceed once per three-year limitation. Allowable for Medicaid-certified dental hygienists.
Space Maintenance (Passive Applicances)
D1510	Space maintainer; fixed-unilateral	No	First and second primary molar only (tooth letters A, B, I, J, K, L, S, and T only). Limited to four per DOS; once per year, per tooth. Narrative required to exceed frequency limitation. Allowable for members up to age 20.
D1515	fixed-bilateral	No	Once per year, per arch. Narrative required to exceed frequency limitation. Allowable for members up to age 20.
D1550	Recementation of space maintainer	No	Limited to two per DOS. Allowable for members up to age 20.

D2000-D2999 Restorative

Covered restorative services are identified by the allowable CDT procedure codes listed in the following table. 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
Amalgam Restorations (Including Polishing)
D2140	Amalgam; one surface, primary or permanent	No	Primary teeth: Once per tooth, per year, per provider¹ (tooth letters A-T and AS-TS only). Permanent teeth: Once per tooth, per three years, per provider¹ (tooth numbers 1-32 and 51-82 only).
D2150	two surfaces, primary or permanent	No	Primary teeth: Once per tooth, per year, per provider¹ (tooth letters A-T and AS-TS only). Permanent teeth: Once per tooth, per three years, per provider¹ (tooth numbers 1-32 and 51-82 only).
D2160	three surfaces, primary or permanent	No	Primary teeth: Once per tooth, per year, per provider¹ (tooth letters A-T and AS-TS only). Permanent teeth: Once per tooth, per three years, per provider¹ (tooth numbers 1-32 and 51-82 only).
D2161	four or more surfaces, primary or permanent	No	Primary teeth: Once per tooth, per year, per provider¹ (tooth letters A-T and AS-TS only). Permanent teeth: Once per tooth, per three years, per provider¹ (tooth numbers 1-32 and 51-82 only).
Resin-Based Composite Restorations - Direct
D2330	Resin-based composite; one surface, anterior	No	Primary teeth: Once per tooth, per year, per provider.¹ Permanent teeth: Once per tooth, per three years, per provider.¹ Allowed for Class I and Class V only (tooth numbers 6-11, 22-27, C-H, M-R, 56-61, 72-77, CS-HS, and MS-RS only).
D2331	two surfaces, anterior	No	Primary teeth: Once per tooth, per year, per provider.¹ Permanent teeth: Once per tooth, per three years, per provider.¹ Allowed for Class III only (tooth numbers 6-11, 22-27, C-H, M-R, 56-61, 72-77, CS-HS, and MS-RS only).
D2332	three surfaces, anterior	No	Primary teeth: Once per tooth, per year, per provider.¹ Permanent teeth: Once per tooth, per three years, per provider.¹ Allowed for Class III and Class IV only (tooth numbers 6-11, 22-27, C-H, M-R, 56-61, 72-77, CS-HS, and MS-RS only).
D2335	four or more surfaces or involving incisal angle (anterior)	No	Primary teeth: Once per tooth, per year, per provider.¹ Permanent teeth: Once per tooth, per three years, per provider.¹ Allowed for Class IV only (tooth numbers 6-11, 22-27, C-H, M-R, 56-61, 72-77, CS-HS, and MS-RS only). Must include incisal angle. Four surface resins may be billed under D2332, unless an incisal angle is included.
D2390	Resin-based composite crown, anterior	No	Primary teeth: Once per year, per tooth (tooth letters D-G, DS-GS only). Permanent teeth: Once per five years, per tooth (tooth numbers 6-11, 22-27, 56-61, 72-77 only.) Limitation can be exceeded with narrative for children¹, and with PA for adults greater than age 20.²
D2391	Resin-based composite - one surface, posterior	No	Primary teeth: Once per year, per provider, per tooth¹ (tooth letters A, B, I, J, K, L, S, T, AS, BS, IS, JS, KS, LS, SS, and TS only). Permanent teeth: Once per three years, per provider, per tooth¹ (tooth numbers 1-5, 12-21, 28-32, 51-55, 62-71, and 78-82 only).
D2392	Resin-based composite - two surfaces, posterior	No	Primary teeth: Once per year, per provider, per tooth¹ (tooth letters A, B, I, J, K, L, S, T, AS, BS, IS, JS, KS, LS, SS, and TS only). Permanent teeth: Once per three years, per provider, per tooth¹ (tooth numbers 1-5, 12-21, 28-32, 51-55, 62-71, and 78-82 only).
D2393	Resin-based composite - three surfaces, posterior	No	Primary teeth: Once per year, per provider, per tooth¹ (tooth letters A, B, I, J, K, L, S, T, AS, BS, IS, JS, KS, LS, SS, and TS only). Permanent teeth: Once per three years, per provider, per tooth¹ (tooth numbers 1-5, 12-21, 28-32, 51-55, 62-71, and 78-82 only).
D2394	Resin-based composite - four or more surfaces, posterior	No	Primary teeth: Once per year, per provider, per tooth¹ (tooth letters A, B, I, J, K, L, S, T, AS, BS, IS, JS, KS, LS, SS, and TS only). Permanent teeth: Once per three years, per provider, per tooth¹ (tooth numbers 1-5, 12-21, 28-32, 51-55, 62-71, and 78-82 only).
Crowns - Single Restorations Only
D2791	Crown - full cast predominantly base metal	No	Once per year, per primary tooth; once per five years, per permanent tooth² (tooth numbers 1-32, A-T, 51-82, and AS-TS.) Reimbursement is limited to the rate of code D2933. Upgraded crown. No dentist is obligated to complete this type of crown.
Other Restorative Services
D2910	Recement inlay, onlay or partial coverage restoration	No	Tooth numbers 1-32, 51-82 only.
D2915	Recement cast or prefabricated post and core	No	Tooth numbers 1-32, A-T, 51-82, AS-TS.
D2920	Recement crown	No	Tooth numbers 1-32, A-T, 51-82, AS-TS.
D2930	Prefabricated stainless steel crown; primary tooth	No	Once per year, per tooth (tooth letters, A-T and AS-TS only).²
D2931	permanent tooth	No	Once per five years, per tooth (tooth numbers 1-32 and 51-82 only).
D2932	Prefabricated resin crown	No	Primary teeth: Once per year, per tooth (tooth letters D-G and DS-GS only). Permanent teeth: Once per five years, per tooth (tooth numbers 6-11, 22-27, 56-61, and 72-77 only.) Limitation can be exceeded with narrative for children¹, and with PA for adults older than age 20.²
D2933	Prefabricated stainless steel crown with resin window	No	Primary teeth: Once per year, per tooth (tooth letters D-G, DS-GS only). Permanent teeth: Once per five years, per tooth (tooth numbers 6-11 and 56-61 only.) Limitation can be exceeded with narrative for children¹, and with PA for adults older than age 20.²
D2934	Prefabricated esthetic coated stainless steel crown - primary tooth	No	Once per year, per tooth. Allowable age less than 21. Tooth letters D-G and DS-GS only.
D2940	Sedative filling	No	Not allowed with pulpotomies, permanent restorations, or endodontic procedures (tooth numbers 1-32, A-T, 51-82, and AS-TS).
D2951	Pin retention - per tooth, in addition to restoration	No	Once per three years, per tooth (tooth numbers 1-32 and 51-82 only).¹
D2952	Post and core in addition to crown, indirectly fabricated	No	Once per tooth, per lifetime, per provider. Tooth numbers 2-15, 18-31, 52-65, and 68-81 only. Cannot be billed with D2954.
D2954	Prefabricated post and core in addition to crown	No	Once per tooth, per lifetime, per provider. Tooth numbers 2-15, 18-31, 52-65, and 68-81 only. Cannot be billed with D2952.
D2971	Additional procedures to construct new crown under existing partial denture framework	No	Tooth numbers 2-15 and 18-31 only.
D2999	Unspecified restorative procedure, by report	Yes	HealthCheck "Other Service." Use this code for single-unit crown. Allowable for members ages 0-20.

1 Limitation may be exceeded if narrative on claim demonstrates medical necessity for replacing a properly completed filling, crown, or adding a restoration on any tooth surface. Limitation may be exceeded for non-prior authorized crowns by indicating medical necessity.
² Frequency limitation may be exceeded only with PA.

D3000-D3999 Endodontics

Covered endodontic services are identified by the allowable CDT procedure codes listed in the following table. 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
Pulpotomy
D3220	Therapeutic pulpotomy (excluding final restoration); removal of pulp coronal to the dentinocemental junction and application of medicament	No	Once per tooth, per lifetime. Primary teeth only (tooth letters A-T and AS-TS only).
D3221	Pulpal debridement, primary and permanent teeth	No	Allowable for tooth numbers 2-15, 18-31, 52-65, and 68-81 only. For primary teeth, use D3220. Not to be used by provider completing endodontic treatment.
Endodontic Therapy (Including Treatment Plan, Clinical Procedures and Follow-Up Care)
D3310	Anterior (excluding final restoration)	No (see limitations)	Normally for permanent anterior teeth. May be used to bill a single canal on a bicuspid or molar (tooth numbers 2-15, 18-31, 52-65, and 68-81 only, once per tooth, per lifetime). Not allowed with sedative filling. Root canal therapy on four or more teeth require PA.
D3320	Bicuspid (excluding final restoration)	No (see limitations)	Normally for permanent bicuspid teeth. May be used to bill two canals on a bicuspid or molar (tooth numbers 2-5, 12-15, 18-21, 28-31, 52-55, 62-65, 68-71, and 78-81 only, once per tooth, per lifetime). Not allowed with sedative filling. Root canal therapy on four or more teeth require PA.
D3330	Molar (excluding final restoration)	Yes, if age >20	Not covered for third molars. Permanent teeth only (tooth numbers 2, 3, 14, 15, 18, 19, 30, 31, 53, 53, 64, 65, 68, 69, 80, and 81 only, once per tooth, per lifetime). Not allowed with sedative filling. Root canal therapy on four or more teeth require PA.
Apexification/Recalcification Procedures
D3351	Apexification/recalcification; initial visit (apical closure/calcific repair of perforations, root resorption, etc.)	No	Permanent teeth only (tooth numbers 2-15, 18-31, 52-65, 68-81 only). Not allowable with root canal therapy. Bill the entire procedure under this code. Allowable for recipients ages less than 21.
Apicoectomy/Periradicular Services
D3410	Apicoectomy/periradicular surgery; anterior	No	Permanent anterior teeth only (tooth numbers 6-11, 22-27, 56-61, and 72-77 only). Not payable with root canal therapy on the same DOS. Code does not include retrograde filling (D3430), which may be billed separately.
D3430	Retrograde filling - per root	No	Permanent anterior teeth only (tooth numbers 6-11, 22-27, 56-61, and 72-77 only). Not payable with root canal therapy on the same DOS.

D4000-D4999 Periodontics

Covered periodontic services are identified by the allowable CDT procedure codes listed in the following table. 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.

D9000-D9999 Adjunctive General Services

Covered adjunctive general services are identified by the allowable CDT procedure codes listed in the following table. 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
Surgical Services (Including Usual Postoperative Care)
D4210	Gingivectomy or gingivoplasty - four or more contiguous teeth or bounded teeth spaces per quadrant	Yes	Allowable area of oral cavity codes: 10 (upper right), 20 (upper left), 30 (lower left), and 40 (lower right).
D4211	one to three contiguous teeth or bounded teeth spaces per quadrant	Yes	Allowable area of oral cavity codes: 10 (upper right), 20 (upper left), 30 (lower left), and 40 (lower right).
Non-Surgical Periodontal Service
D4341	Periodontal scaling and root planing - four or more teeth per quadrant	Yes	Allowable area of oral cavity codes: 10 (upper right), 20 (upper left), 30 (lower left), and 40 (lower right). Allowable for members ages 13 and older. Limited in most circumstances to once per three years per quadrant. Up to four quadrants per DOS are allowed when provided in hospital or ambulatory surgical center POS. Limited to two quadrants per DOS when provided in an office, home, ECF, or other POS, unless the PA request provides sound medical or other logical reasons, including long distance travel to the dentist or disability, which makes travel to the dentist difficult. Not payable with prophylaxis.
D4342	one to three teeth, per quadrant	Yes	Allowable area of oral cavity codes: 10 (upper right), 20 (upper left), 30 (lower left), and 40 (lower right). Allowable for members ages 13 and older. Limited in most circumstances to once per three years per quadrant. Up to four quadrants per DOS are allowed when provided in a hospital or ambulatory surgical center POS. Limited to two quadrants per DOS when provided in an office, home, ECF, or other POS, unless the PA request provides sound medical or other logical reasons, including long distance travel to the dentist or disability, which makes travel to the dentist difficult. Not payable with prophylaxis.
D4355	Full mouth debridement to enable comprehensive evaluation and diagnosis	No (see limitations)	Full mouth code. Excess calculus must be evident on an x-ray. One per three years, per provider. Billed on completion date only. May be completed in one long appointment. No other periodontal treatment (D4341, D4342, or D4910) can be authorized immediately after this procedure. Includes tooth polishing. Not payable with prophylaxis. Allowable for recipients ages 13 and older. Allowable with PA for members ages 0-12.
Other Periodontal Services
D4910	Periodontal maintenance	Yes	Prior authorization may be granted up to three years. Not payable with prophylaxis. Once per year in most cases. Allowable for recipients ages 13 and older.
D4999	Unspecified periodontal procedure, by report	Yes	HealthCheck "Other Service." Use this code for unspecified surgical procedure with a HealthCheck referral. Allowable for recipients up to age 20.

Code	Description of Service	Prior Authorization	Limitations and Requirements
Unclassified Treatment
D9110	Palliative (emergency) treatment of dental pain - minor procedure	No	Not payable immediately before or after surgery. Emergency only. Limit of $62.50 reimbursement per DOS for all emergency procedures done on a single DOS. Narrative required to override limitations.
Anesthesia
D9220	Deep sedation/general anesthesia	Yes (see limitations)	PA not required in the following circumstances: For hospital or ambulatory surgical center POS. In an emergency.¹ For children (ages 0-20), when performed by an oral surgeon or pediatric dentist. Entire procedure is reimbursed under this code (first 30 minutes and any additional minutes). D9221 "each additional 15 minutes" is not a covered service. Not billable to the member. Bill only D9220 for general anesthesia. Not payable with D9230, D9241, or D9248.
D9230	Analgesia, anxiolysis, inhalation of nitrous oxide	No	Allowable for children (ages 0-20), when performed by an oral surgeon or pediatric dentist. Not payable with D9220, D9241, or D9248.
D9241	Intravenous conscious sedation/analgesia	Yes (see limitations)	PA not required in the following circumstances: For hospital or ambulatory surgical center POS. In an emergency.¹ For children (ages 0-20), when performed by an oral surgeon or pediatric dentist. Entire procedure is reimbursed under this code (first 30 minutes and any additional minutes). D9242 "each additional 15 minutes" is not a covered service. Not billable to the member. Bill only D9241 for intravenous sedation. Not payable with D9220, D9230, or D9248.
D9248	Non-intravenous conscious sedation	Yes (see limitations)	Prior authorization not required for children (ages 0-20), when performed by an oral surgeon or pediatric dentist. Not analgesia. Not payable with D9220, D9230, or D9241. Not inhalation of nitrous oxide.
Professional Visits
D9410	House/extended care facility call	No	Reimbursed for professional visits to nursing homes and skilled nursing facilities. Only reimbursed for claims that indicate POS code 31 (skilled nursing facility) or 32 (nursing home). Service is limited to once every 333 days per member. Service must be performed by a Medicaid-certified dentist.
D9420	Hospital call	No	Up to two visits per stay. Only allowable in hospital and ambulatory surgical center POS.
Drugs
D9612	Therapeutic parenteral drugs, two or more administrations, different medications	No
Miscellaneous Services
D9910	Application of desensitizing medicament	No	Tooth numbers 1-32, A-T, 51-82, and AS-TS. Limit of $62.50 reimbursement per DOS for all emergency procedures done on a single DOS. Narrative required to override limitations. Not payable immediately before or after surgery, or periodontal procedures (D4210, D4211, D4341, D4342, D4355, D4910). Cannot be billed for routine fluoride treatment. Emergency only.
D9999	Unspecified adjunctive procedure, by report	Yes	HealthCheck "Other Service." Use this code for unspecified non-surgical procedures with a HealthCheck referral.

¹Retain records in member files regarding nature of emergency.