NEW YORK STATE MEDICAID PROGRAM DENTAL POLICY AND

NEW YORK STATE

MEDICAID PROGRAM

DENTAL

POLICY AND PROCEDURE

CODE

MANUAL

Version 2024

Dental
 
Policy
 
and
 
Procedure
 
Code
 
Manual
 
Version 2024   
Page 2 of 68 
 
 
Table of Contents 
SECTION
 
I
 
-
 
REQUIREMENTS
 
FOR
 
PARTICIPATION
 
IN
 
MEDICAID
 .......................... 3 
Q
UALIFICATIONS
 
OF
 
S
PECIALISTS
 .................................................................................................................................. 3 
G
ROUP
 PROVIDERS ....................................................................................................................................................... 3 
A
PPLICATION
 
OF
 
F
REE
 
C
HOICE
 ...................................................................................................................................... 4 
C
REDENTIAL
 
V
ERIFICATION
 
R
EVIEWS
 ........................................................................................................................... 4 
SECTION II - DENTAL SERVICES ............................................................................... 5 
C
HILDREN
’
S
 
D
ENTAL
 
S
ERVICES
 .................................................................................................................................... 5 
S
TANDARDS
 
OF
 
Q
UALITY
 .............................................................................................................................................. 5 
S
COPE
 
OF
 
H
OSPITALIZATION
 
S
ERVICES
 ......................................................................................................................... 5 
C
HILD
/T
EEN
 
H
EALTH
 
P
ROGRAM
 ................................................................................................................................... 5 
C
HILD
 
H
EALTH
 
P
LUS
 
P
ROGRAM
 .................................................................................................................................... 5 
D
ENTAL
 
M
OBILE
 
V
AN
 ................................................................................................................................................... 5 
R
EQUIREMENTS
 
AND
 
E
XPECTATIONS
 
OF
 
D
ENTAL
 
C
LINICS
 ............................................................................................ 6 
S
ERVICES 
N
OT 
W
ITHIN THE 
S
COPE OF THE 
M
EDICAID 
P
ROGRAM
 ..................................................................................... 7 
S
ERVICES 
W
HICH 
D
O 
N
OT 
M
EET 
E
XISTING 
S
TANDARDS OF 
P
ROFESSIONAL 
P
RACTICE 
A
RE 
N
OT 
R
EIMBURSABLE
 ............... 7 
O
THER 
N
ON
-R
EIMBURSABLE 
S
ERVICES
 .......................................................................................................................... 8 
R
ECORD 
K
EEPING
 .......................................................................................................................................................... 8 
L
OCUM 
T
ENENS 
A
RRANGEMENTS
 ................................................................................................................................... 8 
M
ISCELLANEOUS 
I
SSUES
 ................................................................................................................................................ 9 
SECTION III - BASIS OF PAYMENT FOR SERVICES PROVIDED............................ 10 
P
AYMENT
 
FOR
 
S
ERVICES
 
N
OT
 
L
ISTED
 
ON
 
THE
 
D
ENTAL
 
F
EE
 
S
CHEDULE
 ....................................................................... 10 
P
AYMENT
 
FOR
 
S
ERVICES
 
E
XCEEDING
 
THE
 
P
UBLISHED
 
F
REQUENCY
 
L
IMITATIONS
 ....................................................... 10 
P
AYMENT
 
FOR
 
O
RTHODONTIC
 
C
ARE
 ........................................................................................................................... 10 
M
ANAGED
 
C
ARE
 ......................................................................................................................................................... 10 
D
ENTAL
 
S
ERVICES
 
I
NCLUDED
 
IN
 
A
 
F
ACILITY
 
R
ATE
 ..................................................................................................... 10 
PAYMENT IN FULL ...................................................................................................................................................... 11 
P
REPAYMENT
  REVIEW ................................................................................................................................................ 12 
T
HIRD
-P
ARTY
 
I
NSURERS
 ............................................................................................................................................. 12 
U
NSPECIFIED
 
P
ROCEDURE
 
C
ODES
 ............................................................................................................................... 12 
PRIOR AUTHORIZATION CHECKLIST……………………………………………………………………………...13 
P
RIOR
 
A
PPROVAL
 
/
 
P
RIOR
 
A
UTHORIZATION
 
R
EQUIREMENTS
 ........................................................................................ 14 
R
ECIPIENT
 
R
ESTRICTION
 
P
ROGRAM
 ............................................................................................................................. 16 
U
TILIZATION
  THRESHOLD ........................................................................................................................................... 16 
SECTION IV – DEFINITIONS AND CONTACTS ................................................................. 16 
A
TTENDING
  DENTIST, REFERRAL, MEDICALLY NECESSARY ........................................................................................ 16 
SECTION
 
V
 
-
 
DENTAL
 
PROCEDURE
 
CODES
 ........................................................... 17 
G
ENERAL
 
I
NFORMATION
 
AND
 
I
NSTRUCTIONS
 ............................................................................................................... 18 
I. 
DIAGNOSTIC
 
D0100
 
-
 
D0999
 ...................................................................................... 20 
II. 
PREVENTIVE
 
D1000
 
-
 
D1999
 ..................................................................................... 24 
III. 
RESTORATIVE
 
D2000
 
-
 
D2999
 ................................................................................... 28 
IV. 
ENDODONTICS
 
D3000
 
-
 
D3999
 .................................................................................. 31 
V. 
PERIODONTICS
 
D4000
 
-
 
D4999
 ................................................................................. 33 
VI. 
PROSTHODONTICS
 
(REMOVABLE)
 
D5000
 
-
 
D5899
 ................................................ 35 
VII. 
MAXILLOFACIAL
 
PROSTHETICS
 
D5900
 
-
 
D5999
 ..................................................... 38 
VIII. 
IMPLANT
 
SERVICES
 
D6000
 
-
 
D6199
 ......................................................................... 39 
IX. 
PROSTHODONTICS,
 
FIXED
 
D6200
 
-
 
D6999
 .............................................................. 44 
X. 
ORAL
 
AND
 
MAXILLOFACIAL
 
SURGERY
 
D7000
 
-
 
D7999
 ......................................... 46 
XI. 
ORTHODONTICS
 
D8000
 
-
 
D8999
 ............................................................................... 53 
XII. 
ADJUNCTIVE
 
GENERAL
 
SERVICES
 
D9000
 
-
 
D9999
 ................................................ 60 
APPENDIX (IDD POPULATION-SPECIFIC REIMBURSEMENT) ............................................... 67 
 
 
 

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Section I - Requirements for Participation in Medicaid

Dental providers must be licensed and currently registered by the New York State Education

Department (NYSED), or, if in practice in another state, by the appropriate agency of that state,

and must be enrolled as providers in the New York State Medicaid program. No provider who

has been excluded from the Medicaid program may receive reimbursement by the

Medicaid program, either directly or indirectly, while such sanctions are in effect.

Qualifications of Specialists

A specialist is one who:

• Is a diplomat of the appropriate American Board; or,

• Is listed as a specialist in the American Dental Directory of the American Dental

Association section on “character of practice”; or,

• Is listed as a specialist on the roster of approved dental specialists of the New York State

Department of Health (DOH).

All dental providers enrolled in the Medicaid program are eligible for reimbursement for all types

of services except for orthodontic care, dental anesthesia, and those procedures where a

specialty is indicated. There is no differential in levels of reimbursement between general

practitioners and specialists.

• Orthodontic care is reimbursable only when provided by a board certified or board eligible

orthodontist or an Article 28 facility which have met the qualifications of the DOH and are

enrolled with the appropriate specialty code.

• General anesthesia, parenteral and enteral conscious sedation are reimbursable only

when provided by a qualified dental provider who has the appropriate level of certification

in dental anesthesia by the NYSED. The NYSED issues five separate certificates:

i. General Anesthesia Certificate, which authorizes a licensed dentist to employ

conscious (moderate) sedation (enteral or parenteral route with or without

inhalation agents), deep sedation, and general anesthesia;

ii. Dental Parenteral Conscious (Moderate) Sedation for patients 13 years old

and older, which authorizes a licensed dentist to employ conscious (moderate)

sedation (enteral or parenteral route with or without inhalation agents) on all

patients 13 years old and older;

iii. Dental Parenteral Conscious (Moderate) Sedation for patients 12 years old

and younger, which authorizes a licensed dentist to employ conscious (moderate)

sedation (enteral or parenteral route with or without inhalation agents) on all

patients;

iv. Dental, Enteral Conscious (Moderate) Sedation for patients 13 years old and

older, which authorizes a licensed dentist to employ conscious (moderate)

sedation (enteral route only with or without inhalation agents) on all patients 13

years old and older; and

v. Dental Enteral Conscious (Moderate) Sedation for patients 12 years old and

younger, which authorizes a licensed dentist to employ conscious (moderate)

sedation (enteral route only with or without inhalation agents) on all patients.

Additional information is located on the following New York State Education Department website

(NYSED.gov): Dental Anesthesia/Sedation | Office of the Professions (nysed.gov)

Group Providers

A group of practitioners is defined in 18 NYCRR 502.2 as:

“…two or more health care practitioners who practice their profession at a common

location (whether or not they share common facilities, common supporting staff, or

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common equipment).”

Regardless of the arrangement among practitioners (associates, employer-employee, principal-

independent contractor), practitioners who practice in a group setting are required to enroll as a

group and to comply with the requirements associated with group practices.

Regardless of the nature of the practice (group, employer-employee, associate, etc.), the name,

NPI and other required information of the dentist actually providing the service or treatment

must be entered in the “Servicing Provider” or “Treating Dentist” field on all claims and prior

approval requests. Except for FEE-FOR-SERVICE (FFS) billing by institutions, including Article

28, and Diagnostic and Treatment centers, all private FFS dental claims should list the treating or

servicing dentist as the biller when submitting for services rendered. Payments can be designated

to be made to a group, if desired, by entry of the group information in a separate field. Please

refer to the section “Requirements and Expectations of Dental Clinics” for Institutional FFS billing.

Initial and periodic exam (D0120, D0145, and D0150) frequency limitations will be applied to a

claim based on the member’s exam history within the group when the servicing provider has a

group affiliation.

Application of Free Choice

A Medicaid member is guaranteed free choice of a dental provider in obtaining the dental care

available under the New York State Medicaid program.

Credential Verification Reviews

Credential Verification Reviews (CVRs) are periodic onsite visits of a provider’s place of business

to ensure overall compliance with Medicaid regulations. These visits are conducted by the

Medicaid program and the Office of the Medicaid Inspector General (OMIG), and assess such

areas as:

• provider and staff identification and credentialing

• physical attributes of the place of business

• recordkeeping protocols and procedures regarding Medicaid claiming.

CVRs are conducted for such sites as:

• medical and dental offices

• pharmacies

• durable medical equipment retailers, and

• part time clinics.

CVRs are not performed at hospitals, nursing homes, etc.

Every effort is made to conduct these visits in a professional and non-obtrusive manner.

Investigators conducting these reviews will have a letter of introduction signed by the Office of the

Medicaid Inspector General (OMIG) and a photo identification card.

Should providers, or their staff, have questions regarding these Credential Verification Reviews,

they can contact:

The New York State Office of the Medicaid Inspector General

Division of Medicaid Investigations

1-877-873-7283

Additional information on OMIG protocols can be found at: https://omig.ny.gov/audit/audit-

protocols.

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Section II - Dental Services

Dental Care in the Medicaid program shall include only ESSENTIAL SERVICES rather than

comprehensive care. The provider should use this Manual to determine when the Medicaid

program considers dental services "essential". The application of standards related to individual

services is made by the DOH when reviewing individual cases.

Children’s Dental Services

A child is defined as anyone under age 21 years.

Standards of Quality

Services provided must conform to acceptable standards of professional practice.

Quality of Services Provided

Dental care provided under the Medicaid program must meet as high a standard of quality as can

reasonably be provided to the community-at-large. All materials and therapeutic agents used or

prescribed must meet the minimum specifications of the American Dental Association and must

be acceptable to the State Commissioner of Health. Experimental procedures are not

reimbursable in the Medicaid program.

Scope of Hospitalization Services

Medicaid members are provided a full range of necessary diagnostic, palliative, and therapeutic

inpatient hospital care, including but not limited to dental, surgical, medical, nursing, radiological,

laboratory and rehabilitative services.

Limitations of Hospitalization

Medicaid utilization review (UR) agents are authorized to review the necessity and

appropriateness of hospital admissions and lengths of stay, and to determine Medicaid benefit

coverage. These review agents will review inpatient dental services both on a pre-admission and

retrospective basis. Emergency admissions may be reviewed retrospectively for necessity and

appropriateness.

If you have any questions regarding specific Medicaid hospital review requirements, you may

contact the DOH, Bureau of Hospital and Primary Care Services at: (518) 402-3267

Child/Teen Health Program

Please refer to the New York Medicaid Child/Teen Health Program (C/THP) Provider Manual

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) available at the following

website: https://www.emedny.org/ProviderManuals/index.aspx.

Child Health Plus Program

The goal of the Child Health Plus Program is to improve child health by increasing access to

primary and preventive health care through a subsidized insurance program. A child eligible for

Medicaid is not eligible for Child Health Plus.

For more information on benefits, contact the Child Health Plus Program at: (800) 698-4543

Dental Mobile Van

The use of mobile vans to provide the operatories for the provision of dental services is

commonplace. All claims for services rendered in a mobile unit must have the corresponding

Place of Service code which identifies this type of location. That is, the use of a mobile unit (POS

- 15). The correct POS code must be reported on every claim. Reporting the incorrect place of

service could result in inaccurate payment, audit review and/ or ensuing disallowances.

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Please refer to the Centers for Medicare and Medicaid Services website (CMS.gov) for additional

information: Place of Service Code Set | CMS

Requirements and Expectations of Dental Clinics

Dental clinics licensed under Article 28 reimbursed on a rate basis or through APG’s (e.g., hospital

outpatient departments, diagnostic and treatment centers, and dental schools) are required to

follow the policies stated in the Dental Policy and Procedure Code Manual and should use this

Manual to determine when dental services are considered "essential" by the Medicaid program.

Except for implants, implant related services and orthodontic treatment, clinics and schools are

exempt from the prior approval procedure because of internal quality assurance processes that

ensure their compliance with existing Medicaid policy.

The provision of dental care and services are limited to those procedures presented in the Dental

Policy and Procedure Code Manual and are to be provided within the standards and criteria

listed in the procedure code descriptions.

Dental care provided under the Medicaid program includes only essential services (rather than

“comprehensive” services).

Non-emergency initial visits should include a cleaning, radiographic images (if required), and a

dental examination with a definitive treatment plan. Generally, this should be accomplished in one

visit. However, in rare instances, a second visit may be needed for completion of these services.

A notation in the record to indicate the necessity for a second visit should be made.

Public health programs in schools, Head-Start Centers, dental schools, clinics treating those

individuals identified with a Restriction Exception code of RE 81 (“TBI Eligible”) or RE 95

(“OPWDD/Managed Care Exemption”) and other settings are exceptions that may require more

than one visit to complete the above-mentioned services.

Quadrant dentistry should be practiced, wherever practicable, and the treatment plan followed in

normal sequence.

Procedures normally requiring multiple visits (e.g., full dentures, partial dentures, root canals,

crowns, etc.) should be completed in a number of visits that would be considered consistent with

the dental community at large and the scope of practice of the provider. If additional visits are

required, a notation in the member’s treatment record to indicate the necessity for each additional

visit must be made.

Procedures normally completed in a single visit (examination, prophylaxis, x-rays, etc.) but which

require additional visits must include a notation in the member’s treatment record documenting

the justification for the additional visit.

When billing:

• For Article 28 and Diagnostic and Treatment Centers (D&TC) facilities, the institution may

be the billing provider, but the rendering /treating provider must be listed on the claim in the

appropriate field.

• Clinics billing using Ambulatory Payment Group methodology should submit a FEE-FOR-SERVICE

(FFS) claim only when billing for orthodontic services (D8000 – D8999) and implant and specified

implant-related services (D6010-D6199). Prior approval is required for orthodontic services,

implants, and specified implant-related services.

• Except for FEE-FOR-SERVICE (FFS) billing by institutions, including Article 28, and Diagnostic

and Treatment centers, all private FFS dental claims should list the treating or servicing dentist as

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the biller when submitting for services rendered. Payments can be designated to be made to a

group, if desired, by entry of the group information in a separate field.

• Practitioners can submit a professional claim in the inpatient, Emergency Department, and

Ambulatory Surgery settings.

• The supervising provider at a dental school must be a Medicaid enrolled provider who will

be responsible for the treatment rendered. This individual could be an attending clinical

instructor, dental department chair, or dean of a dental school.

• Certify that the services were provided.

• For specific instructions, please refer to the Dental Billing Guidelines at: https://www.emed

ny.org/ProviderManuals/Dental/index.aspx or contact eMedNY - (800) 343-9000.

Services Not Within the Scope of the Medicaid Program

These services include but are not limited to:

• Fixed bridgework, except for cleft palate stabilization, or when a removable prosthesis

would be contraindicated.

• Immediate full or partial dentures.

• Crown lengthening, except when associated with medically necessary crown or endodontic

treatment.

• Dental work for cosmetic reasons or because of the personal preference of the member or

provider.

• Periodontal surgery, except when associated with implants or implant related services.

• Gingivectomy or gingivoplasty, except for the sole correction of severe hyperplasia or

hypertrophy associated with drug therapy, hormonal disturbances, or congenital defects.

• Adult orthodontics, except in conjunction with, or as a result of, approved orthognathic

surgery necessary in conjunction with an approved course of orthodontic treatment or the

on-going treatment of clefts.

• Placement of sealants for members under 5 or over 15 years of age.

• Improper usage of panoramic images (D0330) along with intraoral complete series of

images (D0210).

Services Which Do Not Meet Existing Standards of Professional Practice Are Not

Reimbursable

These services include but are not limited to:

• Partial dentures provided prior to completion of all Phase I restorative treatment which

includes necessary extractions, removal of all decay and placement of permanent

restorations.

• Other dental services rendered when teeth are left untreated.

• Extraction of clinically sound teeth.

• Treatment provided when there is no clinical indication of need noted in the

treatment record. Procedures should not be performed without documentation of clinical

necessity. Published “frequency limits” are general reference points on the anticipated

frequency for that procedure. Actual frequency must be based on the clinical needs of the

individual member.

• Restorative treatment of teeth that have a hopeless prognosis and should be extracted.

• Taking of unnecessary or excessive radiographic images.

• Services not completed and,

• “Unbundling” of procedures.

• Treatment of deciduous teeth when exfoliation is reasonably imminent.

• Extraction of deciduous teeth without clinical necessity.

o Claims submitted for the treatment of deciduous cuspids and molars for children

ten (10) years of age or older, or for deciduous incisors in children five (5) years of

age or older will be pended for professional review. As a condition for payment, it

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may be necessary to submit, upon request, radiographic images, and other

information to support the appropriateness and necessity of these restorations.

Other Non-Reimbursable Services

Services associated with a non-approved procedure may not be considered for reimbursement.

Record Keeping

Health professionals are required to maintain records for each patient that accurately reflect the

evaluation and treatment of the patient according to section 29.2(a)(3) of the Rules of the Board

of Regents. Recipient medical histories should be updated periodically (annually at a minimum)

and be maintained as part of the recipient’s dental records. The treating practitioner should refer

to the recipient’s medical/dental history and treatment record to avoid unnecessary repetition of

services. Please refer to NYSED.gov for further information: NYS Dentistry:Practice Guidelines

(nysed.gov)

The patient’s Dental Record is to include:

• Medical History;

• Dental History (including dated treatment plans, identification of all pathology present);

• Dental Charting;

• Radiographs;

• Study Models (if taken);

• Copies of all prescriptions and invoices (pharmacy / lab);

• All correspondences;

• Consultation and referral reports; and,

• Signed consent and HIPAA forms;

• Justification of Need for Replacement Prosthesis Form and Evaluation of the Dental Implant Patient

Form (if used).

Treatment notes are to include the following for each dental appointment:

• Accurate and detailed description of all services rendered including the identification of

the healthcare professional providing the service(s);

• Documentation of diagnosis/reason for procedure;

• Documentation of the materials used;

• Date (and time when appropriate) of visit and signature or initials of the team member

writing the entry;

• Instructions to the patient;

• Drugs administered / prescription (includes all anesthesia provided);

• Unusual reactions;

• Cancellations / missed appointments;

• Telephone conversations (date and time);

• Patient comments and complaints;

• Referrals made;

• Referrals not followed or refused; and,

• General anesthesia / I.V. sedation reports. Note: Reports must include start and stop

times for:

o Anesthetic provided; and,

o Operative treatment provided.

Claims and prior authorization requests must be complete. All attachments must be

labeled with patient and provider identification and date.

Locum Tenens Arrangements

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Federal law requires that payment for services be made to the provider of service. An exception

to this requirement may be made when one dentist arranges for another dentist to provide

services to his/her patients under a locum tenens arrangement.

The law allows such locum tenens arrangements:

• On an informal, reciprocal basis for periods not to exceed 14 days, or;

• For periods of up to 90 days with a more formal agreement.

Record of either arrangement must be maintained in writing to substantiate locum tenens

payment.

Locum tenens arrangements should not be made with any dentists who are not enrolled or have

been disqualified by the New York State Medicaid program.

Miscellaneous Issues

Radiographic images should be clear and allow for diagnostic assessment. They are performed

based on need, age, prior dental history, and clinical findings. All radiographic images, whether

digitalized or conventional, must be of good diagnostic quality, properly dated and positionally

mounted including accurate right/left orientation, and identified with the member's name and

provider name and address. The cost of all materials and equipment used shall be included in

the fee for the image.

Medicaid claims payment decisions for types, numbers and frequency of images will be related

to the needs of the individual member, dental age, past dental history and, most importantly,

clinical findings. Guidelines on the selection of members for Dental radiographic examination can

be obtained from the American Dental Association (ADA) or the U.S. Department of Health and

Human Services, Food and Drug Administration (FDA).

Good quality, diagnostic, duplicate radiographic images, must be made available for review upon

request of the New York State Department of Health (NYSDOH) or the Office of the Medicaid

Inspector General (OMIG). There is no reimbursement for duplication of images. If original

radiographs are submitted, they will be returned after each review. Other types of images that can

be readily reproduced will not be returned. All images must be retained by the provider for a

minimum of six years, or the minimum duration prescribed by law, from the date of payment.

Facilities should use the NYS Medicaid Exclusion List when checking and verifying the credentials

of the dental professionals that make up their staff. The NYS Medicaid Exclusion List is currently

available on the OMIG website at: https://omig.ny.gov/medicaid-fraud/medicaid-exclusions.

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Section III - Basis of Payment for Services Provided

It is the provider’s responsibility to verify each member’s eligibility at EVERY appointment.

Even when a service has been prior approved / prior authorized, the provider must verify a

member’s eligibility via the MEVS before the service is provided and comply with all other service

delivery and claims submission requirements described in each related section of the provider

manual.

Payment for dental services is limited to the lower of the usual and customary fee charged to the

general public or the fee developed by the DOH and approved by the New York State Director of

the Budget. The Dental Fee Schedule is available online at: http://www.emedny.org

/ProviderManuals/Dental/index.aspx.

Claims must be submitted when the product or service is completed and delivered to the member

with the appropriate procedure code, using the date that the service is actually completed and

delivered as the date of service. Treatment submitted on claims must be supported in the patient

record by documentation of medical need.

Payment for Services Not Listed on the Dental Fee Schedule

If an "essential" service is rendered that is not listed in the fee schedule, the fee will be determined

by the DOH, which will use the most closely related service or procedure in the fee schedule as

the basis for determining such fee.

Payment for Services Exceeding the Published Frequency Limitations

Reimbursement for services that exceed the published frequency limitations but that are

determined to be medically necessary following professional review may be considered.

Payment for Orthodontic Care

When Prior Approval is obtained for orthodontic care for severe physically handicapping

malocclusions, the care will be reimbursed for an eligible member for a maximum of three years

of active orthodontic care plus one year of retention care. Cleft palate or approved orthognathic

surgical cases may be approved for additional treatment time. Treatment not completed within

the maximum allowed period must be continued to completion without additional compensation

from the NYS Medicaid program, the member or family.

Managed Care

If a member is enrolled in a Managed Care Plan which covers the specific care or services being

provided, it is inappropriate to bill such services to the Medicaid program on a fee- for-service

basis whether or not prior approval has been obtained. At the time of this publication, School

Based Health Center services are carved out of Managed Care and should be billed as Fee-for-

Service.

Dental Services Included in a Facility Rate

Article 28 facilities must adhere to the program policies as outlined in this manual.

Hospital In-Patient

The “professional component” for dental services can be reimbursed on a fee-for- service basis.

Payment for those services requiring prior approval / prior authorization is dependent upon

obtaining approval from the Department of Health or the Medicaid Managed Care Plan. Refer to

the prior approval section of this manual and the Prior Approval Guidelines located on the

eMedNY.org website for additional information on how to obtain prior approval: https://www.

emedny.org/ProviderManuals/Dental/index.aspx.

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Out-Patient Services

Clinic: Dental services rendered in outpatient clinics are reimbursed using an “Ambulatory

Patient Groups (APG)” payment methodology and include both the facility and professional

reimbursement. There is no fee-for-service billing allowed.

Ambulatory Surgery and Emergency Room: The “professional component” for dental services

can be reimbursed on a fee-for-service basis. Payment for those services requiring prior approval

/ prior authorization is dependent upon obtaining approval from the Department of Health or the

Medicaid Managed Care Plan. Refer to the prior approval section of this manual and the Prior

Approval Guidelines located on the eMedNY.org website for additional information on how to

obtain prior approval.

Ambulatory Surgical Centers submitting an Ambulatory Patient Group (APG) claim to NYS

Medicaid should indicate the number of units on the claim line for CPT code "41899" based on

the duration of the encounter, up to a maximum of four units for those individuals identified with a

recipient exception code of “RE 81” (“TBI Eligible”) or “RE 95” (OPWDD/Managed Care

Exemption”), using guidance provided in the July 2023 Medicaid Update, found at New York

State Medicaid Update - July 2023 Volume 39 - Number 12 (ny.gov).

OMH Psychiatric Centers: Dental services are included in the facility rates. Payment for services

in such facilities will not be made on a fee-for-service basis.

It is the responsibility of the facility to make arrangements for the provision of all dental services

listed in the Provider Manual either within the facility or with area providers. Claims should not be

submitted by either the provider(s) or facility for covered dental services or for transportation.

Intermediate Care Facilities (ICF)-DD: ICF-DD providers should contact OPWDD for guidance

on billing for dental services for their residents.

Residential Health Care Facilities (RHCF’s)

• In State: Dental services are included in the facility rates. Payment for services to residents

of such facilities will not be made on a fee-for-service basis. It is the responsibility of the

facility to make arrangements for the provision of all dental services listed in the Provider

Manual either within the facility or with area providers. Claims should not be submitted by

either the provider(s) or facility for covered dental services or for transportation.

• Out of State: It is the responsibility of the out-of-state RHCF to inform the provider if

dental services are included in the rate.

Payment in Full

Fees paid by the Medicaid program shall be considered full payment for services rendered.

Review general policy “When Medicaid Enrollees Cannot be Billed” at

https://www.emedny.org/ProviderManuals/AllProviders/PDFS/Information_for_All_Providers-

General_Policy.pdf.

Except for appropriate co-pay’s, no additional charge may be made by a provider.

Additional guidance can be found at

https://www.health.ny.gov/health_care/medicaid/program/update/2014/2014-02.htm#bill

Providers are mandated to comply and adhere with NYS Medicaid prior approvals and claims

submission protocols. Patients cannot be billed and charged due to providers’ lack of compliance

with these policies. Providers are prohibited from charging any additional amount for a service

billed to the Medicaid program. Medicaid members cannot be charged for broken or missed

appointments.

A dentist may enter into a private pay agreement with a Medicaid member. This agreement must

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be in writing and mutually agreed upon prior to the start of treatment; these guidelines must be

followed:

• The member must be informed of alternative treatment plans, including procedures

covered by the Medicaid Program or procedures that require prior authorization by the

NYS DOH or Medicaid Managed Care Plan, the advantages and disadvantages of each,

as well as the expense and financial responsibilities of each (If any of the procedures in

the treatment plan require prior approval from the Medicaid Program, the provider is

encouraged to submit the necessary forms and documentation for review and

determination, which may eliminate the need for a private payment agreement and

Medicaid could cover the procedure(s) in full);

• The NYSDOH (Medicaid Program) will not review a prior approval request, or render any

opinion, associated with a private pay agreement after treatment has been started;

• The member must have full understanding and consent that there may be

service(s) or alternatives that could be provided through Medicaid coverage

without any expense to them.

• The member is responsible for 100% of the entire fee. There cannot be any

payment from Medicaid;

• The provision of this service might alter future benefits available through

Medicaid (e.g., if payment is made through a private payment agreement for root

canal(s) therapy, the member might not qualify for a partial denture and/or crowns

for these teeth either now or in the future that they might otherwise be eligible for);

and,

• The member may be responsible for any subsequent or associated expenses.

Prepayment Review

The DOH and OMIG reserve the right to pend any claim(s) for review prior to payment without

notification.

Third-Party Insurers

Third-party insurers (including Medicare) provide reimbursement for various dental procedures.

Since Medicaid is the payer of last resort, the provider must bill the member’s third-party payers

prior to requesting payment from Medicaid. Prior to initiating treatment which has been approved

by a third-party insurance plan, the provider should obtain a prior approval from Medicaid to

ensure that the treatment plan falls within the current guidelines of the Medicaid Program. Failure

to do so may result in the denial of Medicaid benefits for these services.

If the third party is a commercial plan, Medicaid will reimburse the difference only if the total third-

party payment(s) is (are) less than the lesser of the provider’s fee charged to the general public

or the fee developed by the DOH for the specific procedure code. If the third party is a Medicare

Advantage plan, Medicaid will reimburse one hundred percent (100%) of the deductible and

eighty-five percent (85%) of the coinsurance/copay.

Under the Medicare Physician Fee Schedule, the Centers for Medicare and Medicaid Services

(CMS) issued new regulations for payment for dental services that are inextricably linked to

certain covered medical services, such as dental exams and necessary treatments prior to organ

transplants, cardiac valve replacements, valvuloplasty procedures, and treatment for head and

neck cancers. For more information, visit the CMS website Medicare Dental Coverage | CMS.

Unspecified Procedure Codes

Unspecified procedure codes at the end of each section of the fee schedule are miscellaneous

codes applicable to procedures within the scope of the Medicaid program, but for which suitable

procedure codes do not currently exist.

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PRIOR AUTHORIZATION CHECKLIST

To avoid unnecessary delays when requesting prior authorization, please use this

checklist to help ensure you provide adequate documentation. In this manual, procedures

requiring prior approval have underlined CDT codes. You must include the reason

(medical necessity) for all treatment requested on prior authorizations.



Accurate pre-treatment charting is required. Charting must clearly depict all existing

restorations, prosthetics, and missing natural teeth, including implants and implant-

supported crowns/prosthetics and should be submitted on a tooth chart/graphic

depiction.



Complete treatment plan is required. When any portion of a treatment plan requires

prior approval, the complete treatment plan listing all necessary procedures, whether

or not they require prior approval, must be listed.



Radiographs of good diagnostic quality are required and must clearly show all current

conditions and allow for evaluation, supporting diagnosis/treatment plan of the entire

dentition. All radiographs must be labeled with patient’s name and date of image taken

and should be labeled (left/right side). Full mouth series should be sent in a single

mount to facilitate visualization of the entire mouth. Radiographs are required for initial

fabrication of full dentures (or first Medicaid full denture request). Radiographic images

are not routinely required to obtain prior approval for sealants, denture re-base, etc.



Additional Supporting Information:

An accompanying narrative supporting Medical Necessity should include a

diagnosis.

The current condition of existing crowns and prosthetics must be described,

indicating status and prognosis. Include the reason any replacement is

requested.

Relevant Medical History, Dental history, Record of Patient Compliance, Caries

Index, Intraoral Photos, Documented Symptoms, Endodontic Testing notes, and

Periodontal Status may be submitted as supporting documentation for prior

authorization requests to establish Medical Necessity.

If prior authorization is requested for endodontic procedures where no periapical

radiolucency is evident on images, include a narrative.

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Prior Approval / Prior Authorization Requirements

Prior approval / prior authorization does not ensure payment. The provider must verify a

member’s eligibility before every appointment and comply with all other service delivery and

claims submission requirements described in each related section of the provider manual.

Claims for fixed and removable prosthetics (including implant related prosthetics) and

endodontics are not to be submitted until the approved procedure code is completed.

Prior authorization is required through the use of the Dispensing Validation System (DVS) when

specified. These specifications are indicated after the procedure code description by the following:

(DVS REQUIRED)

When DVS is required, providers must place the DVS prior authorization number on the claim. If

DVS rejects the request due to service limits exceeded, a prior approval is required. The prior

approval request must include medical documentation as to why the service limit needs to be

exceeded. Prior approval requests received where the provider has not requested prior

authorization through DVS will be rejected and returned to the provider.

Procedures that require prior approval, or where a DVS over-ride is required, must not begin until

the provider has received approval from the DOH. When any portion of a treatment plan requires

prior approval, the complete treatment plan listing all necessary procedures, whether or not they

require prior approval, must be listed, and coded on the prior approval request form. Any

completed treatment which is not evident on submitted images should be noted. No treatment

other than provision of symptomatic relief of pain and/or infection is to be instituted until such time

as cases have been reviewed and a prior approval determination made.

All prior approval requests must include accurate pretreatment charting clearly depicting all

existing restorations and missing natural teeth. Any existing fixed or removable prosthetic

appliances should be noted, and their current conditions described, and the date of initial

placement noted. If applicable, a complete medical history, nutritional assessment, certification of

employment, and any other pertinent information that will assist in determining the necessity and

appropriateness of the proposed treatment plan should be submitted. The treatment requested

must be substantiated by the submitted medical documentation and not primarily for the

preference of the client or provider.

The approved treatment plan, in its entirety, must be adhered to. Any alteration of the approved

course of treatment may render the entire approval null and void and subject to recoupment.

Changes to an approved course of treatment should be submitted to NYSDOH by using a “Prior

Approval Change Request Form”.

If a change is needed or there is a disagreement with a prior approval review and you would like

to challenge a determination rendered by the DOH on an existing finalized prior approval, a

request may be submitted with supporting documentation and a detailed report using a “Prior

Approval Change Request Form”. This form may be submitted pre- or post-operatively. If the

requested change is submitted post-operatively a copy of the treatment notes should be included

with the request.

The Prior Approval Change Request Form can be found at: https://www.emedny.org

/info/phase2/paper.aspx, or by calling eMedNY at (800) 343-9000.

The minimum number of pre-treatment radiographic images needed to clearly show all

current conditions, and which allow for the proper evaluation and diagnosis of the entire

dentition must accompany all requests for prior approval. Radiographic images are not routinely

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required to obtain prior approval for replacement full dentures, sealants, denture re-base, etc. The

previously referenced guidelines on the selection of members for radiographs should be followed.

Payment for multiple restorations which are placed in teeth subsequently determined to need

extraction as part of an approved prosthetic treatment plan is not acceptable if the restorations

were provided less than six months prior to the date of the prior approval request for the

prosthesis.

When a treatment plan has been denied, services that were a portion of that plan may not be

reimbursable, or subsequently prior approved.

For non-emergency treatment, the same prior approval guidelines apply when treatment is being

rendered by a specialist. If the member is referred to a specialist for treatment requiring prior

approval, the referring provider can obtain the prior approval for use by the specialist, or the

specialist can submit his/her own request.

When Prior Approval is required

For professional dental services, payment for those listed procedures where the procedure code

number is underlined and listed as (PA REQUIRED) is dependent upon obtaining the approval of

the Department of Health or the Medicaid Managed Care Plan prior to performance of the

procedure. If such prior approval is not obtained, no reimbursement will be made.

For information on completion and submission of prior approval requests refer to the Prior

Approval Guidelines at: https://www.emedny.org/ProviderManuals/Dental/index.aspx.

Prior approval does not guarantee payment. It should be noted that:

• Prior approval requests will automatically be rejected if there is no response to a request

for additional information and the provider notified. The request will

be reactivated without

submitting a new request provided that the information is returned using the “Return

Information Routing Sheet” provided with the original

request for information.

• Prior approval requests may be denied if there is incomplete or insufficient response to a

request for additional information.

• Dental providers may submit documents stored in a digitized format (x-rays, treatment

plans, charting, photographs, etc.) as electronic attachments to dental prior approval

requests when submitted through ePACES. This enhanced feature is currently only

available through ePACES. The following file formats are currently supported: JPEG;

TIF; PDF; PNG; and GIF. For more information on ePACES, or to enroll, please contact

the eMedNY Call Center at (800) 343-9000.

• Back-dated prior approval can be issued on an exception basis, such as when eligibility

has been back-dated and treatment requiring prior approval has already been rendered.

The following guidelines apply:

o The request must be received within 90 days of the date of treatment.

o There is NO guarantee that the request will be approved or back-dated even if

treatment has already begun and / or completed.

o Treatment already rendered will NOT change the review criteria. Approval will not

be issued that wouldn't have been approved otherwise.

o The same documentation must be submitted as any other request (complete

treatment plan, sufficient radiographic images to allow for the evaluation of the

entire dentition, charting, etc.) as appropriate for the case.

o Appropriate documentation must be submitted showing that extenuating

circumstances existed warranting back-dating of the request as well as the date

that the service(s) was (were) performed.

o Actions of either the provider or member do not commit the DOH to any particular

course of treatment.

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o Approvals will NOT be issued for the convenience of the provider or member, or

because the provider forgot or didn't realize that prior approval was required.

Emergency Treatment

The provider should refer to the billing guidelines on the eMedNY.org website for claim submission

instructions for emergency services when there is a severe, life threatening, or potentially

disabling condition that required immediate intervention. The billing guidelines are available at:

https://www.emedny.org/ProviderManuals/Dental/index.aspx.

Recipient Restriction Program

Medicaid members with any coverage type (i.e., managed care, fee-for-service) will be reviewed

and those who have been found to have a demonstrated pattern of abusive behavior will be placed

in the recipient restriction program in an effort to control the abuse. Restricted members are

monitored by the Office of the Medicaid Inspector General (OMIG). When the member’s benefit

is administered by a Managed Care Plan, the Managed Care Plan is responsible for identifying

and restricting the member who is abusing their Medicaid benefit. The Managed Care Plan is

required to report any new, re-restricted, or modified restrictions to OMIG for tracking. The

recipient restriction program follows the member when a member’s coverage changes. If a

member is switched to a different Managed Care Plan OMIG will notify the new Managed Care

Plan of the existence of the restriction. The restriction process does not force the member to be

enrolled in a Medicaid Managed Care Plan.

Utilization Threshold

The Utilization Threshold Program (UT) is a post payment review of services and procedures

provided to members that evaluates medical necessity while maintaining fiscal responsibility to

the Medicaid Program. For additional information please see the General Providers Policy Manual

at: Information for All Providers - General Policy (emedny.org)

Section IV - Definitions

For the purposes of the Medicaid program and as used in this Manual, the following terms are

defined to mean:

Attending Dentist

The attending dentist is the dentist who is primarily and continuously responsible for the treatment

rendered.

Referral

A referral is the direction of a member to another provider for advice or treatment.

Medically Necessary

Medically necessary is set forth as “medical, dental and remedial care, services and supplies…”

which are necessary to prevent, diagnose, correct or cure conditions in the person that cause

acute suffering, endanger life, result in illness or infirmity, interfere with such person’s capacity for

normal activity, or threaten some significant handicap…” (New York State Social Services Law §

365-a(2).)

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Questions

• General questions related to the New York State Medicaid Fee-for-Service Dental

Program should be directed to the Office of Health Insurance Programs, Division of

Program Development and Management at (518) 473-2160 or

dentalpolicy@health.ny.gov.

• Providers are encouraged to enroll in ePACES and subsequently submit their prior

approval requests and claims electronically. Prior approval status and claims inquiry can

be checked online via ePACES. Providers who are not enrolled in ePACES can call the

eMedNY Call Center at 1-800-343-9000 with questions regarding prior approvals and

claims. eMedNY customer service representatives will refer appropriate calls to the

Bureau of Dental Review (1-800-342-3005, option #2) if further assistance is required.

• Questions related to New York State Medicaid Managed Care should be directed to the

enrollee's Managed Care Plan.

Section V - Dental Procedure Codes

General Information and Instructions

This section lists those procedure codes and nomenclature listed in the “Current Dental

Terminology (CDT®)” as published by the “American Dental Association (ADA®)” which are

covered services by the NYS Medicaid program. Some procedure descriptions are included for

clarification of Medicaid policy. The CDT should be referenced for a full descriptor of each

procedure.

The dental procedure codes are grouped into sections as follows:

Section

Code Series

Diagnostic

D0100-D0999

II.

Preventive

D1000-D1999

III.

Restorative

D2000-D2999

IV.

Endodontics

D3000-D3999

Periodontics

D4000-D4999

VI.

Prosthodontics, removable

D5000-D5899

VII.

Maxillofacial Prosthetics

D5900-D5999

VIII.

Implant Services

D6000-D6199

IX.

Prosthodontics, fixed

D6200-D6999

Oral and Maxillofacial Surgery

D7000-D7999

XI.

Orthodontics

D8000-D8999

XII.

Adjunctive General Services

D9000-D9999

Miscellaneous Procedures

Q3014

Local anesthesia is considered to be part of the procedure(s) and is not payable separately.

1 - “(REPORT NEEDED)” / “BY REPORT (BR)” PROCEDURES:

Procedures that do not have a published fee are indicated as “By Report” (BR). Procedures with

or without a published fee that are listed as “(REPORT NEEDED)” require professional review for

validation and/or pricing. All claims for these procedures must be submitted with supporting

documentation. Claims submitted without any report/documentation will be denied.

Information concerning the nature, extent, and need for the procedure or service must be

furnished. Appropriate documentation (e.g., operative report, procedure description, and/or

itemized invoices and name/dosage of therapeutic agents) is required. To ensure appropriate

payment in the context of current Medicaid fees, the usual and customary fee charged to the

general public should be billed. Claims should only be submitted AFTER treatment is completed.

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Operative reports must include the following information:

a) Diagnosis;

b) Size, location, and number of lesion(s) or procedure(s) where appropriate;

c) Major surgical procedure and supplementary procedure(s);

d) Whenever possible, list the nearest similar procedure by code number;

e) Estimated follow-up period;

f) Operative time;

g) Specific details regarding any anesthesia provided (this should include start - stop times

and all medications administered).

If documentation needs to be submitted in support of any “(REPORT NEEDED)” / “By Report

(BR)” procedure, the claim MUST be submitted on a paper claim form ‘A’ with the documentation

as an attachment. Attachments must be on paper the same size as the claim form. This

documentation must be maintained in the member’s record and made available upon request.

DO NOT SEND RADIOGRAPHIC IMAGES AS A CLAIM ATTACHMENT. If radiographs are

needed, DOH or OMIG will request that you submit them directly to the reviewing unit. Claim Form

‘A’ can be obtained from eMedNY by calling (800) 343-9000.

2 - DENTAL SITE IDENTIFICATION:

Certain procedure codes require specification of surface, tooth, quadrant, or arch when billing.

These specifications are indicated after the procedure code description by the following

abbreviations:

Specify surface: (SURF)

Specify tooth: (TOOTH)

Specify quadrant: (QUAD)

Specify arch: (ARCH)

When more than one specification is required, both specifications are included, for example:

(SURF/TOOTH).

Only the dental site information required should be provided. Prior approval requests and/or

claims may be rejected when extraneous or incorrect site information is included. Multiple

submission of codes that do not require site designation should be entered on a single line with

the site designation (e.g., tooth, arch, quad) left blank and the number of times performed entered.

A report or narrative should be submitted where applicable.

“Unspecified” procedure codes at the end of each section should not be used for supernumerary

teeth. Refer to the Dental Billing Guidelines, Appendix B, “Code Sets” found at:

https://www.emedny.org/ProviderManuals/Dental/index.aspx for valid values.

3 - “ESSENTIAL” SERVICES:

When reviewing requests for services, the following guidelines will be used:

• Caries index

, periodontal status, recipient compliance, dental history, medical history, and

the overall status and prognosis of the entire dentition, among other factors, will be taken

into consideration when determining medical necessity. Treatment is considered

appropriate when the prognosis of the tooth is favorable. Treatment may be

appropriate where the total number of teeth which require or are likely to require treatment

is not considered excessive or when maintenance of the tooth is considered essential or

appropriate in view of the overall dental status of the recipient.

ADA information on Caries Risk Assessment and Management: Caries Risk Assessment and Management | American Dental

Association (ada.org) and ADA Caries Risk Assessment Tool: Caries Risk Assessment Tool

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• Treatment of deciduous teeth when exfoliation is reasonably imminent will not be routinely

reimbursable. Claims submitted for the treatment of deciduous cuspids and molars for

children ten (10) years of age or older, or for deciduous incisors in children five (5) years

of age or older will be pended for professional review. As a condition for payment, it may

be necessary to submit, upon request, radiographic images and other information to

support the appropriateness and necessity of these restorations. Extraction of deciduous

teeth will only be reimbursed if injection of a local anesthetic is required.

As utilized in this Manual eight (8) posterior points of contact refers to four (4) maxillary and four

(4) mandibular (molars/premolars) in natural or prosthetic functional contact with each other. For

the criteria to be used when determining medical necessity, refer to the following specific sections

of the Manual:

• Crowns (located in Section III);

• Endodontics (Section IV);

• Prosthodontics (Section VI); and

• Implant Services (Section VIII)

4 - INTERRUPTED TREATMENT:

Claims must be submitted when the product or service is completed and delivered to the

member with the appropriate procedure code using the date that the service is actually completed

and delivered as the date of service.

However, in those cases involving multiple appointments to complete the service or product, and

the service or product cannot be completed or delivered, or the member loses eligibility prior to

the completion of the service or delivery of the product, then the appropriate billing code listed

below may be used with the date of the “decisive appointment” as the date of service.

If the "decisive appointment" (listed below) has not been met, or the member was not

eligible on the date of the "decisive appointment", no compensation is available.

Medicaid Fee-For-Service Providers:

The "billing code" in the chart on page 26 can be used with the date of the "decisive appointment"

as the date of service if:

• The service is completed and delivered, but the member lost fee-for-service Medicaid

eligibility after the date of the "decisive appointment" (e.g. lost Medicaid entirely or was

switched to a Managed Care Plan) but prior to the date of delivery; or,

• The service is NOT completed and delivered (e.g. member died, detained for an indefinite

period, etc.) after the date of the decisive appointment. It must be documented that every

reasonable attempt was made to complete and deliver the service.

All claims submitted using the interrupted treatment billing codes will be pended for manual

review. Payment in full may be considered if the supporting documentation demonstrates that the

service was completed and delivered.

Payment, either in full or pro-rated, may be considered if the service is NOT completed and

delivered. The amount of compensation will be determined based on the documentation provided.

Managed Care Plans:

All Medicaid Managed Care Plans, and Essential Plans offering dental services, must continue to

cover any remaining treatments required to complete the procedures listed below if a managed

care enrollee is disenrolled from the plan for any reason (including, but not limited to, losing

Medicaid eligibility, transferring to another plan or voluntary disenrollment) after a decisive

appointment. Such coverage is required even if the member does not qualify for guaranteed

eligibility.

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Type of Service

Approved Multiple

Visit Procedures

Billing

Code

Decisive

Appointment

Space Maintainers

D1510, D1516,

D1517, D1575

D0999

Tooth preparation

Crowns, Posts

D2710-D2792 D2794,

D2952

D2999

Tooth preparation or final post pattern

fabrication and final impression

Root Canal Therapy

D3310-D3348

D3999

Pulp extirpation or debridement to at

least the apical 1/3 of all canals

Complete Dentures

D5110-D5120

D5899

Final impression

Partial Dentures

D5211-D5214 D5225,

D5226

D5899

Final impression

Denture Repair

D5510-D5660

D5899

Acceptance of the prosthesis for repair

Denture Rebase or

Relining

D5710-D5721

D5750-D5761

D5899

Final impression

Other Prosthetic Services

D5820-D5821

D5899

Final impression

Maxillofacial Prosthetics

D5911-D5988

D5999

Final impression

Implant Services

D6052-D6067,

D6094, D6095,

D6110- D6113

D6199

Final impression for the specific

procedure code

Implant Services

D6090, D6091

D6199

Acceptance of prosthesis for repair

Fixed Prosthetics

D6210-D6252

D6545-D6792, D6794

D6999

Preparation and impression of all

abutment teeth

Orthodontic Retention

D8680

D8999

Final impression

Occlusal Guards

D9944, D9945,

D9946

D9999

Final impression

Fee

DIAGNOSTIC

D0100

D0999

CLINICAL

ORAL

EVALUATIONS

The codes in this section recognize the cognitive skills necessary for patient evaluation.

The collection

and recording of some data and components of the dental examination may be delegated;

however, the evaluation, which includes diagnosis and treatment planning, is the responsibility of

the dentist and must be documented in the treatment record. As with all ADA procedure codes,

there is no distinction made between the evaluations provided by general practitioners and

specialists. Report additional diagnostic and/or definitive procedures separately.

Initial and periodic exam (D0120, D0145, and D0150) frequency limitations will be applied to a

claim based on the member’s exam history within the group when the servicing provider has a

group affiliation.

Includes

charting,

history,

treatment

plan,

and

completion

forms.

Orthodontist should ONLY use procedure code D8660 for examinations prior to starting active

care.

Code

Description

D0120

Periodic oral evaluation - established patient

An evaluation performed on a patient of record to determine any changes in

the patient’s dental and medical health status since a previous comprehensive

or periodic evaluation. This includes an oral cancer evaluation, periodontal

screening where indicated, and may require interpretation of information

acquired through additional diagnostic procedures. The findings are discussed

with the patient. Report additional diagnostic procedures separately.

Reimbursement is limited to once per six (6) month period.

$25.25

D0140

Limited oral evaluation – problem focused

$14.14

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Not used in conjunction with a regular appointment. Cannot be billed with

any other evaluation procedure, including but not limited to D9310 and

D9430. Not intended for follow-up care.

D0145

Oral evaluation for a patient under three years of age and counseling

with primary caregiver

Diagnostic services performed for a child under the age of three, preferably

within the first six months of the eruption of the first primary tooth, including

recording the oral and physical health history, evaluation of caries

susceptibility, development of an appropriate preventive oral health regimen

and communication with and counseling of the child’s parent, legal guardian

and/or primary caregiver.

$30.30

D0150

Comprehensive oral evaluation – new and established patient

Can only be billed once per provider-member relationship.

$30.30

D0160

Detailed and extensive oral evaluation – problem focused, by report

(REPORT NEEDED)

This procedure will not be reimbursed if performed within ninety days of

a consultation or any other evaluation by the same provider.

(BR)

DIAGNOSTIC IMAGING

The most current recommendations for prescribing dental radiographs should be followed.

Revised guidance from ADA, HHS, and FDA can be found at: The Selection of Patients for Dental

Radiographic Examinations | FDA.

This information should guide the dentist in the determination of the type of imaging to be used,

the frequency of its use, and the number of images to obtain. All images taken should be medically

necessary and of diagnostic quality, properly identified, and dated. Claims for dental radiographs

may be pended for professional review and are subject to denial unless there is a documented

need of medical necessity. Capture and interpretation of intraoral images are not separately

reimbursed by this program.

When ordering a CT, CTA, MRI, MRA, Cardiac Nuclear, or PET procedure an approval number

through the Radiology Prior Approval Program is required. For additional information refer to:

http://www.emedny.org/ProviderManuals/Radiology/index.html.

Note: The radiology prior approval program does not include procedure code D0367, cone beam

computed tomography. For more information see description of D0367.

Code

Description

D0210

Intraoral - comprehensive series of radiographic images

A radiographic survey of the whole mouth

intended to display

the crowns and roots of all teeth, periapical areas,

interproximal areas and alveolar bone including edentulous

areas. For purposes of the NYS Medicaid program, an

intraoral, comprehensive series (full mouth) consists of at

least ten (10) periapical films plus bitewings.

$50.50

D0220

Intraoral

periapical

first

radiographic

image

To be billed only for the FIRST periapical image and ONLY

when periapical images are taken. Cannot be used in

conjunction with any other type of images on the same date

of service (e.g. bitewing, occlusal, panoramic etc.). If another

type of radiograph is taken on the same day, all the periapical

films must be reported as D0230 (intraoral – periapical each

additional radiographic image).

$8.08

D0230

Intraoral - periapical each additional radiographic

$5.05

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image

When periapical images are taken in conjunction with

bitewing(s), occlusal or panoramic images, use procedure

code D0230 for ALL periapical images including the first

periapical image. The total fee for ALL intraoral

radiographic images (including the first periapical

image) may not exceed the total fee allowed for a

complete intraoral series.

D0240

Intraoral - occlusal radiographic image (ARCH)

One maxillary and one mandibular radiographic image are

allowed within three years. May be supplemented by

necessary intraoral periapical or bitewing images.

$15.15

D0250

Extra-oral - 2D projection radiographic image created

using

a stationary radiation source, and detector

These images include but are not limited to: Lateral Skull;

Posterior-Anterior Skull; Submentovertex; Waters; Reverse

Tomes; Oblique Mandibular Body; Lateral Ramus. Not

reimbursable for Temporomandibular Joint images.

$25.25

D0251

Extra-oral posterior dental radiographic image

Image is limited to exposure of complete posterior teeth in

both dental arches. This is a unique image that is not derived

from another image. Maximum of two images. Not

reimbursable for Temporomandibular Joint images.

Bitewings are allowed no more than once in six months for

each member. The procedure code is an indication of the

number of images performed. Leave the “Times Performed”

on the claim form blank or enter “1”.

$12.12

D0270

Bitewing – single radiographic image

$8.08

D0272

Bitewings – two radiographic images

$14.14

D0273

Bitewings – three radiographic images

$20.20

D0274

Bitewings – four radiographic images

$24.24

D0310

Sialography

$41.41

D0320

Temporomandibular joint arthrogram, including

injection

$175.74

D0321

Other temporomandibular joint radiographic images, by

report (PER JOINT) (REPORT NEEDED)

$29.29

D0330

Panoramic radiographic image

Reimbursable every three years if clinically indicated. For

use in routine caries determination, diagnosis of periapical or

periodontal pathology only when supplemented by other

necessary radiographic intraoral images (bitewing and/or

periapical), completely edentulous cases, diagnosis of

impacted teeth, oral surgery treatment planning, or diagnosis

of children with mixed dentition. Postoperative panoramic

images are reimbursable for post-surgical evaluation of

fractures, dislocations, orthognathic surgery, osteomyelitis,

or removal of unusually large and/or complex cysts or

neoplasms. Panoramic radiographic images are not required

or reimbursable for post orthodontic documentation.

Panoramic images are not reimbursable when an intraoral

complete series or panoramic image has been taken within

three years, except for the diagnosis of a new condition

(e.g., traumatic injury, orthodontic evaluation).

$35.35

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D0340

2D cephalometric radiographic image – acquisition,

measurement and analysis

Image of the head made using a cephalostat to standardize

anatomic positioning, and with reproducible x-ray beam

geometry. Reimbursable every three years if clinically

indicated. Reimbursement is limited to enrolled orthodontists

of oral and maxillofacial surgeons for the diagnosing and

treatment of a physically handicapping malocclusion.

Cephalometric images are not required by the DOH for

routine post-orthodontic documentation and are not routinely

reimbursable. A tracing and analysis are required and are

not payable separately. Use D0252 if a tracing and analysis

is not performed.

$55.55

D0350

2D oral/facial photographic image obtained intra-orally

or extra-orally

Photographs are reimbursable when associated with

procedures described under sections:

• V. PERIODONTICS, limited to gingivectomy or

gingivoplasty, procedure codes D4210, D4211

• VIII. IMPLANTS

• XI. ORTHODONTICS

➢

When requested by the Department Health; and, the fee

includes all intra-oral and extra-oral images taken on the

same date of service.

$12.12

CONE BEAM CT CAPTURE

• Includes axial, coronal and sagittal data.

• Includes all interpretation.

• There is no professional reimbursement for facility place of service. Facility reimbursement is

through APG.

For treatment not involving implants or implant-related services, a panoramic radiograph (D0330)

or similar film, along with documentation of medical necessity, must be submitted with requests

for prior approval. Approval is limited to those cases demonstrating significant risk for a

complication such as nerve injury or jaw fracture, as well as pathology or trauma workups. For

treatment involving implants or implant-related services, refer to section VIII. IMPLANTS.

Code

Description

D0364

Cone beam CT capture and interpretation with limited field of

view – less than one whole jaw (PA REQUIRED)

$281.79

D0365

Cone beam CT capture and interpretation with field of view of

one full dental arch - mandibular (PA REQUIRED)

$281.79

D0366

Cone beam CT capture and interpretation with field of view of

one full dental arch – maxilla, with or without cranium (PA

REQUIRED)

$281.79

D0367

Cone beam CT capture and interpretation with field of view of

both jaws; with or without cranium (PA REQUIRED)

$281.79

D0368

Cone beam CT capture and interpretation for TMJ series

including two or more exposures (PA REQUIRED)

$281.79

D0470

Diagnostic casts

Reimbursement is limited to enrolled orthodontists or oral and

maxillofacial surgeons. Includes both arches when necessary.

$34.34

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ORAL

PATHOLOGY

LABORATORY

These are procedures generally performed in a pathology laboratory and do not include

the removal

of the tissue sample from the patient. For removal of tissue sample, see codes D7285 and D7286.

Reimbursement for procedure codes D0470, D0485 and D0502 are limited to enrolled Oral

Pathologists.

Code

Description

D0474

Accession of tissue, gross and microscopic examination,

including assessment of surgical margins for presence of disease,

preparation and transmission of written report.

$87.87

D0485

Consultation, including preparation of slides from biopsy material

supplied by referring source

$87.87

D0502

Other oral pathology procedures, by report (REPORT NEEDED)

(BR)

D0999

Unspecified diagnostic procedure, by report (REPORT NEEDED)

(BR)

II.

PREVENTIVE

D1000

D1999

DENTAL PROPHYLAXIS

Dental prophylaxis is reimbursable in addition to an initial dental examination and recall

examinations once per six (6) month period. Prophylaxis cannot be used in conjunction with

periodontal maintenance (D4910) or in conjunction with scaling and root planing (D4341) on the

same date of service.

An additional prophylaxis may be considered within a twelve (12) month period for those

individuals identified with a Restriction Exception code of RE 81 (“TBI Eligible”) or RE 95

(“OPWDD/Managed Care Exemption”). The additional prophylaxis should be submitted using the

appropriate procedure code (D1110 or D1120). Documentation supporting necessity must be

submitted with the claim. Reimbursement will not be considered if performed within a four-month

interval of previous prophylaxis (D1110, D1120) or D4910.

Code

Description

D1110

Prophylaxis – adult

Removal of plaque, calculus and stains from tooth structures and

implants in the permanent and transitional dentition. It is intended to

control local irritational factors. For members 13 years of age and older.

$45.45

D1120

Prophylaxis – child

Removal of plaque, calculus and stains from tooth structures and

implants in the primary and transitional dentition. It is intended to control

local irritational factors. For members under 13 years of age.

$43.43

TOPICAL FLUORIDE TREATMENT (OFFICE PROCEDURE)

Topical fluoride treatment is reimbursable when professionally administered in accordance with

appropriate standards. Benefit is limited to gel, foam, and varnish. There must be a minimum

interval of three (3) months between all fluoride treatments (D1206 and/or D1208).

Fluoride treatments that are not reimbursable under the program include:

• Treatment that incorporates fluoride with prophylaxis paste;

• Topical application of fluoride to the prepared portion of a tooth prior to restoration;

• Fluoride rinse or “swish”; and,

• Treatment for desensitization.

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Note: FQHCs who opt out of Ambulatory Patient Groups (APG) cannot bill a separate threshold

rate for Topical Fluoride Application (D1206, D1208) as a standalone procedure at a patient

encounter where no other reimbursable services are delivered.

Code

Description

D1206

Topical application of fluoride varnish

Reimbursable once per three (3) month period for members, from

eruption of first tooth through age 20 (inclusive). For individuals 21 years

of age and older D1206 is only approvable for those individuals identified

with a Restriction Exception code of RE 81 (“TBI Eligible”) or RE 95

(“OPWDD/Managed Care Exemption”), or, in cases where salivary gland

function has been compromised through surgery, radiation, or disease.

Reimbursable to physicians and nurse practitioners under CPT code

99188.

$30.30

D1208

Topical

application

fluoride

–

excluding

varnish

Reimbursable once per six (6) month period for members between 1 and

20 years

of age (inclusive).

Fluoride must be applied separately from

prophylaxis paste.

For

individuals 21 years of age and older D1208 is only

approvable for those

individuals

identified

with

Restriction

Exception

code

(“TBI

Eligible”)

95 (“OPWDD/Managed Care

Exemption”), or, in cases where salivary gland function has been

compromised through surgery, radiation, or disease.

$14.14

OTHER PRECENTATIVE SERVICES

Code

Description

D1320

Tobacco counseling for the control and prevention of oral

disease

$10.10

Tobacco prevention and cessation services reduce patient risks of developing tobacco-related

oral diseases and conditions and improves prognosis for certain dental therapies. Reimbursement

for smoking cessation counseling (SCC) must meet the following criteria:

• SCC must be provided face-to-face by either a dentist or by a dental hygienist that is

supervised by the dentist;

• SCC must be billed by either an office-based dental practitioner or by an Article 28 clinic that

employs a dentist;

• Dental practitioners can only provide individual SCC services, which must be greater than

three minutes in duration, NO group sessions are allowed;

• Dental claims for SCC must include the CDT procedure code D1320 (tobacco counseling for

the control and prevention of oral disease);

• In a dental office or an Article 28 clinic, SCC should only take place during a dental visit as an

adjunct when providing a dental service and NOT billed as a stand-alone service;

• Smoking Cessation Counseling complements existing Medicaid covered benefits for

prescription and non- prescription smoking cessation products including nasal sprays,

inhalers, Zyban (bupropion), Chantix (varenicline), over-the counter nicotine patches and

gum;

• To receive reimbursement for SCC services the following information must be documented

in the patient’s dental record:

o At least 4 of 5 A’s: smoking status and if yes, willingness to quit;

o If willing to quit, offer medication as needed, target date for quitting, and follow-up date

(with documentation in the record that the follow-up occurred);

o If unwilling to quit, the patient’s expressed roadblocks;

o Referrals to the New York State Smoker’s Quitline and/or community services to address

roadblocks and for additional cessation resources and counselling, if needed. Smoking

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cessation services are included in the prospective payment system (PPS) rate for those

FQHCs that do not participate in APG reimbursement.

Dentists should be aware of the following guideline for smoking cessation counseling:

The Clinical Practice Guideline, “Treating Tobacco Use and Dependence: 2008

Update”

demonstrated that efficacious treatments for tobacco users exist and should

become a part of

standard care giving.

This guideline recommends that a practitioner should follow the “5 A’s” of treating tobacco

dependence, which include:

1. Ask: Ask the patient about tobacco use at every visit and document the response.

2. Advise: Advise the patient to quit in a clear and personalized manner.

3. Assess: Assess the patient’s willingness to make a quit attempt at this time.

4. Assist: Assist the patient to set a quit date and make a quit plan; offer medication as

needed.

5. Arrange: Arrange to follow-up with the patient within the first week, either in person or by

phone, and take appropriate action to assist them.

For patients not ready to make a quit attempt, clinicians should use a brief intervention designed

to promote the motivation to quit. Content areas that should be addressed can be captured by

the “5 R’s”:

1. Relevance: Encourage the patient to state why quitting is relevant to them, being as

specific as possible.

2. Risks: Ask the patient to identify potential negative consequences of their tobacco use,

including acute, environmental, and long-term risks.

3. Rewards: Ask the patient to identify potential benefits, such as improved health, saving

money, setting a good example for children, and better physical performance.

4. Roadblocks: Ask the patient to identify barriers (e.g., fear of withdrawal, weight gain,

etc.), and provide treatment and resources to address them.

5. Repetition: The motivational intervention should be repeated every time the patient is

seen.

Research suggests that the “5 R’s” enhance future quit attempts. Additional information is

available in Chapter 3 of the guideline, titled Clinical Interventions for Tobacco Use and

Dependence.

Code

Description

D1351

Sealant – per tooth (TOOTH) (DVS REQUIRED)

Mechanically and/or chemically prepared enamel surface sealed to

prevent decay. Refer to the “Prior Approval/Prior Authorization

Requirements” section for use of DVS. Application of sealant is

restricted to previously unrestored permanent first and second molars

that exhibit no signs of occlusal or proximal caries for members between

5 and 15 years of age (inclusive). Buccal and lingual grooves are

included in the fee. The use of opaque or tinted sealant is

recommended for ease of checking bond efficacy. Reapplication, if

necessary, is permitted once every five (5) years.

$35.35

D1354

Application of caries arresting medicament – per tooth

Conservative treatment of an active, non-symptomatic carious lesion by

topical application of a caries arresting or inhibiting medicament and

without mechanical removal of sound tooth structure - Limited to Silver

Diamine Fluoride

$15.15

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Clinical criteria for the use of silver diamine fluoride:

• Stabilize non-symptomatic teeth with active carious lesion and

no pulpal exposure

• High caries risk (e.g. xerostomia, severe early childhood caries)

• Treatment challenged by behavioral or medical management

• Difficult to treat carious lesions

Criteria for reimbursement:

• Benefit covers 0-20 years of age inclusive

• For individuals 21 years of age and older “D1354” is only

approvable for those individuals identified with a Restriction

Exception code of “RE 81” (“TBI Eligible”) or “RE 95”

(OPWDD/Managed Care Exemption”)

• Covered two (2) times per tooth within a 12-month period with a

total of four (4) times per lifetime of the tooth.

• Covered with topical application of fluoride (“D1206” or “D1208”)

when they are performed on the same date of service if “D1354”

is being used to treat caries and “D1206” or “D1208” is being

used to prevent caries.

• Silver diamine fluoride may be applied to five (5) teeth on the same

date of service with more teeth considered in exceptional

circumstances. Documentation supporting necessity must be

submitted with the claim.

• Caries arresting medicament is not reimbursable when used as a

base for a final restoration.

Providers are required to: Fully disclose the risks and benefits of

silver diamine fluoride use and to discuss treatment alternatives where

appropriate. Obtain written consent.

SPACE MAINTENANCE (PASSIVE APPLIANCES)

Only fixed appliances are reimbursable. Documentation including pre-treatment images to justify

all space maintenance appliances must be available upon request. Space maintenance should

not be provided as an isolated service. All carious teeth must be restored before placement of

any space maintainer. The member should be practicing a sufficient level of oral hygiene to

ensure that the space maintainer will not become a source of further carious breakdown of the

dentition. All permanent teeth in the area of space maintenance should be present and developing

normally. Space maintenance in the deciduous dentition (defined as prior to the interdigitation of

the first permanent molars) can generally be considered.

Space maintenance in the mixed dentition initiated within one month of the necessary extraction

will be reimbursable on an individual basis. Space maintenance in the mixed dentition initiated

more than one month after the necessary extraction, with minimum space loss apparent, may be

reimbursable.

Code

Description

D1510

Space maintainer – fixed, unilateral – per quadrant (QUAD)

Excludes a distal show space maintainer.

$117.16

D1516

Space maintainer – fixed – bilateral, maxillary

$175.75

D1517

Space maintainer – fixed – bilateral, mandibular

$175.75

D1551

Re-cement or re-bond bilateral space maintainer - maxillary

$19.19

D1552

Re-cement or re-bond bilateral space maintainer - mandibular

$19.19

D1553

Re-cement or re-bond unilateral space maintainer – per quadrant

(QUAD)

$19.19

D1999

Unspecified preventive procedure, by report

(BR)

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SPACE MAINTAINERS

Code

Description

D1575

Distal shoe space maintainer – fixed, unilateral, per quadrant

(QUAD)

Fabrication and delivery of fixed appliance extending subgingivally

and distally to guide the eruption of the first permanent molar. Does

not include ongoing follow-up or adjustments, or replacement

appliances, once the tooth has erupted.

$117.16

III.

RESTORATIVE

D2000

–

D2999

Unless otherwise specified, the cost of analgesic and anesthetic agents is included in the

reimbursement for the dental service.

The maximum fee for restoring a tooth with either amalgam or composite resin material will be

the fee allowed for placement of a four-surface restoration. With the exception of the placement

of reinforcement pins (use code D2951), fees for amalgam and composite restorations include

tooth preparation, all adhesives (including amalgam and composite bonding agents), acid etching,

cavity liners, bases, curing and pulp capping.

Caries index, periodontal status, and the overall status and prognosis of the entire

dentition, as well as recipient compliance, dental history, and medical history, among other

factors, will be taken into consideration when determining medical necessity. Treatment is

considered appropriate where the prognosis of the tooth is favorable. Treatment may be

appropriate where the total number of teeth which require or are likely to require treatment is not

considered excessive or when maintenance of the tooth is considered essential or appropriate in

view of the overall dental status of the recipient. Please review Scope of Program and Non-

Reimbursable Services (p 7) and Essential Services (p 18).

Restorations placed solely for the treatment of abrasion, attrition, erosion or abfraction and are

not associated with the treatment of any other pathology are beyond the scope of the program

and will not be reimbursed. Restorative procedures should not be performed without

documentation of clinical necessity. Published “frequency limits” are general reference points on

the anticipated frequency for that procedure. Actual frequency must be based on the clinical

needs of the individual member.

If a non-covered surgical procedure is required to properly restore a tooth, any associated

restorative or endodontic treatment will NOT be considered for reimbursement. Note, this

provision does not apply to crown lengthening, which will be considered for reimbursement when

associated with any medically necessary crown or endodontic treatment.

For codes D2140, D2330 and D2391, only a single restoration will be reimbursable per surface.

Occlusal surface restorations including all occlusal pits and fissures will be reimbursed as one-

surface restorations whether or not the transverse ridge of an upper molar is left intact. Codes

D2150, D2160, D2161, D2331, D2332, D2335, D2781, D2392, D2393, and D2394 are compound

restorations encompassing 2, 3, 4 or more contiguous surfaces. Restorations that connect

contiguous surfaces must be billed using the appropriate multi-surface restorative procedure

code.

AMALGAM RESTORATIONS (INCLUDING POLISHING)

Code

Description

D2140

Amalgam - one surface, primary or permanent (SURF/TOOTH)

$50.50

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D2150

Amalgam - two surfaces, primary or permanent (SURF/TOOTH)

$67.67

D2160

Amalgam - three surfaces, primary or permanent (SURF/TOOTH)

$82.82

D2161

Amalgam - four or more surfaces, primary or permanent

(SURF/TOOTH)

$98.98

RESIN-BASED COMPOSITE-RESTORATIONS DIRECT

Code

Description

D2330

Resin-based composite - one surface, anterior (SURF/TOOTH)

$50.50

D2331

Resin-based composite - two surfaces, anterior (SURF/TOOTH)

$73.73

D2332

Resin-based composite - three surfaces, anterior (SURF/TOOTH)

$87.87

D2335

Resin-based composite - four or more surfaces (anterior)

(SURF/TOOTH)

$98.98

D2390

Resin-based composite crown, anterior (TOOTH)

$98.98

D2391

Resin-based composite; one surface, posterior (SURF/TOOTH)

Used to restore a carious lesion into the dentin or a deeply eroded area

into the dentin. Not a preventive procedure.

$50.50

D2392

Resin-based composite - two surfaces, posterior (SURF/TOOTH)

$67.67

D2393

Resin-based composite - three surfaces, posterior

(SURF/TOOTH)

$82.82

D2394

Resin-based composite - four or more surfaces, posterior

(SURF/TOOTH)

$98.98

CROWNS - SINGLE RESTORATIONS ONLY

The materials used in the fabrication of a crown (e.g. all-metal, porcelain, ceramic, resin) is at the

discretion of the provider. The crown fabricated must correctly match the procedure code

approved on the Prior Approval. Crowns include any necessary core buildups.

Crowns for members under the age of 21 will be covered when medically necessary. In

determining whether a requested crown is medically necessary, the following factors may be

considered:

• The periodontal status, member compliance and overall status and prognosis of the tooth

is favorable.

• The tooth is not routinely restorable with a filling.

Crowns for members 21 and over will be covered when medically necessary. In determining

whether a requested crown is medically necessary, the following factors may be considered:

• There is a documented medical condition which precludes an extraction.

• The tooth is a critical abutment for an existing or proposed prosthesis.

• If the tooth is a posterior tooth, the following additional factors may be considered:

o The periodontal status, member compliance and overall status and prognosis of

the tooth is favorable

o The tooth is not routinely restorable with a filling

o There are eight or more natural or prosthetic posterior points of contact present

o If the posterior tooth is a molar, treatment of the molar is necessary to maintain

functional or balanced occlusion of the patient’s dentition

o Consideration for a third molar will be given if the third molar occupies the first or

second molar position

o Note: Requests for treatment on unopposed molars must include a narrative

documenting medical necessity.

• If the tooth is an anterior tooth, the following additional factors may be considered:

o The periodontal status, member compliance and overall status and prognosis of

the tooth is favorable

o The tooth is not routinely restorable with a filling

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Code

Description

D2710

Crown – resin-based composite (indirect) (laboratory) (TOOTH) (PA

REQUIRED)

Acrylic (processed) jacket crowns may be approved as restorations for

severely fractured anterior teeth.

$292.90

D2720

Crown – resin with high noble metal (TOOTH) (PA REQUIRED)

$505.00

D2721

Crown – resin with predominantly base metal (TOOTH) (PA

REQUIRED)

$505.00

D2722

Crown – resin with noble metal (TOOTH) (PA REQUIRED)

$505.00

D2740

Crown – porcelain/ceramic (TOOTH) (PA REQUIRED)

$505.00

D2750

Crown – porcelain fused to high noble metal (TOOTH) (PA

REQUIRED)

$505.00

D2751

Crown – porcelain fused to predominately base metal (TOOTH) (PA

REQUIRED)

$505.00

D2752

Crown – porcelain fused to noble metal (TOOTH) (PA REQUIRED)

$505.00

D2753

Crown – porcelain fused to titanium and titanium alloys

(TOOTH) (PA REQUIRED)

$505.00

D2780

Crown – ¾ cast high noble metal (TOOTH) (PA REQUIRED)

$404.00

D2781

Crown – ¾ cast predominantly base metal (TOOTH) (PA REQUIRED)

$404.00

D2782

Crown – ¾ cast noble metal (TOOTH) (PA REQUIRED)

$404.00

D2790

Crown – full cast high noble metal (TOOTH) (PA REQUIRED)

$505.00

D2791

Crown – full cast predominately base metal (TOOTH) (PA

REQUIRED)

$505.00

D2792

Crown – full cast noble metal (TOOTH) (PA REQUIRED)

$505.00

D2794

Crown – Titanium and titanium alloys

$505.00

OTHER

RESTORATIVE

SERVICES

For all prefabricated crowns (D2930, D2931, D2932, D2933, D2934) there must be supporting

documentation substantiating the need for the crown (e.g. radiographic images).

Code

Description

D2920

Re-cement or re-bond crown (TOOTH)

Claims for recementation of a crown by the original provider within one

year of placement, or claims for subsequent recementations of the same

crown, will be pended for professional review. Documentation to justify

the need and appropriateness of such recementations may be required

as a condition for payment.

$30.30

D2930

Prefabricated stainless steel crown - primary tooth (TOOTH)

$117.16

D2931

Prefabricated stainless steel crown - permanent tooth (TOOTH)

$117.16

D2932

Prefabricated resin crown (TOOTH)

Must encompass the complete clinical crown and should be utilized with

the same criteria as for full crown construction. This procedure is limited

to one occurrence per tooth within two years. If replacement becomes

necessary during that time, claims submitted will be pended for

professional review. To justify the appropriateness of replacements,

documentation must be included as a claim attachment. Placement on

deciduous anterior teeth is generally not reimbursable past the age of five

(5) years of age, unless medically necessary based on the clinical needs

of the individual member.

$117.16

D2933

Prefabricated stainless steel crown with resin window (TOOTH)

Restricted to primary anterior teeth, permanent maxillary bicuspids and

first molars.

$131.30

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D2934

Prefabricated esthetic coated stainless steel crown – primary tooth

(TOOTH)

$131.30

D2951

Pin retention – per tooth, in addition to restoration (TOOTH)

$29.29

D2952

Post and core in addition to crown, indirectly fabricated (TOOTH)

$126.25

D2954

Prefabricated post and core in addition to crown (TOOTH) There is

no separate reimbursement for the core material.

$126.25

D2955

Post removal (TOOTH)

$95.95

D2980

Crown repair necessitated by restorative material failure

(TOOTH) (REPORT NEEDED)

(BR)

D2999

Unspecified restorative procedure, by report (REPORT NEEDED)

(BR)

IV. ENDODONTICS D3000 - D3999

All radiographic images taken during the course of root canal therapy and all post- treatment

radiographic images are included in the fee for the root canal procedure. At least one pre-

treatment radiographic image demonstrating the need for the procedure, and one post-treatment

radiographic image that demonstrates the result of the treatment, must be maintained in the

member's record.

Surgical root canal treatment or apicoectomy may be considered appropriate and covered when

the root canal system cannot be acceptably treated non-surgically, there is active root resorption,

or access to the canal is obstructed. Treatment may also be covered where there is gross over

or under extension of the root canal filling, periapical or lateral pathosis persists, or there is a

fracture of the root.

Pulp capping, either direct or indirect, is not reimbursable.

Root canal therapy for members under the age of 21 will be covered when medically necessary.

In determining whether a requested root canal is medically necessary, the following factors may

be considered:

• The periodontal status, member compliance and overall status and prognosis of the tooth

is favorable.

• The tooth is not routinely restorable with a filling

Root canal therapy for members 21 years of age and over will be covered when medically

necessary. In determining whether requested endodontic treatment is medically necessary, the

following factors may be considered:

• There is a documented medical condition which precludes an extraction

• The tooth is a critical abutment for an existing or proposed prosthesis

• If the tooth is a posterior tooth, the following additional factors may be considered:

o The periodontal status, member compliance and overall status and prognosis of

the tooth is favorable

o There are eight or more natural or prosthetic posterior points of contact present

o If the posterior tooth is a molar, treatment of the molar is necessary to maintain

functional or balanced occlusion of the patient’s dentition

o Consideration for a third molar will be given if the third molar occupies the first or

second molar position

o Note: Requests for treatment on unopposed molars must include a narrative

documenting medical necessity

• If the tooth is an anterior tooth, the following additional factors may be considered:

o The periodontal status, member compliance and overall status and prognosis of

the tooth is favorable.

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Code

Description

D3220

Therapeutic pulpotomy (excluding final restoration) - removal of

pulp coronal to the dentinocemental junction and application of

medicament (TOOTH)

To be performed on primary or permanent teeth up until the age of 21

years. This is not to be considered as the first stage of root canal

therapy. Pulp capping (placement of protective dressing or cement over

exposed or nearly exposed pulp for protection from injury or as an aid

in healing and repair) is not reimbursable. This procedure code may not

be used when billing for an "emergency pulpotomy", which should be

billed as palliative treatment.

$87.87

ENDODONTIC

THERAPY

PRIMARY

TEETH

Endodontic therapy on primary teeth with succedaneous teeth and placement of resorbable filling.

This includes pulpectomy, cleaning, and filling of canals with resorbable material.

Code

Description

D3230

Pulpal therapy (resorbable filling) – anterior, primary tooth

(excluding final restoration) (TOOTH) (PA REQUIRED)

$151.50

D3240

Pulpal therapy

(resorbable filling) – posterior, primary

tooth

(excluding final restoration) (TOOTH) (PA REQUIRED)

$237.35

ENDODONTIC

THERAPY

(INCLUDING

TREATMENT

PLAN,

CLINICAL

PROCEDURES AND

FOLLOW-UP CARE)

Includes

primary

teeth

without

succedaneous

teeth

and

permanent

teeth.

Code

Description

D3310

Endodontic therapy – anterior tooth (excluding final

restoration) (TOOTH) (PA REQUIRED)

$252.50

D3320

Endodontic therapy – premolar tooth (excluding final

restoration) (TOOTH) (PA REQUIRED)

$303.00

D3330

Endodontic therapy – molar tooth (excluding final

restoration)

(TOOTH) (PA REQUIRED)

$404.00

ENDODONTIC

RETREATMENT

Code

Description

D3346

Retreatment of previous root canal therapy – anterior (TOOTH)

(PA REQUIRED)

$252.50

D3347

Retreatment of previous root canal therapy – premolar

(TOOTH) (PA REQUIRED)

$303.00

D3348

Retreatment of previous root canal therapy - molar (TOOTH)

(PA REQUIRED)

$404.00

APEXIFICATION

RECALCIFICATION

PROCEDURES

Code

Description

D3351

Apexification / recalcification - initial visit (apical closure/calcific

repair of perforations, root resorption, etc.) (TOOTH)

Includes opening tooth, pulpectomy, preparation of canal spaces, first

placement of medication and necessary radiographic images. (This

procedure includes first phase of complete root canal therapy.)

$82.82

D3352

Apexification / recalcification - interim medication replacement

(TOOTH) For visits in which the intra-canal medication is replaced with

new medication. Includes any necessary radiographs. There may be

several of these visits. The published fee is the maximum reimbursable

$80.80

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amount regardless of the number of visits.

D3353

Apexification / recalcification - final visit (includes completed root

canal therapy – apical closure/calcific repair of perforations, root

resorption, etc.) (TOOTH)

Includes the removal of intra-canal medication and procedures necessary

to place final root canal filling material including necessary radiographs.

(This procedure includes last phase of complete root canal therapy.)

$104.03

APICOECTOMY

Periradicular surgery is a term used to describe surgery to the root surface (e.g., apicoectomy),

repair of a root perforation or resorptive defect, exploratory curettage to look for root fractures,

removal of extruded filling materials or instruments, removal of broken root fragments, sealing of

accessory canals, etc. This does not include retrograde filling material placement. Performed as

a separate surgical procedure and includes periapical curettage.

Code

Description

D3410

Apicoectomy - anterior (TOOTH) (PA REQUIRED)

$161.60

D3421

Apicoectomy - premolar (first root) (TOOTH) (PA REQUIRED)

If more than one root is treated, see D3426.

$161.60

D3425

Apicoectomy - molar (first root) (TOOTH) (PA REQUIRED)

If more than one root is treated, see D3426.

$181.80

D3426

Apicoectomy (each additional root) (TOOTH) (PA REQUIRED)

$60.60

D3430

Retrograde filling - per root (TOOTH) (PA REQUIRED)

$50.50

OTHER

ENDODONTIC

PROCEDURES

Code

Description

D3999

Unspecified endodontic procedure, by report (REPORT NEEDED)

(BR)

V. PERIODONTICS D4000 – D4999

For details regarding the “PERIODONTICS” codes that are associated with the implant and implant

related services benefit ONLY (D4245, D4266, D4267, D4273, D4275, D4277, D4278, D4283,

D4285, D6106, D6107), see section VIII. IMPLANTS.

SURGICAL SERVICES (INCLUDING USUAL POST-OPERATIVE CARE)

D4210 and D4211 are reimbursable solely for the correction of severe hyperplasia or

hypertrophy

associated with drug therapy, hormonal disturbances, or congenital defects.

The provider must keep

in the treatment record detailed documentation describing the

need for gingivectomy or gingivoplasty

including pretreatment photographs depicting the

condition of the tissues.

Code

Description

D4210

Gingivectomy or

gingivoplasty –

four or more contiguous

teeth or

tooth bounded spaces per quadrant (QUAD)

(REPORT

NEEDED)

$101.00

D4211

Gingivectomy or gingivoplasty – one to three contiguous teeth or

tooth bounded spaces per quadrant (QUAD) (REPORT NEEDED)

$65.65

D4249

Clinical Crown Lengthening – hard tissue (PA REQUIRED)

➢ Crown lengthening requires reflection of a full thickness flap and removal

of bone, altering the crown to root ratio. The periodontal status, member

compliance, and overall status and prognosis of the tooth may be taken

into consideration when determining medical necessity. Crown

lengthening is reimbursable solely when associated with medically

necessary crown or root canal procedure. All requests for coverage of a

crown lengthening should include a complete treatment plan addressing

all areas of pathology. The provider must keep in the treatment record

$75.00

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detailed documentation describing the need for crown lengthening

including pretreatment photographs depicting the condition of the

tissues.

➢ Coverage of a crown lengthening should be requested at the same time

as a request for coverage of a crown and/or a root canal. If the need for

crown lengthening is discovered during a procedure, then providers

should refer to Prior Approval Change Request information on page 14.

NON-SURGICAL

PERIODONTAL

SERVICES

Code

Description

D4341

Periodontal scaling and root planing – four or more teeth $45.45 per

quadrant (QUAD)

$45.45

D4342

Periodontal scaling and root planing – one to three teeth $30.30 per

quadrant (QUAD)

$30.30

For periodontal scaling and root planing (D4341 and D4342) to be considered, the diagnostic

materials must demonstrate the following, consistent with professional standards:

• Clinical loss of periodontal attachment, and;

o Periodontal pockets and sub-gingival accretions on cemental surfaces in the

quadrant(s) being treated, and/or;

o Radiographic evidence of crestal bone loss and changes in crestal lamina dura,

and/or;

o Radiographic evidence of root surface calculus.

The provider must keep in the treatment record detailed documentation describing the need for

periodontal scaling and root planing, including a copy of the pre-treatment evaluation of the

periodontium, a general description of the tissues (e.g., color, shape, and consistency), the

location and measurement of periodontal pockets, the description of the type and amount of bone

loss, the periodontal diagnosis, the amount and location of subgingival calculus deposits, and

tooth mobility.

Treatment per quadrant is limited to once every two (2) years. For consideration of more

frequent treatment prior approval with supporting documentation is required. Reimbursement for

D4341 and/or D4342 is limited to no more than two quadrants on a single date of service. In

exceptional circumstances, consideration may be given for reimbursement for more than two

quadrants on a single date of service (e.g., treatment under anesthesia). These claims should be

submitted using procedure code D4999 with documentation supporting both the need for

treatment and the exceptional circumstances present.

Prophylaxis or periodontal maintenance (e.g., D1110, D1120, D4910) will not be reimbursed on

the same date of service as periodontal scaling and root planing (D4341, D4342).

OTHER

PERIODONTAL

SERVICES

Code

Description

D4910

Periodontal maintenance

This procedure is for members who have previously been treated for

periodontal disease with procedures such as scaling and root planing

(D4341 or D4342). D4910 cannot be used in conjunction with or billed

within six (6) months of any other prophylaxis procedure (e.g., D1110).

Reimbursement for D4910 is limited to once per six (6) months and

cannot be used in conjunction with D4341 or D4342 on the same date of

$45.45

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service.

D4999

Unspecified periodontal procedure, by report (REPORT NEEDED)

(BR)

VI. PROSTHODONTICS (Removable) D5000 – D5899

Full and /or partial dentures are covered by Medicaid when they are determined to be medically

necessary, including when necessary to alleviate a serious health condition or one that is

determined to affect employability. This service requires prior approval.

Complete dentures and partial dentures, whether unserviceable, lost, stolen, or broken will not be

replaced for a minimum of eight years from initial placement except when determined medically

necessary by the Department or its agent. Prior approval requests for replacement dentures prior

to eight years must include a completed Justification of Need for Replacement Prosthesis Form signed

by the patient’s dentist, explaining the specific circumstances that necessitates replacement of

the denture. If replacement dentures are requested within the eight-year period after they have

already been replaced once, then the dentist’s supporting documentation must include an

explanation of preventative measures instituted to alleviate the need for further replacements.

General Guidelines for All Removable Prosthesis:

• Requests for partial dentures will be reviewed based on the presence/absence of eight (8)

points of natural or prosthetic posterior occlusal contact and/or one (1) missing maxillary

anterior or two (2) missing mandibular anterior teeth.

• Complete and/or partial dentures will be approved only when the existing prosthesis is not

serviceable or cannot be relined or rebased. Reline or rebase of an existing prosthesis will

not be reimbursed when such procedures are performed in addition to a new prosthesis for

the same arch within 6 months of the delivery of a new prosthesis. Only “tissue

conditioning” (D5850 or D5851) is payable within six (6) months prior to the delivery of a

new prosthesis;

• Six (6) months of post-delivery care from the date of insertion is included in the

reimbursement for all newly fabricated prosthetic appliances. This includes rebasing,

relining, adjustments and repairs.

• Cleaning of removable prosthesis or soft tissue not directly related to natural teeth or

implants is not a covered service. Prophylaxis and/or scaling and root planing is only

payable when performed on natural dentition;

• "Immediate" prosthetic appliances are not a covered service. An appropriate length of time

for healing should be allowed before taking any final impressions. Generally, it is expected

that tissues will need a minimum of four (4) to six (6) weeks for healing. Claims for denture

insertion occurring within four (4) weeks of extraction(s) will pend for professional review;

• Claims are not to be submitted until the denture(s) are completed and delivered to the

member. The "date of service" used on the claim is the date that the denture(s) are

delivered. If the prosthesis cannot be delivered or the member has lost eligibility following

the date of the "decisive appointment," claims should be submitted following the guidelines

for "Interrupted Treatment";

• Medicaid payment is considered payment in-full. Except for members with a "spend down,"

members cannot be charged beyond the Medicaid fee. Deposits, down-payments or

advance payments are prohibited;

• All treatment notes, radiographic images, laboratory prescriptions and laboratory invoices

should be made part of the member's treatment record to be made available upon request

in support of any treatment provided, and;

• The total cost of repairs should not be excessive and should not exceed 50% of the cost of

a new prosthesis. If the total cost of repairs and/or relines is to exceed 50% of the cost of

a new prosthesis, a prior approval request for a new prosthesis should be submitted with

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a detailed description of the existing prosthesis including why any replacement would be

necessary per Medicaid guidelines and would be more appropriate than repair of the

existing prosthesis.

COMPLETE DENTURES (INCLUDING ROUTINE POST-DELIVERY CARE)

Radiographs are not routinely required to obtain prior approval for full dentures. The guidelines

published by the ADA and the U.S. Department of Health and Human Services on the use of x-

rays should be followed. Additional information is found here: The Selection of Patients for

Dental Radiographic Examinations | FDA.

Code

Description

D5110

Complete denture – maxillary (PA Required)

$565.60

D5120

Complete denture – mandibular (PA Required)

$565.60

PARTIAL

DENTURES

(INCLUDING

ROUTINE

POST-DELIVERY

CARE)

Caries index, periodontal status, recipient compliance, dental history, medical history and the

overall status and

prognosis of the entire dentition

, among other factors, will be taken into

consideration when determining medical necessity.

Please review Scope of Program and Non-

Reimbursable Services (p 7) and Essential Services (p 18).

Requirements

for

the

placement

partial

dentures

are:

• All phase I restorative treatment which includes extractions, removal of all decay

and restoration with permanent filling materials,

endodontic therapy, crowns, etc.

must be completed prior to taking the

final impression(s) for partial denture(s).

• Partial dentures can be considered for ages 15 years and above; an “Interim

Prosthesis” (procedure codes D5820 and/or D5821) can be considered for

individuals 5 to 15 years of age.

Code

Description

D5211

Maxillary partial denture - resin base (including retentive/clasping

materials, rests, and teeth) (PA REQUIRED)

$353.50

D5212

Mandibular partial denture - resin base (including retentive/clasping

materials, rests, and teeth) (PA REQUIRED)

$353.50

D5213

Maxillary partial denture - cast metal framework with resin denture

bases (including retentive/clasping materials, rests and teeth) (PA

REQUIRED)

$565.60

D5214

Mandibular partial denture - cast metal framework with resin

denture bases (including retentive/clasping materials, rests and

teeth) (PA REQUIRED)

$565.60

D5225

Maxillary partial denture - flexible base (including retentive/clasping

materials, rests and teeth) (PA REQUIRED)

$565.60

D5226

Mandibular partial denture - flexible base (including

retentive/clasping materials, rests and teeth) (PA REQUIRED)

$565.60

ADJUSTMENTS TO DENTURES

Adjustments within six months of the delivery of the prosthesis are considered part of the payment

for the prosthesis. Adjustments (procedure codes D5410, D5411, D5421, and D5422) are not

reimbursable on the same date of service as the initial insertion of the prosthetic appliance OR;

on the same date of service as any repair, rebase, or reline procedure code.

Code

Description

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D5410

Adjust complete denture - maxillary

$25.25

D5411

Adjust complete denture - mandibular

$25.25

D5421

Adjust partial denture - maxillary

$25.25

D5422

Adjust partial denture - mandibular

$25.25

PROSTHETIC APPLIANCE REPAIRS

Limitation: The total cost of repairs should not be excessive and should not exceed 50% of the

cost of a new prosthesis. If the total cost of repairs is to exceed 50% of the cost of a new

prosthesis, a prior approval request for a new prosthesis should be submitted with a detailed

description of the existing prosthesis and why any replacement would be necessary per Medicaid

guidelines and would be more appropriate than repair of the existing prosthesis.

REPAIRS TO COMPLETE DENTURES

Code

Description

D5511

Repair broken complete denture base, mandibular

$65.65

D5512

Repair broken complete denture based, maxillary

$65.65

D5520

Replace missing or broken teeth – complete denture (each tooth)

(TOOTH)

$42.42

REPAIRS TO PARTIAL DENTURES

Code

Description

D5611

Repair

resin

partial

denture

base,

mandibular

$67.67

D5612

Repair

resin

partial

denture

base,

maxillary

$67.67

D5621

Repair

cast

partial

framework,

mandibular

$121.20

D5622

Repair

cast

partial

framework,

maxillary

$121.20

D5630

Repair

replace

broken

retentive/clasping

materials-

per

tooth (TOOTH)

$131.30

D5640

Replace broken teeth - per tooth (TOOTH)

$60.60

D5650

Add tooth to existing partial denture (TOOTH)

$65.65

D5660

Add clasp to existing partial denture - per tooth (TOOTH)

$103.02

DENTURE REBASE PROCEDURES

Rebase procedures are not payable within six months prior to the delivery of a new prosthesis.

Only “tissue conditioning” (D5850 and D5851) is payable within six months prior to the delivery of

a new prosthesis.

Code

Description

D5710

Rebase - complete maxillary denture (PA REQUIRED)

$171.70

D5711

Rebase - complete mandibular denture (PA REQUIRED)

$171.70

D5720

Rebase - maxillary partial denture (PA REQUIRED)

$175.74

D5721

Rebase – mandibular partial denture (PA REQUIRED)

$175.74

DENTURE

RELINE

PROCEDURES

Reline procedures are not payable within six months prior to the delivery of a new prosthesis. For

cases in which it is impractical to complete a laboratory reline, prior approval for an office

(“chairside” or “cold cure”) reline may be requested with credible documentation which would

preclude a laboratory reline. Only “tissue conditioning” (D5850 and D5851) is payable within six

months prior to the delivery of a new prosthesis.

Code

Description

D5730

Reline complete maxillary denture (direct) (PA REQUIRED)

$126.25

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D5731

Reline complete mandibular denture (direct) (PA REQUIRED)

$126.25

D5740

Reline maxillary partial denture (direct) (PA REQUIRED)

$85.85

D5741

Reline mandibular partial denture (direct) (PA REQUIRED)

$85.85

D5750

Reline complete maxillary denture (indirect)

$171.70

D5751

Reline complete mandibular denture (indirect)

$171.70

D5760

Reline maxillary partial denture (indirect)

$126.25

D5761

Reline mandibular partial denture (indirect)

$126.25

INTERIM

PROSTHESIS

Reimbursement is limited to once per year and

only for children between

and

15 years

of age.

Codes D5820 and D5821 are not to be used in lieu of space maintainers. All claims will be

pended for professional review prior to payment.

Code

Description

D5820

Interim partial denture (including retentive/clasping materials, rests,

and teeth), maxillary

$175.74

D5821

Interim partial denture (including retentive/clasping materials, rests,

and teeth), mandibular

$175.74

OTHER

REMOVABLE

PROSTHETIC

SERVICES

Codes D5850 and D5851 are for treatment reline using materials designed to heal unhealthy

ridges prior to more definitive final restoration. This is the ONLY type of reline reimbursable

within six (6) months prior to the delivery of a new prosthesis. Insertion of tissue conditioning

liners in existing dentures will be limited to once per denture unit. D5850 and D5851 are not

reimbursable under age 15 and should be billed one time at the completion of treatment,

regardless of the number of visits involved.

Code

Description

D5850

Tissue conditioning, maxillary

$25.25

D5851

Tissue conditioning, mandibular

$25.25

D5899

Unspecified removable prosthodontic procedure, by report

(REPORT NEEDED)

(BR)

VII. MAXILLOFACIAL PROSTHETICS D5900 – D5999

Code

Description

D5911

Facial

moulage

(sectional

)

(REPORT

NEEDED)

$117.16

D5912

Facial

moulage

(complete)

(REPORT

NEEDED)

$175.74

D5913

Nasal

prosthesis

(REPORT

NEEDED)

(BR)

D5914

Auricular

prosthesis

(REPORT

NEEDED)

(BR)

D5915

Orbital

prosthesis

(REPORT

NEEDED)

$966.57

D5916

Ocular

prosthesis

(REPORT

NEEDED)

$966.57

D5919

Facial

prosthesis

(REPORT

NEEDED)

(BR)

D5922

Nasal

septal

prosthesis

(REPORT

NEEDED)

(BR)

D5923

Ocular

prosthesis,

interim

(REPORT

NEEDED)

$439.35

D5924

Cranial

prosthesis

(REPORT

NEEDED)

(BR)

D5925

Facial

augmentation

implant

prosthesis

(REPORT

NEEDED)

(BR)

D5926

Nasal

prosthesis,

replacement

(REPORT

NEEDED)

(BR)

D5927

Auricular

prosthesis,

replacement

(REPORT

NEEDED)

(BR)

D5928

Orbital

prosthesis,

replacement

(REPORT

NEEDED)

(BR)

D5929

Facial

prosthesis,

replacement

(REPORT

NEEDED)

(BR)

D5931

Obturator

prosthesis,

surgical

(REPORT

NEEDED)

(BR)

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D5932

Obturator

prosthesis,

definitive

(REPORT

NEEDED)

(BR)

D5933

Obturator

prosthesis,

modification

(REPORT

NEEDED)

(BR)

D5934

Mandibular

resection

prosthesis

with

guide

flange

(REPORT

NEEDED)

(BR)

D5935

Mandibular

resection

prosthesis

without

guide

flange

(REPORT

NEEDED)

(BR)

D5936

Obturator

prosthesis,

interim

(REPORT

NEEDED)

(BR)

D5937

Trismus

appliance

(not

for

TMD

treatment

)

(REPORT

NEEDED)

$146.45

D5951

Feeding

aid

(REPORT

NEEDED)

$439.35

D5952

Speech

aid

prosthesis,

pediatric

(REPORT

NEEDED)

(BR)

D5953

Speech

aid

prosthesis,

adult

(REPORT

NEEDED)

(BR)

D5954

Palatal

augmentation

prosthesis

(REPORT

NEEDED)

(BR)

D5955

Palatal

lift

prosthesis,

definitive

(REPORT

NEEDED)

(BR)

D5958

Palatal

lift

prosthesis,

interim

(REPORT

NEEDED)

(BR)

D5959

Palatal

lift

prosthesis,

modification

(REPORT

NEEDED)

(BR)

D5960

Speech

aid

prosthesis,

modification

(REPORT

NEEDED)

(BR)

D5982

Surgical

stent

(REPORT

NEEDED)

(BR)

D5983

Radiation

carrier

(REPORT

NEEDED)

(BR)

D5984

Radiation

shield

(REPORT

NEEDED)

(BR)

D5985

Radiation

cone

locator

(REPORT

NEEDED)

(BR)

D5986

Fluoride

gel

carrier

(per

arch)

(ARCH)

$10.10

D5987

Commissure

splint

(REPORT

NEEDED)

(BR)

D5988

Surgical

splint

(REPORT

NEEDED)

(BR)

D5999

Unspecified

maxillofacial

prosthesis,

report

(REPORT

NEEDED)

(BR)

VIII. IMPLANT SERVICES D6000 – D6199

Dental implants, including single implants, and implant related services, will be covered by

Medicaid when medically necessary. Prior approval requests for implants must have supporting

documentation from the patient’s dentist. The patient’s dentist’s office must submit a completed

Evaluation of the Dental Implant Patient Form documenting, among other things, the patient’s medical

history, current medical conditions being treated, list of all medications currently being taken by

the patient, explaining why implants are medically necessary and why other covered functional

alternatives for prosthetic replacement will not correct the patient’s dental condition, and certifying

that the patient is an appropriate candidate for implant placement. If the patient’s dentist indicates

that the patient is currently being treated for a serious medical condition, the Department may

request further documentation from the patient’s treating physician.

General Guidelines:

• The dentist’s explanation as to why other covered functional alternatives for prosthetic

replacement will not correct the patient’s dental condition will be reviewed based on the

presence/absence of eight (8) points of natural or prosthetic posterior occlusal contact

and/or one (1) missing maxillary anterior or two (2) missing mandibular anterior teeth.

• A complete treatment plan addressing all phases of care is required and should include the

following:

o Accurate pretreatment charting;

o Complete treatment plan addressing all areas of pathology;

o Inter-arch distances;

o Number, type and location of implants to be placed;

o Design and type of planned restoration(s);

o Sufficient number of current, diagnostic radiographs and/or CT scans allowing for

the evaluation of the entire dentition.

• If bone graft augmentation is needed there must be a 4 to 6-month healing period before a

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dental implant can be placed.

• Dental implant code D6010 will be re-evaluated via intraoral radiographs or CT scans prior

to the authorization of abutments, crowns, or dentures four to six months after dental

implant placement.

• Treatment on an existing implant / implant prosthetic will be evaluated on a case- by-case

basis.

• Implant and implant related codes not listed will be considered on a case-by-case basis.

• Documentation must include a list of all medications currently being taken and all conditions

currently being treated.

• All cases will be considered based upon supporting documentation and current standard

of care.

For procedure codes D6010 and D6013 the following must be submitted:

• Full mouth radiographs or a diagnostic panorex including periapicals of site requesting

dental implant(s).

Code

Description

D6010

Surgical placement of implant body(TOOTH) (PA REQUIRED) (POST

OPERATIVE CARE: 90 DAYS)

Full mouth radiographs or diagnostic panorex including periapicals of site

requesting dental implant(s) must be provided.

$1010.00

D6013

Surgical placement of mini implant (TOOTH) (PA REQUIRED) (POST

OPERATIVE CARE: 90 DAYS)

$505.00

For procedure codes D6055– D6057 the following must be submitted:

• Periapical radiograph of the integrated implant(s); and,

• Panorex or sufficient number of radiographs showing the complete arch and the placed

implant(s)

Code

Description

D6055

Connecting bar – implant supported or abutment supported

(ARCH) (PA REQUIRED)

$404.00

D6056

Prefabricated abutment – includes modification and placement

(TOOTH) (PA REQUIRED)

$404.00

D6057

Custom fabricated abutment – includes placement

(TOOTH) (PA REQUIRED)

$404.00

For procedure codes D6058 – D6067, D6094 the following must be submitted:

• Periapical radiograph of integrated implant with abutment

• Intra-oral photograph of healed abutment showing healthy gingiva

Code

Description

D6058

Abutment supported porcelain/ceramic crown (TOOTH) (PA

REQUIRED)

$808.00

D6059

Abutment supported porcelain fused to metal crown (high noble

metal) (TOOTH) (PA REQUIRED)

$808.00

D6060

Abutment supported porcelain fused to metal crown predominantly

base metal) (TOOTH) (PA REQUIRED)

$808.00

D6061

Abutment supported porcelain fused to metal crown (noble metal)

(TOOTH) (PA REQUIRED)

$808.00

D6062

Abutment supported cast metal crown (high noble metal) (TOOTH)

(PA REQUIRED)

$808.00

D6063

Abutment supported cast metal crown (predominately base metal)

(TOOTH) (PA REQUIRED)

$808.00

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D6064

Abutment supported cast metal crown (noble metal) (TOOTH) (PA

REQUIRED)

$808.00

D6065

Implant supported porcelain/ceramic crown (TOOTH) (PA

REQUIRED)

$808.00

D6066

Implant supported crown - porcelain fused to high noble alloys

(TOOTH) (PA REQUIRED)

$808.00

D6067

Implant supported crown - high noble alloys (TOOTH) (PA

REQUIRED)

$808.00

D6081

Scaling and debridement in the presence of inflammation or

mucositis of a single implant, including cleaning on the implant

surfaces, without flap entry and closure (TOOTH) (REPORT

NEEDED)

• Cannot bill for same date of service as D1110 or D4910.

• Cannot bill for same date of service and same quadrant as

D4341, D4342.

(BR)

D6090

Repair implant supported prosthesis (ARCH) (REPORT NEEDED)

(BR)

D6091

Replacement of replaceable part of semi-precision or precision

attachment (male or female component)of implant/abutment

supported prosthesis, per attachment (QUAD) (REPORT NEEDED)

(BR)

D6092

Re-cement or re-bond implant/abutment supported crown (TOOTH)

(REPORT NEEDED)

(BR)

D6093

Re-cement or re-bond implant/abutment supported fixed partial

denture (QUAD) (REPORT NEEDED)

(BR)

D6094

Abutment supported crown – titanium and titanium alloys (TOOTH)

(PA REQUIRED)

$808.00

D6095

Repair implant abutment (TOOTH) (REPORT NEEDED)

(BR)

D6096

Remove broken implant retaining screw (TOOTH) (REPORT

NEEDED)

(BR)

D6100

Surgical removal of implant body (TOOTH) (REPORT NEEDED)

(POST OPERATIVE CARE: 10 DAYS)

(BR)

For procedure codes D6101 – D6103 the following must be submitted:

• Pre-operative radiographic image of defect

• Detailed narrative

• Intra-oral photograph of defect area

Code

Description

D6101

Debridement of a peri-implant defect or defects surrounding a single

implant, and surface cleaning of the exposed implant

surfaces,

including

flap

entry

and

closure

(TOOTH)

(PA

REQUIRED)

(POST

OPERATIVE CARE: 30 DAYS)

$252.50

D6102

Debridement and osseous contouring of a peri-implant defect or

defects

surrounding

single

implant

and

includes

surface

cleaning

of the exposed implant surfaces, including flap entry and closure

(TOOTH)

(PA

REQUIRED)

(POST

OPERATIVE

CARE:

DAYS)

$404.00

D6103

Bone graft for repair of peri-implant defect – does not include flap

entry

and

closure

(TOOTH) (PA

REQUIRED) (POST

OPERATIVE

CARE:

DAYS)

$202.00

D6104

Bone

graft

time

implant placement

(TOOTH)

(PA

REQUIRED)

(POST

OPERATIVE CARE: 90 DAYS)

$252.50

For procedure codes D6110 – D6113 the following must be submitted:

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• Periapical radiograph of integrated implant(s) with abutment placed

• Intra-oral photo of healed abutment showing healthy gingiva

Code

Description

D6110

Implant/abutment supported removable denture for edentulous

arch – maxillary (PA REQUIRED)

$1010.00

D6111

Implant/abutment supported removable denture for edentulous

arch – mandibular (PA REQUIRED)

$1010.00

D6112

Implant/abutment supported removable denture for partially

edentulous arch – maxillary (PA REQUIRED)

$909.00

D6113

Implant/abutment supported removable denture for partially

edentulous arch – mandibular (PA REQUIRED)

$909.00

D6190

Radiographic/surgical implant index, by report (ARCH) (REPORT

NEEDED)

(BR)

D6191

Semi-precision abutment - placement (TOOTH) (PA REQUIRED) This

procedure is the initial placement, or replacement, or a semi-precision

abutment on the implant body.

$202.00

D6192

Semi-precision

attachment

placement

(TOOTH)

(PA

REQUIRED)

This procedure involves the luting of the initial, or replacement, semi-

precision

attachment

the

removable

prosthesis.

$50.50

D6199

Unspecified implant procedure, by report

(REPORT NEEDED)

(BR)

The following procedure codes are a covered benefit only when associated with an

implant

implant-related

service:

D4245,

D 6 1 06, D6107,

D4266,

D4267,

D4273,

D4275,

D4277,

D4278, D4283, D4285.

Code

Description

D4245

Apically positioned flap (TOOTH) (PA REQUIRED) (POST

OPERATIVE CARE: 14 DAYS)

Procedure is used to preserve keratinized gingiva in conjunction with

osseous resection and second stage implant procedure. Procedure may

also be used to preserve keratinized/attached gingiva during surgical

exposure of labially impacted teeth and may be used during treatment of

peri-implantitis.

$126.25

D6106

Guided tissue regeneration – resorbable barrier, per implant

(TOOTH) (PA REQUIRED) (POST OPERATIVE CARE: 14 DAYS)

This procedure does not include flap entry and closure, or, when indicated,

would debridement, osseous contouring, bone replacement grafts, and

placement of biologic materials to aid in osseous regeneration. This

procedure is used for per-implant defects and during implant placement.

$126.25

D6107

Guided tissue regeneration – non-resorbable barrier, per implant

(TOOTH) (PA REQUIRED) (POST OPERATIVE CARE: 14 DAYS)

This procedure does not include flap entry and closure, or, when indicated,

would debridement, osseous contouring, bone replacement grafts, and

placement of biologic materials to aid in osseous regeneration. This

procedure is used for per-implant defects and during implant placement

$151.50

D4266

Guided tissue regeneration, natural teeth – resorbable barrier, per

site (TOOTH) (PA REQUIRED) (POST OPERATIVE CARE: 14 DAYS)

This procedure does not include flap entry and closure, or, when indicated,

wound debridement, osseous contouring, bone replacement grafts, and

$126.25

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placement of biologic materials to aid in osseous regeneration. This

procedure can be used for periodontal defects around natural teeth.

D4267

Guided tissue regeneration, natural teeth – non-resorbable barrier,

per site (TOOTH) (PA REQUIRED)

(POST OPERATIVE CARE: 14 DAYS)

This procedure does not include flap entry and closure, or, when indicated,

wound debridement, osseous contouring, bone replacement grafts, and

placement of biologic materials to aid in osseous

regeneration. This procedure can be used for periodontal defects around

natural teeth.

$151.50

D4273

Autogenous connective tissue graft procedure (including donor and

recipient surgical sites) first tooth, implant or edentulous tooth

position in graft

(TOOTH) (PA REQUIRED) (POST OPERATIVE CARE: 14 DAYS)

There are two surgical sites. The recipient site utilizes a split thickness

incision, retaining the overlapping flap of gingiva and/or mucosa. The

connective tissue is dissected from a separate donor site leaving an

epithelialized flap for closure.

$303.00

D4275

Non-autogenous connective tissue graft (including recipient site and

donor material) – first tooth, implant, or edentulous tooth position in

graft (TOOTH) (PA REQUIRED)

(POST OPERATIVE CARE: 14 DAYS)

$404.00

D4277

Free soft tissue graft procedure (including recipient and donor

surgical sites) first tooth, implant, or edentulous tooth position in

graft (TOOTH) (PA REQUIRED) (POST OPERATIVE CARE: 14 DAYS)

There is only a recipient surgical site utilizing split thickness incision,

retaining the overlaying flap of gingiva and/or mucosa. A donor surgical

site is not present.

$404.00

D4278

Free soft tissue graft procedure (including recipient and donor

surgical sites) each additional contiguous tooth, implant, or

edentulous tooth position in same graft site (TOOTH) (PA

REQUIRED) (POST OPERATIVE CARE: 14 DAYS)

Used in conjunction with D4277.

$303.00

D4283

Autogenous connective tissue graft procedure (including donor

and recipient surgical sites) – each additional contiguous tooth,

implant or edentulous tooth position in same graft site (TOOTH) (PA

REQUIRED) (POST OPERATIVE CARE: 14 DAYS)

Used in conjunction with D4273.

$202.00

D4285

Non-autogenous connective tissue graft procedure (including

recipient surgical site and donor material) – each additional

contiguous tooth, implant or edentulous tooth position in same

graft site. (TOOTH) (PA REQUIRED) (POST OPERATIVE CARE: 14

DAYS) Used in conjunction with D4275.

$303.00

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The following procedure codes are a covered benefit only when associated with an

implant or an implant-related service: D7951, D7952, D7953.

Code

Description

D7951

Sinus augmentation with bone or bone substitutes via a lateral

open approach (QUAD) (PA REQUIRED) (POST OPERATIVE CARE:

14 DAYS)

The augmentation of the sinus cavity to increase alveolar height for

reconstruction of edentulous portions of the maxilla. This procedure is

performed via a lateral open approach. This includes obtaining the bone

or bone substitutes. Placement of a barrier membrane if used should be

reported separately.

$808.00

D7952

Sinus augmentation with bone or bone substitutes via a vertical

approach (QUAD) (PA REQUIRED) (POST OPERATIVE CARE: 14

DAYS)

The augmentation of the sinus to increase alveolar height by vertical

access through the ridge crest by raising the floor of the sinus and grafting

as necessary. This includes obtaining the bone or bone substitutes.

$808.00

D7953

Bone replacement graft for ridge preservation – per site

(TOOTH) (PA REQUIRED) (POST OPERATIVE CARE: 10 DAYS)

Graft is placed in an extraction or implant removal site at the time of the

extraction or removal to preserve ridge integrity (e.g., clinically indicated

in preparation for implant reconstruction or where alveolar contour is

critical to planned prosthetic reconstruction). Does not include obtaining

graft material. Membrane, if used should be reported separately.

$252.50

IX. PROSTHODONTICS, FIXED D6200 - D6999

Fixed bridgework that is supported by natural teeth or dental implants is generally considered

beyond the scope of the NYS Medicaid program. The placement of a fixed prosthetic appliance

will only be considered for the anterior segment of the mouth in those exceptional cases where

there is a documented physical or neurological disorder that would preclude placement of a

removable prosthesis, or in those cases requiring cleft palate stabilization. In cases other than

for cleft palate stabilization, treatment would generally be limited to replacement of a single

maxillary anterior tooth or replacement of two adjacent mandibular teeth. The fabrication of a

fixed bridge is generally considered for members with no recent caries activity (no initial

restorations placed during the past year), no unrestored carious lesions, no significant periodontal

bone loss in the same arch and no posterior tooth loss with replaceable space in the same arch.

The replacement of a missing tooth or teeth with a fixed partial denture will not be approved under

the Medicaid program when either no replacement or replacement with a removable partial

denture could be considered appropriate based on Medicaid prosthetic guidelines.

For a member under the age of 21 or one whose pulpal anatomy precludes crown preparation of

abutments without pulp exposure, acid etched cast bonded bridges (“Maryland Bridges”) may be

approved only for the replacement of a single missing maxillary anterior tooth, two adjacent

missing maxillary anterior teeth, or two adjacent missing mandibular incisors. The same

guidelines as previously listed apply. Abutments for resin bonded fixed partial dentures (i.e.

“Maryland Bridges”) should be billed using code D6545 and pontics using code D6251.

The materials used in the fabrication of a crown (e.g., all-metal, porcelain, ceramic, resin) is at

the discretion of the provider. The crown fabricated must correctly match the procedure code

approved on the Prior Approval.

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FIXED

PARTIAL

DENTURE

PONTICS

Code

Description

D6210

Pontic - cast high noble metal (TOOTH) (PA REQUIRED)

$404.00

D6211

Pontic - cast predominately base metal (TOOTH) (PA REQUIRED)

$404.00

D6212

Pontic - cast noble metal (TOOTH) (PA REQUIRED)

$404.00

D6214

Pontic - titanium and titanium alloys (TOOTH) (PA REQUIRED)

$404.00

D6240

Pontic - porcelain fused to high noble metal (TOOTH) (PA

REQUIRED)

$404.00

D6241

Pontic - porcelain fused to predominately base metal (TOOTH) (PA

REQUIRED)

$404.00

D6242

Pontic - porcelain fused to noble metal (TOOTH) (PA REQUIRED)

$404.00

D6243

Pontic - porcelain fused to titanium and titanium alloys (TOOTH) (PA

REQUIRED)

$404.00

D6245

Pontic - porcelain/ceramic (TOOTH) (PA REQUIRED)

$404.00

D6250

Pontic - resin with high noble metal (TOOTH) (PA REQUIRED)

$404.00

D6251

Pontic - resin with predominately base metal (TOOTH) (PA

REQUIRED) Limited to the pontics for resin bonded fixed partial dentures

(i.e. “Maryland Bridges”).

$404.00

D6252

Pontic - resin with noble metal (TOOTH) (PA REQUIRED)

$404.00

FIXED

PARTIAL

DENTURE

RETAINERS-INLAYS/ONLAYS

Code

Description

D6545

Retainer - cast metal for resin bonded fixed prosthesis (TOOTH)

(PA REQUIRED) Limited to abutment for resin bonded fixed partial

dentures (i.e. “Maryland Bridges”).

$146.45

FIXED

PARTIAL

DENTURE

RETAINERS

–

CROWNS

Code

Description

D6720

Retainer crown - resin with high noble metal (TOOTH) (PA

REQUIRED)

$505.00

D6721

Retainer crown - resin with predominately base metal (TOOTH) (PA

REQUIRED)

$505.00

D6722

Retainer crown - resin with noble metal (TOOTH) (PA REQUIRED)

$505.00

D6740

Retainer crown - porcelain/ceramic (TOOTH) (PA REQUIRED)

$505.00

D6750

Retainer crown - porcelain fused to high noble metal (TOOTH) (PA

REQUIRED)

$505.00

D6751

Retainer crown - porcelain fused to predominantly base metal

(TOOTH) (PA REQUIRED)

$505.00

D6752

Retainer crown - porcelain fused to noble metal (TOOTH) (PA

REQUIRED)

$505.00

D6753

Retainer crown – porcelain fused to titanium and titanium alloys

(TOOTH) (PA REQUIRED)

$505.00

D6780

Retainer crown - ¾ cast high noble metal (TOOTH) (PA REQUIRED)

$404.00

D6781

Retainer crown - ¾ cast predominately base metal (TOOTH) (PA

REQUIRED)

$404.00

D6782

Retainer crown - ¾ cast noble metal (TOOTH) (PA REQUIRED)

$404.00

D6783

Retainer crown - ¾ porcelain/ceramic (TOOTH) (PA REQUIRED)

$404.00

D6784

Retainer crown - ¾ titanium and titanium alloys (TOOTH) (PA

REQUIRED)

$404.00

D6790

Retainer crown – full cast high noble metal (TOOTH) (PA REQUIRED)

$505.00

D6791

Retainer crown - full cast predominantly base metal (TOOTH) (PA

$505.00

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REQUIRED)

D6792

Retainer crown – full cast noble metal (TOOTH) (PA REQUIRED)

$505.00

D6794

Retainer crown – titanium and titanium alloys (TOOTH) (PA

REQUIRED)

$505.00

OTHER FIXED PARTIAL DENTURE SERVICES

Code

Description

D6930

Re-cement or re-bond fixed partial denture (QUAD)

$45.45

D6980

Fixed partial denture repair necessitated by restorative material

failure (QUAD) (REPORT NEEDED) For sectioning of a fixed partial

denture, use procedure code D9120.

(BR)

D6999

Unspecified, fixed prosthodontic procedure, by report (REPORT

NEEDED)

(BR)

X. ORAL AND MAXILLOFACIAL SURGERY D7000 – D7999

For

details

regarding

the

“ORAL

AND

MAXILLOFACIAL

SURGERY”

codes

that are associated

with the implant and implant-related services benefit ONLY (D7951, D7953), see section VIII.

IMPLANTS.

All surgical procedures include the surgery and the follow-up care for the period indicated

after the procedure description (e.g. (POST OPERATIVE CARE: 7 DAYS)). Necessary

follow-up care beyond the listed period should be billed using codes D7999, D9110 or

D9430.

When multiple surgical procedures are performed on the same quadrant or arch, the claim may

be pended for professional review. When extensive multiple surgical procedures are performed

at the same operative session,

the total reimbursement requested will be evaluated on a

case-by-case basis,

with possible reduction or denial of one or more of the billed

procedures. Removal of bilateral tori or bilateral impactions and multiple extractions

performed at the same operative session are examples of exceptions due to the

independence of the individual procedures.

When a provider performs surgical excision and removal of tumors, cysts and neoplasms,

the extent of the procedure claimed must be supported by information in the member's

record. This includes radiographic images, clinical findings, and operative and

histopathologic reports. To expedite review and reimbursement, this material (except

radiographs) should be

submitted on

paper claims

for procedures that have no established

fee and

are priced "By Report."

If a change is needed or there exists a disagreement with a prior approval

review and you

would like to challenge a determination rendered by the DOH

on an existing finalized prior

approval, a request may be submitted with supporting documentation and a detailed

report using a “Prior Approval

Change Request Form”.

This form may be submitted pre-

operatively or post-

operatively. If the requested change is submitted post-operatively a

copy of the treatment notes should be included with the request.

The Prior Approval Change Request Form can be found at the below link below or by calling

eMedNY at 1-800-343-9000. eMedNY: Information: Paper Forms.

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EXTRACTIONS

(INCLUDES

LOCAL

ANESTHESIA,

SUTURING,

NEEDED, AND ROUTINE

POSTOPERATIVE CARE)

Code

Description

D7111

Extraction, coronal remnants – primary tooth (TOOTH)

$35.35

D7140

Extraction, erupted tooth or exposed root (elevation and/or forceps

removal) (TOOTH) (POST OPERATIVE CARE: 3 DAYS)

$50.50

D7210

Extraction, erupted tooth requiring removal of bone and/or

sectioning of tooth, and including elevation of mucoperiosteal flap

if indicated (TOOTH) (POST OPERATIVE CARE: 10 DAYS)

Includes related cutting of gingiva and bone, removal of tooth structure,

minor smoothing of socket bone and closure. Prior approval is required if

performed more than four (4) times within twelve (12) months from the

date of the first surgical extraction (D7210).

$85.85

D7220

Removal of impacted tooth - soft tissue (TOOTH) (PA REQUIRED)

(POST OPERATIVE CARE: 10 DAYS)

$101.00

D7230

Removal of impacted tooth - partially bony (TOOTH) (PA

REQUIRED) (POST OPERATIVE CARE: 10 DAYS)

$181.80

D7240

Removal of impacted tooth - completely bony (TOOTH) (PA

REQUIRED) (POST OPERATIVE CARE: 10 DAYS)

$303.00

D7241

Removal of impacted tooth - completely bony, with unusual

surgical complications (TOOTH) (REPORT NEEDED)

(POST OPERATIVE CARE: 30 DAYS)

(BR)

D7250

Removal of residual tooth roots (cutting procedure) (TOOTH) (POST

OPERATIVE CARE: 10 DAYS) Includes cutting of soft tissue and

bone, removal of tooth structure, and closure.

$58.58

OTHER

SURGICAL

PROCEDURES

Code

Description

D7260

Oroantral fistula closure (QUAD 10 or 20) (POST OPERATIVE CARE:

14 DAYS)

$202.00

D7261

Primary closure of sinus perforation (QUAD 10 or 20) (POST

OPERATIVE CARE: 14 DAYS)

$202.00

D7270

Tooth re-implantation and/or stabilization of accidentally evulsed or

displaced tooth (TOOTH) (POST OPERATIVE CARE: 30 DAYS).

Includes splitting and/or stabilization.

$115.14

D7272

Tooth transplantation (includes re-implantation from one site to

another and splinting and/or stabilization) (TOOTH) (POST

OPERATIVE CARE: 30 DAYS)

$151.50

D7280

Exposure of an unerupted tooth (TOOTH) (POST OPERATIVE CARE:

14 DAYS) An incision is made, and the tissue is reflected, and bone

removed as necessary to expose the crown of an impacted tooth not

intended to be extracted.

$292.90

D7283

Placement of device to facilitate eruption of impacted tooth

(TOOTH) (POST OPERATIVE CARE: 14 DAYS) Report the surgical

exposure separately using D7280.

$50.50

D7285

Incisional Biopsy of oral tissue - hard (bone, tooth) (REPORT

NEEDED) This procedure does not entail an excision. (POST OPERATIVE

CARE: 30 DAYS)

Claims must be submitted on paper with a copy of the operative report,

including the description and location of the lesion and pathology report.

$105.04

D7286

Incisional Biopsy of oral tissue – soft (REPORT NEEDED)

(POST OPERATIVE CARE: 30 DAYS)

$84.84

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This procedure does not entail an excision. Claims must be submitted on

paper with a copy of the operative report, including the description and

location of the lesion and pathology report.

D7290

Surgical repositioning of teeth (TOOTH) (PA REQUIRED) (POST

OPERATIVE CARE: 60 DAYS)

$146.45

ALVEOLOPLASTY

PREPARATION

RIDGE

Code

Description

D7310

Alveoloplasty in conjunction with extractions – four or more teeth or

tooth spaces, per quadrant (QUAD) (POST OPERATIVE CARE: 14

DAYS) This procedure will be reimbursed when additional surgical

procedures above and beyond the removal of the teeth are required to

prepare the ridge for dentures. Not reimbursable in addition to surgical

extractions in the same quadrant. Claims should be submitted on the same

invoice as extractions to expedite review.

$70.70

D7311

Alveoloplasty in conjunction with extractions – one to three teeth or

tooth spaces, per quadrant (QUAD) (POST OPERATIVE CARE: 14

DAYS) This procedure will be reimbursed when additional surgical

procedures above and beyond the removal of the teeth are required to

prepare the ridge for dentures. Not reimbursable in addition to surgical

extractions in the same quadrant. Claims should be submitted on the

same invoice as extractions to expedite review.

$50.50

D7320

Alveoloplasty not in conjunction with extractions – four or more teeth

or tooth spaces, per quadrant (QUAD) (POST OPERATIVE CARE: 14

DAYS) The fee for each quadrant includes the recontouring of both

osseous and soft tissues in that quadrant. Will not be reimbursed in

conjunction with procedure code D7310 in the same quadrant.

$116.15

D7321

Alveoloplasty not in conjunction with extractions – one to three or

tooth spaces, per quadrant (QUAD) (POST OPERATIVE CARE: 14

DAYS) The fee for each quadrant includes the recontouring of both

osseous and soft tissues in that quadrant. Will not be reimbursed in

conjunction with procedure code D7311 in the same quadrant.

$75.75

VESTIBULOPLASTY

Vestibuloplasty may be approved when a denture could not otherwise be worn.

Code

Description

D7340

Vestibuloplasty - ridge extension (secondary epithelialization)

(ARCH) (PA REQUIRED) (POST OPERATIVE CARE: 60 DAYS)

$303.00

D7350

Vestibuloplasty - ridge extension (including soft tissue grafts,

muscle reattachment, revision of soft tissue attachment and

management of hypertrophied and hyperplastic tissue) (ARCH)

(PA REQUIRED) (POST OPERATIVE CARE: 60 DAYS)

$404.00

EXCISION OF SOFT TISSUE LESIONS (INCLUDES NON- ODONTOGENIC CYSTS)

All claims for D7410, D7411, and D7412, must be submitted with a copy of the operative report

and all claims for D7413, D7414, and D7415 must be submitted with a copy of the pathology

and operative report(s). All operative reports must include a description of the lesion and its

location.

Code

Description

D7410

Excision of benign lesion up to 1.25 cm (REPORT NEEDED) (POST

OPERATIVE CARE: 30 DAYS)

$102.01

D7411

Excision of benign lesion greater than 1.25cm (REPORT NEEDED)

(BR)

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(POST OPERATIVE CARE: 60 DAYS)

D7412

Excision of benign lesion complicated (REPORT NEEDED) (POST

OPERATIVE CARE: 60 DAYS)

(BR)

D7413

Excision of malignant lesion up to 1.25cm (REPORT NEEDED) (POST

OPERATIVE CARE: 30 DAYS)

(BR)

D7414

Excision of malignant lesion greater than 1.25cm (REPORT NEEDED)

(POST OPERATIVE CARE: 60 DAYS)

(BR)

D7415

Excision of malignant lesion complicated (REPORT NEEDED) (POST

OPERATIVE CARE: 60 DAYS)

(BR)

EXCISION OF INTRA-OSSEOUS LESIONS

Claims must be submitted with a copy of the pathology and operative report(s) and must

include a description of the lesion and its location. Reimbursement for routine or surgical

extractions includes removal of tooth, soft tissue associated with the root and curettage of the

socket. Periapical granulomas at the apex of decayed teeth will not be separately reimbursed in

addition to the tooth extraction.

Code

Description

D7440

Excision of malignant tumor - lesion diameter up to 1.25 cm (QUAD)

(REPORT NEEDED) (POST OPERATIVE CARE: 30 DAYS)

(BR)

D7441

Excision of malignant tumor -lesion greater than 1.25 cm (QUAD)

(REPORT NEEDED) (POST OPERATIVE CARE: 60 DAYS)

(BR)

D7450

Removal of benign odontogenic cyst or tumor-lesion diameter up to

1.25 cm (QUAD) (REPORT NEEDED) (POST OPERATIVE CARE: 30

DAYS)

$85.57

D7451

Removal

benign

odontogenic

cyst

tumor-lesion

greater than

1.25

(QUAD)

(REPORT

NEEDED) (POST OPERATIVE

CARE:

DAYS)

(BR)

D7460

Removal of

benign nonodontogenic cyst

or tumor - lesion

diameter up

to 1.25 cm (QUAD) (REPORT NEEDED)

(POST

OPERATIVE

CARE:

DAYS)

$102.01

D7461

Removal

benign

nonodontogenic

cyst

tumor

–

greater than

1.25

(QUAD)

(REPORT

NEEDED) (POST

OPERATIVE

CARE:

DAYS)

(BR)

D7465

Destruction

of lesion(s)

by physical

or chemical

methods,

report

(REPORT NEEDED) (POST OPERATIVE CARE: 60 DAYS)

(BR)

EXCISION

BONE

TISSUE

Code

Description

D7471

Removal of lateral exostosis

(maxilla

or mandible)

(QUAD)

(REPORT

NEEDED) (POST OPERATIVE CARE: 21 DAYS)

(BR)

D7472

Removal

torus palatinus

(REPORT

NEEDED) (POST

OPERATIVE

CARE: 21 DAYS)

(BR)

D7473

Removal

torus mandibularis

(QUAD

40) (REPORT

NEEDED)

(POST OPERATIVE CARE: 21 DAYS)

(BR)

D7485

Reduction of osseous tuberosity (QUAD 10 or 20)

(REPORT

NEEDED)

(POST

OPERATIVE

CARE:

DAYS)

(BR)

D7490

Radical resection of maxilla or mandible

(ARCH) (REPORT

NEEDED)

(POST OPERATIVE CARE: 180 DAYS)

(BR)

SURGICAL INCISION

Reimbursement for incision and drainage procedures includes both the insertion and the removal

of all drains.

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Code

Description

D7510

Incision and drainage of abscess – intraoral soft tissue

(QUAD) (POST OPERATIVE CARE: 10 DAYS) (REPORT NEEDED)

$70.70

D7511

Incision and drainage of abscess – intraoral soft tissue –

complicated (includes drainage of multiple fascial spaces)

(QUAD) (REPORT NEEDED)

(BR)

D7520

Incision and drainage of abscess – extraoral soft tissue

(QUAD) (POST OPERATIVE CARE: 21 DAYS) (REPORT NEEDED)

$141.40

D7521

Incision and drainage of abscess – extraoral soft tissue –

complicated (includes drainage of multiple fascial spaces)

(QUAD) (REPORT NEEDED)

(BR)

D7530

Removal of foreign body from mucosa, skin, or

subcutaneous alveolar tissue (QUAD) (REPORT NEEDED) (POST

OPERATIVE CARE: 21 DAYS)

(BR)

D7540

Removal of reaction-producing foreign bodies –

musculoskeletal system (QUAD) (REPORT NEEDED) (POST

OPERATIVE CARE: 90 DAYS)

The report must include a description of the foreign body and its location.

(BR)

D7550

Partial ostectomy / sequestrectomy for removal of non-vital bone

(QUAD) (REPORT NEEDED) (POST OPERATIVE CARE: 90 DAYS)

The report must include a description of the surgical site.

(BR)

D7560

Maxillary sinusotomy for removal of tooth fragment or foreign

body (QUAD) (REPORT NEEDED) (POST OPERATIVE CARE: 60

DAYS) Includes closure of oroantral communication when performed

concurrently.

$439.35

TREATMENT

CLOSED

FRACTURE

Code

Description

D7610

Maxilla - open reduction (teeth immobilized if present)

(REPORT NEEDED) (POST OPERATIVE CARE: 90 DAYS)

$1,171.60

D7620

Maxilla - closed reduction (teeth immobilized if present)

(REPORT NEEDED) (POST OPERATIVE CARE: 90 DAYS)

$439.35

D7630

Mandible - open reduction (teeth immobilized if present)

(REPORT NEEDED) (POST OPERATIVE CARE: 90 DAYS)

$1,318.05

D7640

Mandible - closed reduction (teeth immobilized if present)

(REPORT NEEDED) (POST OPERATIVE CARE: 90 DAYS)

$439.35

D7650

Malar and/or zygomatic arch - open reduction (REPORT NEEDED)

(POST OPERATIVE CARE: 90 DAYS)

$732.25

D7660

Malar and/or zygomatic arch - closed reduction (REPORT NEEDED)

(POST OPERATIVE CARE: 90 DAYS)

(BR)

D7670

Alveolus - closed reduction, may include stabilization of teeth

(REPORT NEEDED) (POST OPERATIVE CARE: 60 DAYS)

$205.03

D7671

Alveolus - open reduction, may include stabilization of teeth

(REPORT NEEDED) (POST OPERATIVE CARE: 90 DAYS)

(BR)

D7680

Facial bones – complicated reduction with fixation and multiple

surgical approaches (REPORT NEEDED) (POST OPERATIVE CARE:

90 DAYS)

(BR)

TREATMENT

OPEN

FRACTURES

Reimbursement

for

codes

D7710-D7740

includes

splint

fabrication when

necessary.

Code

Description

D7710

Maxilla – open reduction

(REPORT NEEDED)

(POST OPERATIVE

CARE: 90 DAYS)

(BR)

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D7720

Maxilla - closed reduction

(REPORT NEEDED)

(POST OPERATIVE

CARE: 90 DAYS)

$585.80

D7730

Mandible - open reduction

(REPORT NEEDED)

(POST OPERATIVE

CARE: 90 DAYS)

(BR)

D7740

Mandible - closed reduction

(REPORT NEEDED)

(POST OPERATIVE

CARE: 90 DAYS)

$585.80

D7750

Malar and/or zygomatic arch

- open reduction

(REPORT

NEEDED)

(POST OPERATIVE CARE: 90 DAYS)

(BR)

D7760

Malar and/or zygomatic arch

- closed

reduction

(REPORT

NEEDED)

(POST OPERATIVE CARE: 90 DAYS)

(BR)

D7770

Alveolus – open reduction

stabilization of teeth

(REPORT

NEEDED)

(POST OPERATIVE CARE: 90 DAYS)

(BR)

D7771

Alveolus - closed reduction stabilization of teeth

(REPORT

NEEDED)

(POST OPERATIVE CARE: 90 DAYS)

(BR)

D7780

Facial bones – complicated reduction with fixation and

multiple

approaches

(REPORT

NEEDED) (POST

OPERATIVE

CARE:

90 DAYS)

(BR)

REDUCTION

DISLOCATION

AND MANAGEMENT

OTHER

TEMPOROMANDIBULAR

JOINT DYSFUNCTIONS

Routine services for treatment of temporomandibular joint, myofascial pain and related

disorders are generally considered beyond the scope of the program. Reimbursement

for temporomandibular joint dysfunctions will be permitted only in the specific conditions

wherein a definitive diagnosis corroborates necessary treatment. Appropriate

documentation (e.g., operative report, procedure description) should accompany all

claims as attachments.

Code

Description

D7810

Open reduction of dislocation (REPORT NEEDED) (POST

OPERATIVE CARE: 90 DAYS)

$1464.50

D7820

Closed reduction of dislocation (REPORT NEEDED) (POST

OPERATIVE CARE: 7 DAYS)

$141.40

D7830

Manipulation under anesthesia (REPORT NEEDED) (POST

OPERATIVE CARE: 7 DAYS)

$175.74

D7840

Condylectomy (REPORT NEEDED) (POST OPERATIVE CARE: 90

DAYS)

$1757.40

D7850

Surgical discectomy; with/without implant (POST OPERATIVE

CARE: 90 DAYS)

$878.70

D7852

Disc repair (REPORT NEEDED) (POST OPERATIVE CARE: 90 DAYS)

$1,054.44

D7854

Synovectomy (REPORT NEEDED) (POST OPERATIVE CARE: 90

DAYS)

$820.12

D7856

Myotomy (REPORT NEEDED) (POST OPERATIVE CARE: 90 DAYS)

(BR)

D7858

Joint reconstruction (REPORT NEEDED) (POST OPERATIVE CARE:

120 DAYS)

$2,929.00

D7860

Arthrotomy (REPORT NEEDED) (POST OPERATIVE CARE: 90

DAYS)

$878.70

D7865

Arthroplasty (REPORT NEEDED) (POST OPERATIVE CARE: 90

DAYS)

$2,050.30

D7870

Arthrocentesis (REPORT NEEDED) (POST OPERATIVE CARE: 7

DAYS)

$117.16

D7872

Arthroscopy - diagnosis, with/without biopsy (REPORT NEEDED)

(POST OPERATIVE CARE: 14 DAYS)

$732.25

D7873

Arthroscopy: lavage and lysis of adhesions (REPORT NEEDED)

(POST OPERATIVE CARE: 30 DAYS)

$732.25

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D7874

Arthroscopy: disc repositioning and stabilization (REPORT

NEEDED) (POST OPERATIVE CARE: 60 DAYS)

$1,054.44

D7875

Arthroscopy: synovectomy (REPORT NEEDED) (POST OPERATIVE

CARE: 60 DAYS)

$1,054.44

D7876

Arthroscopy: discectomy (REPORT NEEDED) (POST OPERATIVE

CARE: 60 DAYS)

$1,054.44

D7877

Arthroscopy: debridement (REPORT NEEDED) (POST OPERATIVE

CARE: 60 DAYS)

$1,054.44

D7880

Occlusal orthotic appliance, by report (REPORT NEEDED) (POST

OPERATIVE CARE: 10 DAYS)

Reimbursable only when performed in conjunction with a covered

surgical procedure. Not used for “night guards”, “occlusal guards”,

bruxism appliances, or other TMJ appliances.

(BR)

D7899

Unspecified TMD therapy, by report (REPORT NEEDED)

(BR)

REPAIR OF TRAUMATIC WOUNDS

Excludes closure of surgical incisions.

Code

Description

D7910

Suture of recent small wounds up to 5 cm (REPORT NEEDED) (POST

OPERATIVE CARE: 14 DAYS)

$101.00

COMPLICATED SUTURING (RECONSTRUCTION REQUIRING DELICATE HANDLING OF

TISSUES AND WIDE UNDERMINING FOR METICULOUS CLOSURE)

Excludes closure of surgical incisions. Utilized in situations requiring unusual and time-consuming

techniques of repair to obtain the maximum functional and cosmetic result. The extent of the

procedure claimed must be supported by information in the operative report.

Code

Description

D7911

Complicated suture - up to 5 cm (REPORT NEEDED) (POST

OPERATIVE CARE: 30 DAYS)

$126.25

D7912

Complicated suture - greater than 5 cm, (REPORT NEEDED) (POST

OPERATIVE CARE: 60 DAYS)

(BR)

OTHER REPAIR PROCEDURES

Code

Description

D7920

Skin graft (identify defect covered, location and type of graft)

(REPORT NEEDED) (POST OPERATIVE CARE: 90 DAYS)

(BR)

D7940

Osteoplasty - for orthognathic deformities (REPORT NEEDED) (POST

OPERATIVE CARE: 90 DAYS) Use to report genioplasty.

(BR)

D7941

Osteotomy - mandibular rami (REPORT NEEDED) (POST OPERATIVE

CARE: 90 DAYS)

$1,464.50

D7943

Osteotomy - mandibular rami with bone graft; includes obtaining the

graft (REPORT NEEDED) (POST OPERATIVE CARE: 90 DAYS)

$2,196.75

D7944

Osteotomy - segmented or subapical (REPORT NEEDED) (POST

OPERATIVE CARE: 90 DAYS)

$1171.60

D7945

Osteotomy - body of mandible (REPORT NEEDED) (POST

OPERATIVE CARE: 90 DAYS)

$1113.02

D7946

LeFort I (maxilla-total) (REPORT NEEDED) (POST OPERATIVE CARE:

90 DAYS)

$2,196.75

D7947

LeFort I (maxilla-segmented) (REPORT NEEDED) (POST OPERATIVE

$2,929.00

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CARE: 90 DAYS) When reporting a surgically assisted palatal expansion

without downfracture, this code would entail a reduced service and should

be “by report” using procedure code D7999.

D7948

LeFort II or LeFort III (osteoplasty of facial bones for midface

hyperplasia or retrusion) - without bone graft (REPORT NEEDED)

(POST OPERATIVE CARE: 90 DAYS)

$2,929.00

D7949

LeFort II or LeFort III with bone graft (REPORT NEEDED) (POST

OPERATIVE CARE: 90 DAYS)

$3,514.80

D7950

Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla

- autogenous or nonautogenous, by report (REPORT NEEDED) (POST

OPERATIVE CARE: 90 DAYS)

(BR)

D7961

Buccal / labial frenectomy (frenulectomy) (ARCH) (REPORT

NEEDED) (POST OPERATIVE CARE: 14 DAYS) Removal or release of

mucosal and muscle elements of a buccal/labial frenum that is associated

with a pathological condition or interferes with proper oral development or

treatment.

$191.90

D7962

Lingual frenectomy (frenulectomy) (ARCH) (REPORT NEEDED)

(POST OPERATIVE CARE: 14 DAYS) Removal or release of mucosal and

muscle elements of a lingual frenum that is associated with a pathological

condition or interferes with proper oral development or treatment.

$191.90

D7970

Excision of hyperplastic tissue- per arch (ARCH) (REPORT NEEDED)

(POST OPERATIVE CARE: 14 DAYS)

$151.50

D7971

Excision of pericoronal gingiva (TOOTH) (REPORT NEEDED)

(POST OPERATIVE CARE: 10 DAYS) All claims will be pended for

professional review.

$60.60

D7972

Surgical reduction of fibrous tuberosity (QUAD) (REPORT NEEDED)

(POST OPERATIVE CARE: 14 DAYS)

(BR)

D7980

Surgical sialolithotomy (POST OPERATIVE CARE: 14 DAYS)

$292.90

D7981

Excision of salivary gland, by report (REPORT NEEDED) (POST

OPERATIVE CARE: 30 DAYS)

(BR)

D7982

Sialodochoplasty (REPORT NEEDED) (POST OPERATIVE CARE: 30

DAYS)

$834.26

D7983

Closure of salivary fistula (REPORT NEEDED) (POST OPERATIVE

CARE: 30 DAYS)

(BR)

D7990

Emergency tracheotomy

$732.25

D7991

Coronoidectomy (REPORT NEEDED) (POST OPERATIVE CARE: 60

DAYS)

$556.51

D7997

Appliance removal (not by dentist who placed appliance), includes

removal of archbar (REPORT NEEDED) (POST OPERATIVE CARE: 14

DAYS) Not for removal of orthodontic appliances. Includes both arches, if

necessary.

(BR)

D7998

Intraoral placement of a fixation device not in conjunction with a

fracture (REPORT NEEDED) Includes both arches, if necessary.

(BR)

D7999

Unspecified oral surgical procedure, by report (REPORT NEEDED)

(BR)

XI. ORTHODONTICS D8000 – D8999

ELIGIBILITY

Eligibility is limited to members who:

1. are under 21 years of age;

2. meet financial standards for Medicaid eligibility; and,

3. exhibit a SEVERE PHYSICALLY HANDICAPPING MALOCCLUSION.

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Orthodontic care for severe physically handicapping malocclusions is a once in a lifetime benefit

that will be reimbursed for an eligible member for a maximum of three years of active orthodontic

care, plus one year of retention care. Retreatment for relapsed cases is not a covered service.

Treatment must be approved, and active therapy begun (appliances placed and activated) prior

to the member’s 21

birthday. Treatment of cleft palate or approved orthognathic surgical cases

may be approved after the age of 21 or for additional treatment time.

With the exception of D8210, D8220 and D8999, orthodontic care is reimbursable only when

provided by an orthodontist or an Article 28 facility which have met the qualifications of

the DOH and are enrolled with the appropriate specialty

code.

PRIOR APPROVAL

The following orthodontic procedures codes require prior approval:

D8010*, D8020*, D8030, D8040, D8070, D8080, D8090, D8670, and D8680

The

following

documentation

must

submitted

along

with

the

prior

approval

request:

• Pages 1 and 2 of the completed and signed “Handicapping Labio-Lingual (HLD)

Index Report”. The HLD Index Report is available on the internet at:

https://www.emedny.org/ProviderManuals/Dental/PDFS/HLD_Index_NY.pdf

• A panoramic and/or mounted full mouth series of intra-oral radiographic images;

• A cephalometric radiographic image with teeth in centric occlusion and

cephalometric analysis / tracing;

•

Photographs

frontal

and

profile

views;

• Intra-oral photographs depicting right and left occlusal relationships as well as an

anterior view;

•

Maxillary

and

mandibular

occlusal

photographs;

•

Photos of articulated models can be submitted optionally (Do

NOT

send stone

casts).

*Note: A HLD index report is not required for procedure codes D8010 and D8020 as they are

primarily intended and utilized for interceptive orthodontic treatment.

Subjective statements submitted by the provider or others must be substantiated by objective

documentation such as photographs, radiographic images, credible medical

documentation, etc.

verifying the nature and extent of the severe physical handicapping

malocclusion. Requests where

there is significant disparity between the subjective documentation (e.g. HLD index report

and narrative) and objective documentation (e.g. photographs and/or radiographic

images) will be returned for clarification without review.

Requests for continuation of orthodontic treatment which was begun without prior approval from

the DOH or a NYS Medicaid Managed Care Plan will be evaluated using the same criteria and

guidelines to determine if a severe physically handicapping malocclusion currently exists. A

completed HLD index report based on the current dentition, and all of the required documentation

(listed above) must be submitted along with the prior approval request. If continuation of treatment

is denied, debanding and retention might be approvable using procedure code D8695.

Orthognathic Surgical Cases with Comprehensive Orthodontic Treatment

• Members must be at least 15 years of age for case consideration;

• The surgical consult, complete treatment plan and approval for surgical treatment (if

necessary) must be included with the request for orthodontic treatment;

• Prior approval and documentation requirements are the same as those for comprehensive

treatment;

• A statement signed by the parent/guardian and member that they understand and accept

the proposed treatment, both surgical and orthodontic, and understand that approval for

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orthodontic treatment is contingent upon completion of the surgical treatment.

LIMITED

EXTENDED

COVERAGE

Regardless of whether the dental benefit is administered through Managed Care or through

fee-for-service, when eligibility is lost after active orthodontic treatment has been initiated, fee-

for-service Medicaid will provide for up to:

• Two (2) quarterly payments; or,

• One (1) quarterly payment and retention; or,

•

Retention

alone.

The treating orthodontist may decide to complete active treatment (including retention care),

initiate retention care to preserve current status, or remove the appliances in cases of minimal

progress during active therapy. At least thirty (30) days of treatment must have been provided

following the loss of eligibility. When billing for the limited extended coverage, submit a paper

claim to eMedNY using procedure code D8999, the last date of eligibility as the date of service

and identify the stage of treatment when eligibility was lost (e.g., 2

quarter of second year; 1

quarter of third year, etc.). The maximum benefit for limited extended coverage is only payable

one (1) time during the course of orthodontic treatment.

If approval for orthodontic treatment was issued through Medicaid Managed Care

(MMC)

copy

the

authorization

for treatment

and

remittance

statement(s) must

also

be included. Only those

cases previously approved for comprehensive orthodontic treatment (D8070, D8080, or D8090)

in which appliances have been placed and activated are eligible for the “Limited Extended

Coverage” benefit. Claims for the “Limited Extended Coverage” benefit MUST be submitted within

9 months of the loss of eligibility. Claims submitted for payment beyond that time range will be

subject to denial.

CONTINUATION OF ACTIVE ORTHODONTIC TREATMENT WHEN THE MEMBER’S

MEDICAID COVERAGE CHANGES

When a member undergoing active orthodontic treatment that was authorized by MMC Plan (or

their vendor) has coverage changed to fee-for-service Medicaid, a prior approval for continued

treatment is required from the fee-for-service program. In such cases, providers must adhere to

the original treatment time authorized by MMC Plans. A prior approval request for continuation of

orthodontic care (D8670) should be submitted to eMedNY with the following documentation:

• A copy of the original Medicaid Managed Care Plan authorization or approval for

comprehensive orthodontic treatment;

• A copy of the remittance statement from the Medicaid Managed Care Plan;

• All pre-treatment records and recent progress photographs depicting the current dentition;

and,

• A brief narrative describing the services already rendered (e.g. Initial placement of

orthodontic appliances and two quarters of D8670 have been paid by Healthplex).

Again, orthodontic coverage for procedure codes D8670 and D8680 is subject to the member’s

eligibility. If a member’s coverage is changed back to managed care a request for these

orthodontic services will need to be submitted to the member’s Managed Care Plan.

The total fee-for-service reimbursement amount for active treatment will not exceed the maximum

fees listed in the Dental Fee Schedule.

CONTINUATION OF ACTIVE ORTHODONTIC TREATMENT FOR CHILDREN WHEN THEIR

DOMICILE CHANGES

When there is a change in the domicile of a member in mid-treatment, a continuation of active

orthodontic treatment may be required with a new orthodontist who participates in the NYS

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Medicaid Orthodontic program (FFS and MMC plan). It is desirable and recommended to

continue and finish the active orthodontic treatment utilizing the existing functional orthodontic

appliances. In a situation when the new orthodontist cannot continue the active orthodontic

treatment with the existing orthodontic appliances due to multiple missing brackets and/or

different treatment plans, then a detailed narrative substantiating the need for new orthodontic

appliances must be submitted with a prior approval request.

A prior approval request for continuation of orthodontic care (D8670) should be submitted to either

eMedNY (for FFS members) or to the member’s Medicaid Managed Care Plan (or their vendors)

with the following documentation:

• Current orthodontic records depicting the current dentition, and treatment plan indicating

the anticipated length of active orthodontic treatment.

• AAO (American Association of Orthodontists) Transfer Form.

MEDICAID MEMBERS CANNOT BE BILLED

By enrolling in the Medicaid program, a provider agrees to accept payment under the Medicaid

program as payment in full for services rendered. There is no separate billing for the replacement

of broken appliances such as bands, brackets or arch wires.

Medicaid payment for orthodontic services represents payment in full for the entire treatment

protocol, regardless of the type of appliances used. Separately billing the member for any

portion of orthodontic treatment is prohibited.

Orthodontists must offer Medicaid members the same treatment options offered to the majority of

patients in the provider’s practice with similar treatment needs (e.g., orthodontists may not restrict

Medicaid members to metal brackets if non- Medicaid patients are routinely provided other types

of devices (e.g. bonded “clear” brackets, “Damon” ® brackets, clear appliance therapy, bite plates

or removable appliances) and may not charge Medicaid members for the use of these other

techniques and/or devices.

Reimbursement for orthodontic services includes the placement and removal of all appliances

and brackets. Should it become necessary to remove the bands due to non-compliance or elective

discontinuation of treatment by the provider, parent, guardian or member the appliance(s) must

be removed at no additional charge to either the member, family or Medicaid.

DISCONTINUATION OF TREATMENT

In cases where treatment is discontinued, a “Release from Treatment” form must be provided by

the dental office which documents the date and the reason for discontinuing care. The release

form must be reviewed and signed by the parent/guardian and member. The “Release from

Treatment” form must indicate that all those involved understand future orthodontic treatment will

not be covered by Medicaid. A copy must be sent to NYSDOH OHIP Bureau of Dental Review.

New York State Department of Health, Office of Health Insurance Programs

Bureau of Dental Review

One Commerce Plaza, Room 1206

Albany, NY 12260

Behavior Not Conducive to Favorable Treatment Outcomes

It is the expectation that the case selection process for orthodontic treatment take into

consideration the member’s ability over the course of treatment to:

• Tolerate orthodontic treatment;

• Comply with necessary instructions for home care (e.g., wear elastics, headgear,

removable appliance, etc.)

• Keep multiple appointments over several years;

• Maintain an oral hygiene regimen;

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• Be cooperative and complete all needed preventive and treatment visits.

If it is determined that the member is exhibiting non-compliant behavior (e.g. multiple missed

orthodontic and general dental appointments, continued poor oral hygiene,

and/or failure

maintain

the

appliances and/or

untreated

dental

disease)

letter

must

be sent to the parent/guardian

that documents the factors of concern and the corrective

actions needed and that failure to comply

can result in discontinuation of treatment. A copy must be sent to the DOH.

If orthodontic treatment is discontinued for cause, the parent/guardian and/or patient must sign a

statement indicating they understand treatment is being discontinued prior to completion; the

reason(s) for discontinuation of treatment; and, that it will jeopardize their ability to have further

orthodontic treatment provided through the NYS Medicaid Program. The treating orthodontist

must make reasonable provisions to provide necessary treatment during the transition of care to

another provider or for debanding.

In a situation when all reasonable attempts to contact the patient

and/or their parent are

unsuccessful, orthodontic treatment may be discontinued without a

patient/parent’s signature. Any attempts to reach the patient should be documented in the

patient’s record. Terminating a doctor patient relationship is a medico-legal issue; therefore, the

treating orthodontist should seek an appropriate legal counsel at their own discretion.

All approved courses of comprehensive orthodontic treatment must be concluded in a manner

acceptable to the DOH and the DOH must be notified. Appropriate means of concluding treatment

include:

• Successful completion of treatment and the issuance of a prior approval by the DOH for

debanding and/or retention;

• Notification that treatment is being discontinued for cause and that the

parent/guardian and/or member have been appropriately notified, or;

• Loss of eligibility and utilization of the “Limited Extended Coverage” benefit to conclude

treatment.

Treatment must continue to a point satisfactory to the DOH, regardless of the length of time

treatment is required and even if all Medicaid benefits have been exhausted, without charge to

the NYS Medicaid Program, the member or family. Failure to conclude treatment in an

acceptable manner can result in the recovery of the entire cost of the complete course

of treatment.

“BY REPORT” CODES THAT ARE ALSO “PA OPTIONAL”

For those procedures listed in this manual and/ or on the Dental Fee Schedule without a published

fee (D8210 and D8220) and are listed as both “(REPORT NEEDED, PA OPTIONAL)”:

• Procedures can be reviewed for appropriateness and tentatively priced before treatment

is initiated by submitting a prior approval request.

- OR -

• Procedures can be priced after treatment without prior approval as a “By Report” based

on documentation submitted with the claim substantiating a qualifying physically

handicapping malocclusion.

ORTHODONTIC RECORDS TAKEN THAT ARE NOT REQUIRED BY DOH ARE NOT

REIMBURSABLE

Any records taken at the discretion of the provider cannot be charged to the NYS Medicaid

Program, the member or family.

The NYS Medicaid Program will reimburse for those services that are medically necessary, are

an integral part of the actual treatment, or that are required by the Department. Orthodontic

records taken solely for the provider’s records, such as photographs (D0350), diagnostic

casts/study models (D0470), and radiographic

images (including a FMS (D0210), panoramic

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(D0330) and cephalometric (D0340)) and are not required by the Department will be considered part

of the reimbursement for the

comprehensive orthodontic treatment and are not payable separately.

The provider can take these records as part of the treatment records, but they cannot charge

the NYS Medicaid Program, the member or family. Payment may be considered on an exceptional

basis if there is documentation of medical necessity.

LIMITED

ORTHODONTIC

TREATMENT

Orthodontic treatment utilizing any therapeutic modality with a limited objective or scale of

treatment. Treatment may occur in any stage of dental development or dentition.

The objective may be limited by:

• not involving the entire dentition.

• not attempting to address the full scope of the existing or developing orthodontic problem.

• mitigating an aspect of a greater malocclusion (i.e., crossbite, overjet, overbite, arch

length, anterior alignment, one phase of multi-phase treatment, treatment prior to the

permanent dentition, etc.).

• a decision to defer or forego comprehensive treatment.

The submitted records must demonstrate a physically handicapping malocclusion indicating the

need for limited orthodontic treatment. Procedure codes for limited orthodontic treatment cannot

be substituted for procedure codes D8070, D8080, and D8090 if a member does not qualify for

comprehensive orthodontic treatment as per NYS Medicaid criteria. There is only one flat fee for

limited orthodontic treatment, that is, all adjustment visits and transitional retainer are included in

one fee—there is no additional compensation beyond that.” Prior Approval and reimbursement

will be determined based on supporting documentation submitted.

If comprehensive treatment is required following a course of limited treatment, a period of 12 to

18 months should be allowed prior to requesting comprehensive treatment to provide for

stabilization of the result.

Code

Description

D8010

Limited orthodontic treatment of the primary dentition (PA REQUIRED)

D8020

Limited orthodontic treatment of the transitional dentition (PA REQUIRED)

D8030

Limited orthodontic treatment of the adolescent dentition (PA REQUIRED)

D8040

Limited orthodontic treatment of the adult dentition (PA REQUIRED)

COMPREHENSIVE

ORTHODONTIC

TREATEMENT

With the exception of cleft palate and other surgical cases, only members with late mixed dentition

or permanent dentition will be considered for the initiation of comprehensive orthodontic

treatment.

Reimbursement for codes D8070, D8080 or D8090 is limited to once in a lifetime as initial

payment for an approved course of orthodontic treatment. The member’s dentition will determine

the single code to be used and can only be billed when all appliances have been placed and

active treatment has been initiated. The placement of the component parts (e.g. brackets,

bands) does not constitute commencement of active treatment.

For quarterly payment, see procedure code D8670. Reimbursement for comprehensive

orthodontic treatment is ALL INCLUSIVE and covers ALL orthodontic services, both fixed and

removable that needs to be provided to correct the orthodontic condition.

A prior approval request for continuation of comprehensive orthodontic treatment (2

year, 3

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year and retention) must be submitted annually to the DOH along with a progress report and

photographs of the current conditions to assess the progress of treatment and determine if

additional treatment time (up to a maximum of three (3) years) is warranted. For members age

21 and over, prior approval requests for continuation of orthodontic care (2

year, 3

year and

retention) will be evaluated if the comprehensive orthodontic treatment was approved by DOH /

Medicaid Managed Care Plans and fixed orthodontic appliances were placed and activated

PRIOR to the member’s 21st birthday.

Requests to RESTART comprehensive orthodontic treatment on a member for which Medicaid

FFS paid the original comprehensive code (D8070, D8080, or D8090), but who now has Managed

Care coverage, should be submitted to the Manage Care plan or their vendor.

As of 10/01/2012, orthodontic treatment is a covered benefit under Medicaid Managed Care

Plans. All prior approvals for orthodontic treatment that were reviewed and approved on 10/1/12

and after, are subject to member’s eligibility under the FFS (fee-for-service) Medicaid program.

Providers must check the member’s eligibility at every visit, as Medicaid eligibility status may

change at any time.

As previously indicated on page 10 of this manual: “If a member is enrolled in a managed care

plan which covers the specific care or services being provided, it is inappropriate to bill

such services to the Medicaid program on a fee-for-service basis whether or not prior

approval has been obtained."

Code

Description

D8070

Comprehensive orthodontic treatment of the transitional dentition

(PA REQUIRED)

$995.86

D8080

Comprehensive orthodontic treatment of the adolescent dentition

(PA REQUIRED)

$995.86

D8090

Comprehensive orthodontic treatment of the adult dentition

(PA REQUIRED)

$995.86

MINOR TREATMENT TO CONTROL HARMFUL HABITS

The following procedures (D8210 and D8220) include appliances for habits such as thumb

sucking and tongue thrusting. They do not have a published fee and are listed as both “(REPORT

NEEDED, PA OPTIONAL)”. These procedure codes can be used by all enrolled dentists

regardless of specialty.

• Procedures can be reviewed for appropriateness and tentatively priced before treatment

is initiated by submitting a prior approval request.

- OR –

• Procedures can be priced after treatment without prior approval as a “By Report” based

on documentation submitted with the claim substantiating a qualifying physically

handicapping malocclusion.

Code

Description

D8210

Removable appliance therapy (REPORT NEEDED, PA OPTIONAL)

D8220

Fixed appliance therapy (REPORT NEEDED, PA OPTIONAL)

OTHER

ORTHODONTIC

SERVICES

Code

Description

D8660

Pre-orthodontic treatment examination to monitor growth and

development

Periodic observation of patient dentition, at intervals established by the

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dentist, to determine when orthodontic treatment should begin. Diagnostic

procedures are documented separately. Orthodontist specialty designation

required. May not be reimbursed in conjunction with other examination

codes. Cannot be reimbursed after active orthodontic treatment has begun.

D8670

Periodic orthodontic treatment visit (as part of contract)

(PA REQUIRED)

The member must have been seen and actively treated at least once during

the quarter. Cannot be used for “observation”. This code requires prior

approval and can be billed quarterly for a maximum of twelve (12)

payments and can only be billed a maximum of four (4) times in a twelve-

month period beginning 90 days after the date of service on which

orthodontic appliances have been placed and active treatment begun and

at the end of each subsequent quarter. Claims billed more frequently will

result in an automatic systems denial. In the event that eligibility is lost

during a quarter, at least one month of active treatment must have elapsed

to qualify for payment under the “limited extended coverage” benefit.

$234.32

D8680

Orthodontic retention (removal of appliances, construction, and

placement of retainer(s)) (PA REQUIRED)

Includes all follow-up visits needed for observation and adjustments.

Requests must be submitted, and approval obtained PRIOR to the removal

of appliances. Any request denied or otherwise returned for insufficient

results will require the re-application of all appliances, if necessary, and

continuation of care without additional compensation. Payment will not be

made for retention (D8680) for a case that had been debanded without

Medicaid prior authorization.

$175.74

D8695

Removal of fixed orthodontic appliances for reasons other than

completion of treatment (REPORT NEEDED)

Services provided by an orthodontist other than the originating orthodontist.

As indicated on page 54, reimbursement for orthodontic services includes

the placement and removal of all appliances and brackets.

(BR)

REPLACEMENT OF LOST OR BROKEN RETAINER

The following procedure codes (D8703 and D8704) will be reimbursed once per lifetime.

Must be within

one year of D8680 having been paid by Medicaid. Appliances which do not fit will not be replaced.

The following documentation is required when submitting a claim for a replacement retainer:

• Copy of a signed statement from patient / parent detailing the circumstances of how the

appliance was lost or broken;

• Copy of patient’s treatment / progress notes indicating the date of insertion; and

• Copy of dental laboratory bill, if available.

Code

Description

D8703

Replacement of lost or broken retainer – maxillary (REPORT

NEEDED)

$73.23

D8704

Replacement of lost or broken retainer – mandibular (REPORT

NEEDED)

$73.23

D8999

Unspecified orthodontic procedure, by report (REPORT NEEDED) )

(BR)

XII. ADJUNCTIVE GENERAL SERVICES D9000 - D9999

UNCLASSIFIED

TREATMENT

Code

Description

D9110

Palliative

treatment of dental pain

-per visit

(REPORT NEEDED)

Treatment that relieves pain but is not curative; services provided do

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not have distinct procedure codes. Not reimbursable in addition to

other therapeutic services performed at the same visit or in conjunction

with initial or periodic oral examinations when the procedure does not

add significantly to the length of time and effort of the treatment

provided

during that particular visit.

When billing, the provider must document the nature of the emergency,

the dental

site and the specific treatment involved. Not to be used

for denture adjustments (Refer to procedure codes D5410 –

D5422).

D9120

Fixed

partial

denture

sectioning

(QUAD)

(REPORT

NEEDED)

(BR)

ANESTHESIA

Unless otherwise specified, the cost of analgesic and anesthetic agents is included in the

reimbursement for the dental service. Reimbursement for general anesthesia, intravenous

(parenteral) sedation, and anesthesia time is conditioned upon meeting the definitions listed

below.

Anesthesia time begins when the doctor administering the anesthetic agent initiates the

appropriate anesthesia and non-invasive monitoring protocol and remains in continuous

attendance of the member. Anesthesia services are considered completed when the member

may be safely left under the observation of trained personnel and the doctor may safely leave the

room to attend to other patients or duties.

The level of anesthesia is determined by the anesthesia provider’s documentation of the

anesthetic’s effect upon the central nervous system and not dependent upon the route of

administration. Appropriate SED certificate is REQUIRED.

Anesthesia time should be commensurate with the treatment performed.

Anesthesia time is divided into 15-minute units for deep sedation/general anesthesia and

intravenous sedation/analgesia for billing purposes; the number of such units should be entered

in the "Times Performed" field of the claim form using the appropriate code (D9223, D9243).

Code

Description

D9222

Deep sedation/general anesthesia – first 15 minutes

Requires SED certificate in “General Anesthesia”

$76.76

D9223

Deep sedation/general anesthesia – each subsequent 15 minute

increment

Requires SED certificate in “General Anesthesia”

$76.76

D9239

Intravenous moderate (conscious) sedation/analgesia – first

15 minutes

Requires SED certificate in “General Anesthesia”

$76.76

D9243

Intravenous moderate (conscious) sedation/analgesia – each

subsequent 15 minute increment

$76.76

Current Dental Terminology (CDT) code D9230 - Inhalation of Nitrous Oxide/Analgesia,

Anxiolysis and code D9248 - Non-Intravenous Conscious Sedation are separately

reimbursable for members/enrollees through 20 years of age (inclusive) with documentation of

clinical necessity and in conjunction with covered dental services.

For members/enrollees 21 years of age and older, D9230 and D9248 are only approvable for

those members/enrollees identified with a Restriction Exception code of RE “81” (Traumatic Brain

Injury Eligible) or RE “95” [Office of Persons With Developmental Disabilities (OPWDD)].

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Note: Where multiple levels of anesthesia are provided on the same day, only one level will be

reimbursed. For clarity, when used in conjunction with another billable method of

anesthesia/analgesia/sedation (i.e., “D9222,” “D9223,” “D9239,” and “D9243”) at an encounter,

“D9230” or “D9248” are not reimbursed. When “D9230” and “D9248” are used together, one is

reimbursed.

Prior Authorization is not required, however written documentation for D9248 should indicate the

specific anesthetic agent administered and the method of administration. For purposes of the NYS

Medicaid program, conscious sedation is reimbursable only when provided by a qualified dental

provider who has the appropriate level of certification in dental anesthesia by the NYS

Education Department, NYSED. Additional information is located on the New York State

Education Department website (NYSED.gov): NYS Dentistry:Dental Anesthesia/Sedation

Certification (nysed.gov).

Code

Description

D9230

Inhalation of Nitrous Oxide/Analgesia, Anxiolysis

$25.00

D9248

Non-Intravenous Conscious Sedation

This includes non-IV minimal and moderate sedation. A medically controlled

state of depressed consciousness while maintaining the patient’s airway,

protective reflexes and the ability to respond to stimulation or verbal

commands. It includes non- intravenous administration of sedative and/or

analgesic agent(s) and appropriate monitoring. The level of anesthesia is

determined by the anesthesia provider’s documentation of the anesthetic’s

effects upon the central nervous system and not dependent upon the route

of administration

$25.00

D9310

Consultation - diagnostic service provided by dentist or physician

other than requesting dentist or physician

The consulted provider must be enrolled in one of the dental specialty areas

recognized by the NYS Medicaid Program. The referring provider cannot

be from the same group as the consulting provider, although an exception

can be made if the referral is from a general dentist to a specialist for an

evaluation requiring the advanced skills and knowledge of that specialist.

If the consultant provider assumes the management of the member after

the consultation, subsequent services rendered by that provider will not be

reimbursed as consultation. Referral for diagnostic aids (including

radiographic images) does not constitute consultation but is reimbursable

at the listed fees for such services. Consultation will not be reimbursed if

claimed by the same provider within 180 days of an examination or an office

visit for observation (D9430). An exception can be made if a subsequent

consultation is held for a distinctly different condition, supported by

documentation.

$30.30

PROFESSIONAL

VISITS

Code

Description

D9410

House/extended care facility call (REPORT NEEDED)

Per visit, regardless of number of members seen and represents the total

extra charge permitted, is not applicable to each member seen at such a

visit. The report must list all Medicaid covered patients seen at the facility

on the date of service.

Fee-for-service reimbursement will not be made for those individuals

who reside in facilities where dental services are included in the

facility rate. In those cases, reimbursement must be sought directly

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from the facility.

D9420

Hospital or ambulatory surgical center call (REPORT NEEDED)

Per visit, per member (to be added to fee for service). This service will be

recognized only for professional visits delivered in hospital in-patient,

Emergency Department, and ambulatory surgical settings.

Payable only when provided in a FACILITY where professional

services are not included in the rate. Please submit documentation

that services were provided in a hospital, such as a copy of the

hospital notes/record.

$75.75

D9430

Office visit for observation (during regularly scheduled hours) – no

other services performed (REPORT NEEDED)

The provider must be enrolled in one of the dental specialty areas

recognized by the NYS Medicaid program. Used to monitor the status of

a member following an authorized phase of surgical treatment that are

required beyond the post- operative care period for that procedure. Not be

used for orthodontic retention follow-up visits. Reimbursement includes

the prescribing of medications and is limited to two instances per clinical

episode.

May also be used for those individuals identified with a Restriction

Exception code of RE 81 (“TBI Eligible”) or RE 95 (“OPWDD/Managed

Care Exemption”) where definitive treatment cannot be performed due to

the member’s behavior. This is a “stand-alone” procedure and cannot be

billed on the same date of service with any other procedure code. Limited

to four (4) instances per year per member. Please include a report or

narrative describing the circumstances involved.

$20.20

D9440

Office visit - after regularly scheduled hours (REPORT NEEDED)

Cannot be billed in conjunction with an examination, observation, or

consultation. Please include a report or narrative describing the

circumstances involved.

$20.20

DRUGS

Code

Description

D9610

Therapeutic parenteral drug, single administration (REPORT

NEEDED)

(BR)

D9612

Therapeutic parenteral drugs, two or more administrations,

different medications (REPORT NEEDED)

(BR)

MISCELLANEOUS SERVICES

For occlusal guards there must be a minimum interval of twelve (12) months between all occlusal

guards (D9944, D9945, and/or D9946) and the report must include documentation of medical

necessity, associated laboratory receipts (unless fabricated in-house), and a copy of treatment

progress notes indicating the type of guard and date of insertion. Treatment notes must include

documentation of symptoms and/or clinical findings supporting guard fabrication.

Code

Description

D9944

Occlusal guard – hard appliance, full arch (ARCH) (REPORT NEEDED)

Removable dental appliance designed to minimize the effects of bruxism or

other occlusal factors. Not to be reported for any type of sleep apnea,

snoring, or TMD appliances.

$146.45

D9945

Occlusal guard – soft appliance, full arch (ARCH) (REPORT NEEDED)

$146.45

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Removable dental appliance designed to minimize the effects of bruxism or

other occlusal factors. Not to be reported for any type of sleep apnea,

snoring, or TMD appliances.

D9946

Occlusal guard – hard appliance, partial arch (ARCH) (REPORT

NEEDED) Removable dental appliance designed to minimize the effects of

bruxism or other occlusal factors. Provides only partial occlusal coverage

such as anterior deprogrammer. Not to be reported for any type of sleep

apnea, snoring or TMD appliances.

$146.45

D9990

Certified translation or sign-language services – per visit*

For patients who are deaf and hard of hearing or with limited English

proficiency defined as patients whose primary language is not English and

who cannot speak, read, write, or understand the English language at a

level sufficient to permit such patients to interact effectively with health care

providers and their staff. The need for medical language interpreter services

must be documented in the medical record and must be provided during a

medical visit by a third-party interpreter, who is either employed by or

contracts with the Medicaid provider. These services may be provided

either face-to-face or by telephone. The interpreter must demonstrate

competency and skills in medical interpretation techniques, ethics, and

terminology. It is recommended, but not required, that such individuals be

recognized by the National Board of Certification for Medical Interpreters

(NBCMI).

$22.22

TELEHEALTH

TELEDENTISTRY

Teledentistry allows dentists and dental hygienists to deliver care from a distance; this includes

performing evaluations and delivering services within scope of practice, using either synchronous

or asynchronous means.

Telehealth is defined as “the use of electronic information and communication technologies to

deliver health care to patients at a distance, which shall include the assessment, diagnosis,

consultation, treatment, education, care management and/or self-management of a patient

(Medicaid member)”.

• Originating Site is defined as “a site at which a patient is located at the time health care

services are delivered to him or her by means of telehealth.”

•

Distant Site

is defined as “a site at which a telehealth

provider

is located while delivering

health care services by means of telehealth.”

Most health care facilities and health care settings can be originating sites, as well as a

Medicaid Member’s place of residence in NYS or temporary location out of state. A full list of

allowable originating sites is found in New York Public Health Law § 2999-CC.

Services provided by means of telehealth must be in compliance with the Health Insurance

Portability and Accountability Act (HIPAA) and all other relevant laws and regulations governing

confidentiality, privacy, and consent (including, but not limited to 45 CFR Parts 160 and 164

[HIPAA Security Rules]; 42 CFR Part 2; PHL Article 27-F; and MHL Section 33.13).

Dentists providing services via telehealth must be licensed and currently registered in accordance

with NYS Education Law or other applicable law and enrolled in NYS Medicaid.

Telehealth services must be delivered by providers acting within their scope of practice. All dental

telehealth providers shall identify themselves to patients, including providing the professional's New

York state license number. Please refer to Legislation addressing Telehealth Delivery of Services,

available at Legislation | NY State Senate (nysenate.gov). Reimbursement will be made in

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accordance with existing Medicaid policy related to supervision and billing rules and requirements.

When services are provided by an Article 28 facility, the telehealth dentist must be

credentialed and

privileged at both the originating and distant sites in accordance with Section 2805-u of PHL. The

law can be viewed at the following link:

http://public.leginfo.state.ny.us/lawssrch.cgi?NVLWO (Select

LAWS; select PBH;

select Article 28; select 2805u).

The acquisition, installation and maintenance of telecommunication devices or systems is not

reimbursable. Providers should bill using the claim format appropriate to their category of service.

Place of Service (POS) code: Use 02 on professional claims to specify the location teledentistry

associated services were provided.

Dental telehealth services shall adhere to the standards of appropriate patient care required in

other dental health care settings, including but not limited to appropriate patient examination and

review of the medical and dental history of the patient. For additional information, providers can

refer to NYS Law Chapter 45 Article 29-G §2999-DD, located at: NYS Open Legislation |

NYSenate.gov.

Code

Description

D9995

Teledentistry – synchronous; real time encounter

➢

Procedure code D9995 may be used by the provider at the distant site;

➢

Must be reported on claim line #1; Report all services rendered on

subsequent lines; There is no reimbursement for procedure code D9995.

$0.00

D9996

Teledentistry – asynchronous; information stored and forwarded

Store-and-Forward Technology - involves the asynchronous, electronic

transmission of a member's health information in the form of patient-specific

pre-recorded videos and/or digital images from a provider at an originating

site to a telehealth provider at a distant site.

➢

Store-and-forward technology aids in diagnoses when live video or face-to-

face contact is not readily available or not necessary. Pre-recorded videos

and/or static digital images (e.g., pictures), excluding radiology, must be

specific to the member's condition as well as be adequate for rendering or

confirming a diagnosis or a plan of treatment.

➢

Procedure code D9996 may be used by the provider at the distant site;

➢

Must be reported on claim line #1; Report all services rendered on

subsequent lines; There is no reimbursement for procedure code D9996.

➢

Accompanying payable services will be reimbursed at 75% of the requested

fee, not exceeding 75% of the current Medicaid fee.

$0.00

Q3014

Telehealth originating site facility fee

• Procedure code Q3014 may be used by the provider at the

originating site;

• Must be reported on claim line #1;

• Report any additional services rendered on subsequent lines.

$28.04

D9997

Dental Case management – patients with special health care needs

Does not require a report.

Special treatment considerations for patients/individuals with physical,

medical, developmental, or cognitive conditions resulting in substantial

functional limitations or incapacitation, which require that modifications be

made to delivery of treatment to provide customized comprehensive oral

health care services. For purposes of the NYS Medicaid program, billing of

this code is limited to individuals who receive ongoing services from

community programs operated or certified by the New York State Office for

People with Developmental Disabilities (OPWDD) with a Restriction

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Exception code of RE 81 (“TBI Eligible”) or RE 95 (“OPWDD/Managed Care

Exemption”).

•

This is a per visit incentive to compensate for the greater knowledge, skill,

sophisticated equipment, extra time, and personnel required to treat this

population; This fee will be paid in addition to the normal fees for specific

dental procedures.

•

A “Medical Immobilization/Protective Stabilization (MIPS)” form (Article 16

institutions only) also qualifies for use of this procedure code. More

information about MIPS found online at NYS Office for People With

Developmental Disabilities at NYS MIPS.

•

Not billable in conjunction with D9430 or procedures performed

under deep sedation/general anesthesia.

•

Not billable as a “stand-alone” procedure; another clinical service

must be provided on the same date.

D9999

Unspecified adjunctive procedure, by report (REPORT NEEDED)

(BR)

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Appendix

Intellectual and Developmental Disabilities (IDD) population

(with Restriction Exception codes RE 81/RE 95 OPWDD/Managed Care Exemption)

NY Medicaid offers extensive dental benefits for members, including diagnostic, preventive, endodontic,

surgical, prosthetic, and restorative services if medically necessary and standard criteria is met. These

benefits are available to the IDD population, with additional benefits summarized in the following table.

Patient records must include documented medical necessity for these benefits.

Code

Benefit

Prior Auth

Required

Narrative

Required

D1110 or

D1120

Prophylaxis – adult or child

Additional prophylaxis may be considered within a twelve-month

period for those individuals identified with a Restriction Exception

code of RE 81 or RE 95.

yes

D1206

Topical application of fluoride varnish

Application once per 3-month period for individuals 21 years of age

and older, identified with a Restriction Exception code of RE 81 or RE

95; Reimbursable in medical settings under CPT code 99188.

D1208

Topical Application of fluoride -- excluding varnish

Applied separately from prophylaxis paste; Reimbursable once per

six-month period for individuals 21 years of age and older D1208 with

a Restriction Exception code of RE 81 or RE 95.

D1354

Application of caries arresting medicament – per tooth

Covered two times per tooth within a 12-month period with a total

of four times per lifetime of the tooth; For individuals 21 years of age

and older, identified with a Restriction Exception code of RE 81 or RE

95. Use must meet stated clinical criteria:

• Stabilize non-symptomatic teeth with active carious lesion

and no pulpal exposure

• High caries risk (e.g. xerostomia, severe early childhood

caries)

• Treatment challenged by behavioral or medical management

• Difficult to treat carious lesions

D9222,

D9223

Deep sedation/general anesthesia

Available for disabled persons who may not be compliant for dental

treatment in the traditional office setting

D9239,

D9243

Intravenous moderate (conscious) sedation/analgesia

Available for disabled persons who may not be compliant for dental

treatment in the traditional office setting

D9230

Inhalation of Nitrous Oxide/Analgesia, Anxiolysis

D9248

Non-Intravenous Conscious Sedation

D9430

Office visit for observation (during regularly scheduled hours) – no

other services performed: May be used for those individuals

identified with a Restriction Exception code of RE 81 or RE 95 where

definitive treatment cannot be performed due to the member’s

yes

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behavior. This is a “stand-alone” procedure and cannot be billed on

the same date of service with any other procedure code. Limited to

four (4) instances per year per member. Please include a report or

narrative describing the circumstances involved.

D9997

Dental Case management – patients with special health care needs

Special treatment considerations for patients/individuals with

physical, medical, developmental, or cognitive conditions resulting in

substantial functional limitations or incapacitation, which require

that modifications be made to delivery of treatment to provide

customized comprehensive oral health care services.

For purposes of the NYS Medicaid program, billing of this code is

limited to individuals who receive ongoing services from community

programs operated or certified by the New York State Office for

People with Developmental Disabilities (OPWDD) with a Restriction

Exception code of RE 81 (“TBI Eligible”) or RE 95 (“OPWDD/Managed

Care Exemption”).

• This is a per visit incentive to compensate for the greater

knowledge, skill, sophisticated equipment, extra time and

personnel required to treat this population;

• This fee will be paid in addition to the normal fees for specific

dental procedures.

• A “Medical Immobilization/Protective Stabilization (MIPS)”

form (Article 16 institutions only) also qualifies for use of this

procedure code. More information about MIPS found online

at NYS Office for People With Developmental Disabilities at

NYS MIPS.

• Not billable in conjunction with D9430 or procedures

performed under deep sedation/general anesthesia.

• Not billable as a “stand-alone” procedure; another clinical

service must be provided on the same date.

D9990

Certified translation or sign-language services

Billing

reminder

• Private practitioners receive an enhanced reimbursement

rate of 20% over fee schedule for all dental services

provided to this population.

• Reminder: An additional 20% enhancement is

added to the APG base rate for services provided

to individuals with a Restriction Exception code

of RE 81 (“TBI Eligible”) or RE 95

(“OPWDD/Managed Care Exemption”) for

facilities billing through APG methodology using

rate codes: 1501, 1489, 1435, and 1425.

n/a