Clinical Criteria Grid
NJ FamilyCare Dental Services Clinical Criteria Policy
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D0120 | PERIODIC ORAL EVALUATION | none | Twice during a rolling year (RY) without PA per servicing provider/group and a maximum of four times during a rolling year for Special Health Care Needs (SHCN) or ECC Members which may require prior authorization. Not within 6 months of D0150 per servicing provider/group. | Medical diagnosis or clinical presentation required for increased frequency; all documentation to be included in dental records. | Subsequent oral evaluation for patient of record. |
D0140 | LIMIT ORAL EVAL PROBLM FOCUS | none | Twice in a RY, per servicing provider/group more require PA with documentation of medical necessity (DMN). | Documentation of medical necessity (DMN) to be included in dental records. | For use in emergent/urgent situations. |
D0145 | ORAL EVALUATION PATIENT < 3yrs | Under 3 years of age | Twice during a rolling year (RY) without PA and a maximum of four times during a rolling year per servicing provider/group for Special Health Care Needs (SHCN) or ECC Members which may require prior authorization. | Medical diagnosis or clinical presentation required for increased frequency; all documentation to be included in dental records. | Oral evaluation and continual counselling of primary caregiver. |
D0150 | COMPREHENSIVE ORAL EVALUATION | Age 3 and older | Once every three years per servicing provider/group unless medical necessity can be documented for additional service. | Medical diagnosis or clinical presentation required for increased frequency. | For new patient or 3 years post previous comprehensive oral evaluation by same provider. |
D0160 | EXTENSV ORAL EVAL PROB FOCUS | none | Twice per RY per servicing provider/group. | DMN; to develop a treatment plan for a specific problem; only radiographs and/or other non-evaluation diagnostic codes provided on same date of service (DOS). | DMN; May be used by general dentists for second opinion for same complaint, condition or diagnosis. |
D0170 | RE-EVAL,EST PT, PROBLEM FOCUS | none | Twice per RY | DMN; only additional services allowed on same DOS are radiographs (D0220, D0240, D0270, D0277 and D0330). | For follow-up of recent prior visit for same complaint, condition or diagnosis. |
D0171 | RE-EVAL POST-OP VISIT | none | Twice a RY per servicing provider/group; additional units require prior authorization. | DMN; only additional services allowed on same DOS are radiographs (D0220, D0270, D0277 and D0330). | For follow-up of recent prior oral surgical or periodontal surgery visit. |
D0180 | COMP PERIODONTAL EVALUATION | none | Once every three years unless medical necessity can be documented for more frequent service. | Recent full mouth perio charting and radiographs as needed for diagnosis; narrative and photos if bone loss not visible on x-rays. | Evidence of periodontal disease. |
D0190 | SCREENING OF A PATIENT | Under 19 years of age | Allowed once per RY to same member | Service must be provided in non-office setting. | No other services on same DOS. |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D0210 | INTRAORAL COMPLETE FILM SERIES | none | Complete series D0210 allowed once every three years per servicing provider/group unless medical necessity can be documented for additional service. | DMN; for additional service-documentation of extreme change in medical or dental condition. | Radiographic evaluation for diagnosis. |
D0220 | INTRAORAL PERIAPICAL FIRST | none | AMN for diagnosis | Provider is to indicate diagnosis in dental records. Periapical films (D0220, D0230) and bitewings (D0270, D0272) may be taken as needed for diagnosing a condition. | For diagnosing. |
D0230 | INTRAORAL PERIAPICAL EACH ADDITIONAL | none | AMN for diagnosis | Provider is to indicate diagnosis in dental records. Periapical films (D0220, D0230) and bitewings (D0270, D0272) may be taken as needed for diagnosing a condition. | For diagnosing. |
D0240 | INTRAORAL OCCLUSAL FILM | none | 2 per RY | DMN in dental records; image covers a larger area than a periapical view; based on image, not size of film. | For diagnosing. Differential diagnosis supports image. |
D0250 | EXTRA ORAL 2D PROJECT IMAGE | none | 2 per RY | Provider is to indicate diagnosis in dental records. Periapical films (D0220, D0230) and bitewings (D0270, D0272) may be taken as needed for diagnosing a condition; one per DOS. | For diagnosing. |
D0251 | EXTRA ORAL POSTERIOR IMAGE | none | AMN for diagnosis | Provider is to indicate diagnosis in dental records. Periapical films (D0220, D0230) and bitewings (D0270, D0272) may be taken as needed for diagnosing a condition. | For diagnosing. For complete view of posterior teeth, both arches. |
D0270 | DENTAL BITEWING SINGLE IMAGE | none | AMN for diagnosis | Provider is to indicate diagnosis in dental records. Periapical films (D0220, D0230) and bitewings (D0270, D0272) may be taken as needed for diagnosing a condition. | For diagnosing. |
D0272 | DENTAL BITEWINGS TWO IMAGES | none | 1 per RY, then AMN for diagnosis | When same DOS as D0330, consider as full mouth series. | For diagnosing. |
D0273 | BITEWINGS - THREE IMAGES | none | 1 per RY, then AMN for diagnosis | When same DOS as D0330, consider as full mouth series. | For diagnosing. |
D0274 | BITEWINGS FOUR IMAGES | none | 1 per RY, then AMN for diagnosis | When same DOS as D0330, consider as full mouth series. | For diagnosing. |
D0277 | VERT BITEWINGS 7 TO 8 IMAGES | Age 21 and older | 1 per RY, then AMN for diagnosis | When same DOS as D0330, consider as full mouth series; may be taken as needed for diagnosing condition. | For diagnosing. |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D0310 | DENTAL SIALOGRAPHY | none | AMN | Surgical narrative or dental records. | Salivary gland pathology diagnosis and treatment. |
D0320 | DENTAL TMJ ARTHROGRAM INCL INJECTION | none | AMN | Surgical narrative or dental records. | TMJD diagnosis and treatment. |
D0321 | OTHER TMJ IMAGES BY REPORT | none | AMN | DMN | TMJD diagnosis and treatment. |
D0322 | DENTAL TOMOGRAPHIC SURVEY | none | AMN-PA required | DMN; surgical narrative or dental records | Must demonstrate that tomographic survey improves treatment decisions and outcome/prognosis. |
D0330 | PANORAMIC IMAGE | none | D0330 allowed once every three years per servicing provider/group unless medical necessity can be documented for additional service. Is equivalent to full mouth series with 2, 3 or 4 BWs on same DOS. | Medical diagnosis, clinical presentation, orthodontic narrative. Additional service as needed to diagnose extensive oral surgery; interceptive or comprehensive orthodontic treatment; extreme change in medical or dental condition. | Diagnosis and treatment |
D0340 | 2D CEPHALOMETRIC IMAGE | none | 1 per RY per servicing provider/group. | DMN for use by OMFS; Orthodontists may take D0330 and D0340 as needed for diagnosing and must document rationale for this in dental records. | DMN for use by OMFS; case evaluation for interceptive or comprehensive orthodontics. |
D0350 | ORAL/FACIAL PHOTO IMAGES | none | Maximum 4 per RY | Documentation of medical necessity when radiographs cannot be provided for SHCN members or LTCF residents; orthodontic treatment included with orthodontic case rate. | Diagnosis and treatment |
D0351 | 3D PHOTOGRAPHIC IMAGE | none | 1 per RY per provider/group per DOS | DMN; differential diagnosis, medical and dental history associated with treatment request | For OMFS diagnosis. |
D0364 | CONE BEAM CT CAPTURE & INTERPRETATION LIMITED VIEW | none | AMN-PA required | PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, assessment of cracked teeth when subgingival or furcational, large bony lesions, complex impactions, TMJ treatment where indicated. | Must demonstrate that CBCT improves treatment decisions and outcome/prognosis. |
D0365 | CONE BEAM CT INTERPRETATION MANDIBLE | none | AMN-PA required | PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, large bony lesions, complex impactions, TMJ treatment where indicated. | Must demonstrate that CBCT improves treatment decisions and outcome/prognosis. |
D0366 | CONE BEAM CT INTERPRETATION MAXILLA | none | AMN-PA required | PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, large bony lesions, complex impactions, TMJ treatment where indicated. | Must demonstrate that CBCT improves treatment decisions and outcome/prognosis. |
D0367 | CONE BEAM CT INTERP BOTH JAW | none | AMN-PA required | PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, large bony lesions, complex impactions, TMJ treatment where indicated. | Must demonstrate that CBCT improves treatment decisions and outcome/prognosis. |
D0368 | CONE BEAM CT CAPTURE AND INTERPRETE TMJ | none | AMN-PA required | PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, large bony lesions, complex impactions, TMJ treatment where indicated. May be included in TMJ case rate. | For TMJD Must demonstrate that CBCT improves treatment decisions and outcome/prognosis. |
D0380 | CONE BEAM CT IMAGE CAPTURE LIMITED | none | AMN-PA required | PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, assessment of cracked teeth when subgingival or furcational, large bony lesions, complex impactions, TMJ treatment where indicated. | Must demonstrate that CBCT improves treatment decisions and outcome/prognosis. |
D0381 | CONE BEAM CT CAPT MANDIBLE | none | AMN-PA required | PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, large bony lesions, complex impactions, TMJ treatment where indicated. | Must demonstrate that CBCT improves treatment decisions and outcome/prognosis. |
D0382 | CONE BEAM CT IMAGE CAPT MAXILLA | none | AMN-PA required | PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, large bony lesions, complex impactions, TMJ treatment where indicated. | Must demonstrate that CBCT improves treatment decisions and outcome/prognosis. |
D0383 | CONE BEAM CT BOTH JAWS | none | AMN-PA required | PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, large bony lesions, complex impactions, TMJ treatment where indicated. | Must demonstrate that CBCT improves treatment decisions and outcome/prognosis. |
D0384 | CONE BEAM CT IMAGE CAPTURE TMJ | none | AMN-PA required | PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, large bony lesions, complex impactions, TMJ treatment where indicated. May be included in TMJ case rate. | For TMJD Must demonstrate that CBCT improves treatment decisions and outcome/prognosis. |
D0393 | TREATMENT SIMULATION 3D IMAGE TMJ | none | AMN-PA required | PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, large bony lesions, complex impactions, TMJ treatment where indicated. | Must demonstrate that CBCT improves treatment decisions and outcome/prognosis. |
D0394 | DIGITAL SUBTRACTION- 2 OR MORE IMAGES | none | AMN-PA required | PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, large bony lesions, complex impactions, TMJ treatment where indicated. | Must demonstrate that CBCT improves treatment decisions and outcome/prognosis. |
D0395 | FUSION 2 OR MORE 3D IMAGES | none | AMN-PA required | PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, large bony lesions, complex impactions, TMJ treatment where indicated. | Must demonstrate that CBCT improves treatment decisions and outcome/prognosis. |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D0411 | HBA1C IN OFFICE TESTING | none | Once per RY | Medical history positive for diabetes, clinical presentation. | For planned perio or OMFS service. Limited to teaching facilities to include residencies and hygiene schools. W/obesity, history of DM, poor glycemic control; referral to PCP. |
D0416 | DENTAL TMJ ARTHROGRAM INCL INJECTION | none | AMN | Lab report, clinical rationale for test, biopsy and test requested/performed dental records; maximum 2 per DOS. | Diagnosis and treatment |
D0417 | COLLECTION & PREPARE SALIVA SAMPLE | none | AMN; Maximum 1 per DOS | Differential diagnosis, medical and dental history associated with treatment request | diagnosis and treatment. |
D0470 | DIAGNOSTIC CASTS | none | AMN | Reimbursement and approval of service cannot be limited to orthodontic cases but allowed based on medical necessity. Prior authorization may be required with documentation supporting the procedure. Service is included in payment for services that have a laboratory component. | Documentation of diagnosis (malocclusion, traumatic occlusal relationships), clinical presentation to include involved quadrants and purpose as noted in dental records. |
D0472 | GROSS EXAM, PREP & REPORT | none | AMN | Lab report, clinical rationale for test, biopsy and test requested/performed dental records; Maximum 8 per DOS. | Diagnosis and treatment |
D0473 | MICRO EXAM, PREP & REPORT | none | AMN | Lab report, clinical rationale for test, biopsy and test requested/performed dental records; Maximum 8 per DOS. | Diagnosis and treatment |
D0474 | MICRO EXAM OF SURGICAL MARGINS | none | AMN | Lab report, clinical rationale for test, biopsy and test requested/performed dental records; Maximum 8 per DOS. | Diagnosis and treatment |
D0480 | CYTOLOGY SMEAR PREP AND REPORT | none | AMN | Lab report, clinical rationale for test, biopsy and test requested/ performed dental records; Max. 4 per DOS. | Diagnosis and treatment |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D0502 | OTHER ORAL PATHOLOGY PROCEDURE | none | DMN | BR | Diagnosis and treatment |
D0601 | CARIES RISK ASSESS LOW RISK | Under 21 years of age | Once per RY | CRA form in dental record; Service is provided on same date as oral evaluations (D0120, D0145, and D0150). | Diagnosis and treatment |
D0602 | CARIES RISK ASSESS MODERATE RISK | Under 21 years of age | Once per RY | CRA form in dental record; Service is provided on same date as oral evaluations (D0120, D0145, and D0150). | diagnosis and treatment. |
D0603 | CARIES RISK ASSESS HIGH RISK | Under 21 years of age | Once per RY | CRA form in dental record; Service is provided on same date as oral evaluations (D0120, D0145, and D0150). | diagnosis and treatment. |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D0999 | UNSPECIFIED DIAGNOSTIC PROCEDURE | none | BR。DMN; diagnosis, clinical presentation of provided service. | Service not described by CDT code | |
D1110 | DENTAL PROPHYLAXIS ADULT | Age 16 and older | Allowed twice during a RY and a maximum of four times during a RY per servicing provider/group for SHCN Members which may require prior authorization. | DMN for increased frequency. Prophylaxes will not be reimbursed on same date of service (DOS) as D4346, D4341, D4342, D4355, D4910 or any periodontal surgical code. | Evidence of plaque, stains, calculus on tooth structure of permanent or transitional dentition. |
D1120 | DENTAL PROPHYLAXIS CHILD | Under age 16 | Allowed twice during a RY and a maximum of four times during a RY per servicing provider/group for SHCN or ECC Members which may require prior authorization. | DMN for increased frequency. Prophylaxes will not be reimbursed on same date of service (DOS) as D4346, D4341, D4342, D4355, D4910 or any periodontal surgical code. | Evidence of plaque, stains, calculus on tooth structure of primary or transitional dentition. |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D1206 | TOPICAL FLUORIDE VARNISH | none | Can be provided to members twice in a RY per servicing provider/group under 21 with moderate to high risk on CRA; SHCN and ECC members up to four times annually with documentation of medical necessity; LTCF residents with high caries incidence and/or root caries. | Will not be reimbursed on same date of service (DOS) as D4346, D4341, D4342, D4355, D4910 or any periodontal surgical code. DMN for increased frequency. | Applied same day as D1110 or D1120; not same DOS as D1208.To prevent caries. |
D1208 | 局部应用氟化物不包括清漆 | none | Can be provided to members of all ages (children and adults) twice in a RY per servicing provider/group; considered for SHCN and ECC members every 3 months with consideration based on documentation of medical necessity. | Will not be reimbursed on same date of service (DOS) as D4346, D4341, D4342, D4355, D4910 or any periodontal surgical code. DMN for increased frequency. | Applied same day as D1110 or D1120; not same DOS as D1206. To prevent caries. |
D1351 | DENTAL SEALANT PER TOOTH | Under age 17 | May be provided every 3 years for children through the age of 16. Age restriction does not apply to SHCN. | Diagnostic periapical or bitewing; provide documentation of medical necessity. Moderate to high CRA score; previous history of restorations and/or caries. | D1353 and D1351 are allowed on unrestored surfaces of permanent molars and bicuspids. Deep fissures and grooves with no evidence of caries. |
D1352 | PREVENTIVE RESIN REST, PERMENENT TOOTH | none | Once per tooth | Diagnostic periapical or bitewing; caries risk assessment. | 国防部erate to high caries risk; active cavitated pit or fissure lesion not extended into dentin; includes sealant on same tooth. |
D1353 | SEALANT REPAIR PER TOOTH | Under age 17 | May be provided every 3 years for children through the age of 16. Age restriction does not apply to SHCN. | Diagnostic periapical or bitewing; provide documentation of medical necessity. | D1353 and D1351 are allowed on unrestored surfaces of permanent molars and bicuspids. For damaged sealant in the absence of caries Includes primary molars. |
D1354 | INTTERIM CARIES MED APPLICATION PER TOOTH | none | Twice per RY without PA | Medical history, clinical presentation | Primary and permanent teeth; ECC/rampant decay, SHCN members, root caries, LTCF residents. |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D1510 | SPACE MAINTAINER- FIXED- UNILATERAL PER QUADRANT | Under age 15 | Once per quadrant without PA | Diagnostic periapicals or bitewings. | For premature loss of primary tooth; permanent tooth not ready to erupt; congenitally missing teeth; to prevent tooth movement; includes adjustments. |
D1516 | SPACE MAINTAINER- FIXED BILATERAL, MAXILLARY | Under age 15 | Once without PA | Diagnostic periapicals or bitewings | For premature loss of primary tooth; permanent tooth not ready to erupt; congenitally missing teeth; to prevent tooth movement; includes adjustments. |
D1517 | SPACE MAINTAINER- FIXED-BILATERAL, MANDIBULAR | Under age 15 | Once without PA | Diagnostic periapicals or bitewings | For premature loss of primary tooth; permanent tooth not ready to erupt; congenitally missing teeth; to prevent tooth movement; includes adjustments. |
D1526 | SPACE MAINTAINER- REMOVABLE- BILATERAL, MAXILLARY | Under age 15 | Once without PA | Diagnostic periapicals or bitewings | For premature loss of primary tooth; permanent tooth not ready to erupt; congenitally missing teeth; to prevent tooth movement; includes adjustments. |
D1527 | SPACE MAINTAINER- REMOVABLE- BILATERAL, MANDIBULAR | Under age 15 | Once without PA | Diagnostic periapicals or bitewings | For premature loss of primary tooth; permanent tooth not ready to erupt; congenitally missing teeth; to prevent tooth movement; includes adjustments. |
D1551 | RE-CEMENT OR RE-BOND BILATERAL SPACE MAINTAINER- MAX | Under age 15 | Once without PA | Diagnostic periapicals or bitewings | Dislodged appliance for premature loss of primary tooth; permanent tooth not ready to erupt; congenitally missing teeth; to prevent tooth movement; includes adjustments. |
D1552 | RE-CEMENT OR RE-BOND BILATERAL SPACE MAINTAINER- MAND | Under age 15 | Once without PA | Diagnostic periapicals or bitewings | Dislodged appliance for premature loss of primary tooth; permanent tooth not ready to erupt; congenitally missing teeth; to prevent tooth movement; includes adjustments. |
D1553 | RE-CEMENT or RE- BOND UNILATERAL SPACE MAINTAINER-PER QUAD | Under age 15 | Once without PA | Diagnostic periapicals or bitewings | Dislodged appliance for premature loss of primary tooth; permanent tooth not ready to erupt; congenitally missing teeth; to prevent tooth movement; includes adjustments. |
D1556 | REMOVAL OF FIXED UNILATERAL SPACE MAINTAINER-PER QUAD | none | Once per space maintainer | Diagnostic periapicals or bitewings Not to same provider who placed appliance. | Treatment completed, appliance broken, causing problem. |
D1557 | REMOVAL OF FIXED BILATERAL SPACE MAINTAINER- MAX | none | Once per space maintainer | Diagnostic periapicals or bitewings Not to same provider who placed appliance. | Treatment completed, appliance broken, causing problem. |
D1558 | REMOVAL OF FIXED BILATERAL SPACE MAINTAINER- MAND | none | Once per space maintainer | Diagnostic periapicals or bitewings Not to same provider who placed appliance. | Treatment completed, appliance broken, causing problem. |
D1575 | DISTAL SHOE SPACE MAINT, FIXED- UNILATERAL-PER QUAD | Under age 11 | Once without PA | Diagnostic periapicals or bitewings | For premature loss of primary tooth; permanent tooth not ready to erupt; congenitally missing teeth; to prevent tooth movement; includes adjustments. |
D1999 | UNSPECIFIED PREVENTIVE PROCEDURE | none | BR。DMN; diagnosis, clinical presentation of provided service. | Service not described by CDT code. |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D2140 | AMALGAM ONE SURFACE PERMANENT | none | There are no limits for replacement of restorations when medical necessity can be documented. | Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s). Replacement one year after placement will be reimbursed. 替换一年内不会报销to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for PA consideration. |
For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Occlusal extends onto one third of buccal/ lingual. Extension to self-cleansing areas not additional surfaces. |
D2150 | AMALGAM TWO SURFACES PERMANENT | none | There are no limits for replacement of restorations when medical necessity can be documented. | Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s). Replacement one year after placement will be reimbursed. 替换一年内不会报销to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for PA consideration. |
For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Occlusal extends onto one third of buccal/ lingual. Extension to self-cleansing areas not additional surfaces. |
D2160 | AMALGAM THREE SURFACES PERMANENT | none | There are no limits for replacement of restorations when medical necessity can be documented. | Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s). Replacement one year after placement will be reimbursed. 替换一年内不会报销to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for PA consideration |
For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Occlusal extends onto one third of buccal/ lingual. Extension to self-cleansing areas not additional surfaces. |
D2161 | AMALGAM 4 OR > SURFACES PERMANENT | none | There are no limits for replacement of restorations when medical necessity can be documented. | Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s). Replacement one year after placement will be reimbursed. 替换一年内不会报销to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for PA consideration. |
For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Occlusal extends onto one third of buccal/ lingual. Extension to self-cleansing areas not additional surfaces. |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D2330 | 树脂之一SURFACE- ANTERIOR | none | There are no limits for replacement of restorations when medical necessity can be documented. | Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s). Replacement one year after placement will be reimbursed. 替换一年内不会报销to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for PA consideration. |
For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Restoration may be limited to incisal, mesial, distal, facial or lingual surface. Extension to self-cleansing areas not additional surfaces. |
D2331 | RESIN TWO SURFACES- ANTERIOR | none | There are no limits for replacement of restorations when medical necessity can be documented. | Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s). Replacement one year after placement will be reimbursed. 替换一年内不会报销to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for PA consideration. |
For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Restoration extends onto one third of facial/ lingual. Extension to self-cleansing areas not additional surfaces. |
D2332 | RESIN THREE SURFACES- ANTERIOR | none | There are no limits for replacement of restorations when medical necessity can be documented. | Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s Replacement one year after placement will be reimbursed. 替换一年内不会报销to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for PA consideration. |
For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Restoration extends onto one third of facial/ lingual. Extension to self-cleansing areas not additional surfaces. |
D2335 | RESIN 4 SURF OR W INCISAL ANGLE | none | There are no limits for replacement of restorations when medical necessity can be documented. | Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s). Replacement one year after placement will be reimbursed. 替换一年内不会报销to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for PA consideration. |
For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Restoration must include incisal angle or at least four of the five tooth surfaces. Extension to self-cleansing areas not additional surfaces. |
D2390 | ANT RESIN- BASED COMPSITE CROWN | none | There are no limits for replacement of restorations when medical necessity can be documented. | Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s). Replacement one year after placement will be reimbursed. 替换一年内不会报销to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for PA consideration. |
For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Occlusal extends onto one third of buccal/ lingual. Extension to self-cleansing areas not additional surfaces. |
D2391 | POST 1 SURFACE RESIN BASED COMPOSITE | none | There are no limits for replacement of restorations when medical necessity can be documented. | Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s). Replacement one year after placement will be reimbursed. 替换一年内不会报销to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for PA consideration. |
For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Occlusal extends onto one third of buccal/ lingual. Extension to self-cleansing areas not additional surfaces. |
D2392 | POST 2 SURFACE RESIN BASED COMPOSITE | none | There are no limits for replacement of restorations when medical necessity can be documented. | Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s). Replacement one year after placement will be reimbursed. 替换一年内不会报销to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for PA consideration. |
For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Occlusal extends onto one third of buccal/ lingual. Extension to self-cleansing areas not additional surfaces. |
D2393 | POST 3 SURFACE RESIN BASED COMPOSITE | none | There are no limits for replacement of restorations when medical necessity can be documented. | Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s). Replacement one year after placement will be reimbursed. 替换一年内不会报销to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for PA consideration. |
For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Occlusal extends onto one third of buccal/ lingual. Extension to self-cleansing areas not additional surfaces. |
D2394 | 邮报> = 4表面复合树脂 | none | There are no limits for replacement of restorations when medical necessity can be documented. | Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s). Replacement one year after placement will be reimbursed. 替换一年内不会报销to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for PA consideration. |
For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Occlusal extends onto one third of buccal/ lingual. Extension to self-cleansing areas not additional surfaces. |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D2542 | DENTAL ONLAY METALLIC 2 SURFACE | none | There are no limits for replacement of restorations when medical necessity can be documented. | Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s). Replacement one year after placement will be reimbursed. 替换一年内不会报销to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for PA consideration. |
Restoration is lab fabricated, covers one or more cusp tips and adjoining occlusal surfaces, but not entire occlusal surface; reimbursable to dental schools and dental residency programs only. |
D2543 | DENTAL ONLAY METALLIC 3 SURFACE | none | There are no limits for replacement of restorations when medical necessity can be documented. | Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s). Replacement one year after placement will be reimbursed. 替换一年内不会报销to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for PA consideration. |
Restoration is lab fabricated, covers one or more cusp tips and adjoining occlusal surfaces, but not entire occlusal surface; reimbursable to dental schools and dental residency programs only. |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D2710 | CROWN RESIN- BASED INDIRECT | none | There are no time limits on replacement or re- cementations when medical necessity can be documented. | For single crowns, recent, diagnostic full mouth radiographs or panoramic image. If tooth has no occlusion, narrative documenting that there is an opposing denture or tooth will be used as an abutment to a fixed or removable denture. Documentation of caries control. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics. |
D2720 | CROWN RESIN W/HIGH NOBLE METAL | none | There are no time limits on replacement or re- cementations when medical necessity can be documented. | For single crowns, recent, diagnostic full mouth radiographs or panoramic image. If tooth has no occlusion, narrative documenting that there is an opposing denture or tooth will be used as an abutment to a fixed or removable denture. Documentation of caries control. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics. |
D2721 | CROWN RESIN W/BASE METAL | none | There are no time limits on replacement or re- cementations when medical necessity can be documented. | For single crowns, recent, diagnostic full mouth radiographs or panoramic image. If tooth has no occlusion, narrative documenting that there is an opposing denture or tooth will be used as an abutment to a fixed or removable denture. Documentation of caries control. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics. |
D2722 | CROWN RESIN W/NOBLE METAL | none | There are no time limits on replacement or re- cementations when medical necessity can be documented. | For single crowns, recent, diagnostic full mouth radiographs or panoramic image. If tooth has no occlusion, narrative documenting that there is an opposing denture or tooth will be used as an abutment to a fixed or removable denture. Documentation of caries control. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics. |
D2740 | CROWN PORCELAIN/ CERAMIC | none | There are no time limits on replacement or re- cementations when medical necessity can be documented. | For single crowns, recent, diagnostic full mouth radiographs or panoramic image. If tooth has no occlusion, narrative documenting that there is an opposing denture or tooth will be used as an abutment to a fixed or removable denture. Documentation of caries control. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics. |
D2750 | CROWN PORCELAIN w/HIGH NOBLE METAL | none | There are no time limits on replacement or re- cementations when medical necessity can be documented. | For single crowns, recent, diagnostic full mouth radiographs or panoramic image. If tooth has no occlusion, narrative documenting that there is an opposing denture or tooth will be used as an abutment to a fixed or removable denture. Documentation of caries control. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics. |
D2751 | CROWN PORCELAIN FUSED BASE METAL | none | There are no time limits on replacement or re- cementations when medical necessity can be documented. | For single crowns, recent, diagnostic full mouth radiographs or panoramic image. If tooth has no occlusion, narrative documenting that there is an opposing denture or tooth will be used as an abutment to a fixed or removable denture. Documentation of caries control. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics. |
D2752 | CROWN PORCELAIN W/NOBLE METAL | none | There are no time limits on replacement or re- cementations when medical necessity can be documented. | For single crowns, recent, diagnostic full mouth radiographs or panoramic image. If tooth has no occlusion, narrative documenting that there is an opposing denture or tooth will be used as an abutment to a fixed or removable denture. Documentation of caries control. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics. |
2790 | CROWN FULL CAST HIGH NOBLE METAL | none | There are no time limits on replacement or re- cementations when medical necessity can be documented. | For single crowns, recent, diagnostic full mouth radiographs or panoramic image. If tooth has no occlusion, narrative documenting that there is an opposing denture or tooth will be used as an abutment to a fixed or removable denture. Documentation of caries control. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics. |
D2791 | CROWN FULL CAST BASE METAL | none | There are no time limits on replacement or re- cementations when medical necessity can be documented. | For single crowns, recent, diagnostic full mouth radiographs or panoramic image. If tooth has no occlusion, narrative documenting that there is an opposing denture or tooth will be used as an abutment to a fixed or removable denture. Documentation of caries control. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics. |
D2792 | CROWN FULL CAST NOBLE METAL | none | There are no time limits on replacement or re- cementations when medical necessity can be documented. | For single crowns, recent, diagnostic full mouth radiographs or panoramic image. If tooth has no occlusion, narrative documenting that there is an opposing denture or tooth will be used as an abutment to a fixed or removable denture. Documentation of caries control. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics. |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D2910 | RECEMENT镶裱贴或部分 | none | There are no time limits on replacement or re- cementations when medical necessity can be documented. | For single crowns, recent, diagnostic full mouth radiographs or panoramic image. If tooth has no occlusion, narrative documenting that there is an opposing denture or tooth will be used as an abutment to a fixed or removable denture. Documentation of caries control. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. |
Restoration intact, absence of decay or additional loss of tooth structure. |
D2915 | RECEMENT CAST OR PREFABRICATED POST | none | There are no time limits on replacement or re- cementations when medical necessity can be documented. | For single crowns, recent, diagnostic full mouth radiographs or panoramic image. If tooth has no occlusion, narrative documenting that there is an opposing denture or tooth will be used as an abutment to a fixed or removable denture. Documentation of caries control. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. |
Restoration intact, absence of decay or additional loss of tooth structure. |
D2920 | RE-CEMENT OR RE-BOND CROWN | none | There are no time limits on replacement or re- cementations when medical necessity can be documented | For single crowns, recent, diagnostic full mouth radiographs or panoramic image. If tooth has no occlusion, narrative documenting that there is an opposing denture or tooth will be used as an abutment to a fixed or removable denture. Documentation of caries control. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | Restoration intact, absence of decay or additional loss of tooth structure. |
D2921 | REATTACH TOOTH FRAGMENT | none | There are no time limits on replacement or re- cementations when medical necessity can be documented. | Recent diagnostic photographs and radiographs, clinical findings and dental history associated with treatment request. | No pulpal involvement, for incisal edge or single cusp fracture. Tooth is fully erupted and restorable. Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. |
D2929 | PREFABRICATED PORCELAIN/ CERAMIC CROWN PRIMARY TOOTH | none | There are no time limits on replacement or re- cementations when medical necessity can be documented. | Diagnostic radiographs. Allowed for SHCN members regardless of age or with demonstration of medical necessity. | Primary tooth cannot retain direct restoration. Exfoliation is not imminent. |
D2930 | PREFABRICATED STAINLESS STEEL CROWN, PRIMARY TOOTH | none | There are no time limits on replacement or re- cementations when medical necessity can be documented. | Diagnostic radiographs. Allowed for SHCN members regardless of age or with demonstration of medical necessity. | Primary tooth cannot retain direct restoration. Exfoliation is not imminent. |
D2931 | PREFABRICATED STAINLESS STEEL CROWN, PERMANENT TOOTH | none | There are no time limits on replacement or re- cementations when medical necessity can be documented. | Diagnostic radiographs. Allowed for SHCN members regardless of age or with demonstration of medical necessity. | Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics. For permanent tooth |
D2932 |
PREFABRICATED RESIN CROWN |
none |
There are no time limits on replacement or re- cementations when medical necessity can be documented. |
Diagnostic radiographs. Allowed for SHCN members regardless of age or with demonstration of medical necessity for permanent or primary tooth. |
牙齿不能保留直接修复。如果革命制度党mary tooth, exfoliation is not imminent. Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. |
D2933 | PREFABRICATED STAINLESS STEEL CROWN | none | There are no time limits on replacement or re-cementations when medical necessity can be documented. | Diagnostic radiographs. Allowed for SHCN members regardless of age or with demonstration of medical necessity. | Primary tooth cannot retain direct restoration.. If for primary tooth, exfoliation is not imminent. Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. . |
D2934 | PREFABRICATED ESTHETIC COATED STAINLESS STEEL CROWN PRIMARY TOOTH | Under age 9 unless SHCN | There are no time limits on replacement or re- cementations when medical necessity can be documented. | Diagnostic radiographs. Allowed for SHCN members regardless of age or with demonstration of medical necessity. | Primary anterior tooth cannot retain direct restoration. Exfoliation is not imminent. |
D2940 | PROTECTIVE RESTORATION | none | There are no time limits on replacement or re- cementations when medical necessity can be documented. | Diagnostic radiographs; for tooth in occlusion or planned abutment; diagnosis and reason for treatment | To relieve pain, promote healing or prevent further deterioration, preserve tooth and/or tissue form; for primary and permanent teeth. |
D2941 | 临时治疗恢复主要生齿 | none | There are no time limits on replacement or re- cementations when medical necessity can be documented. | Diagnostic radiographs | Adhesive restorative material placed to arrest caries in primary teeth; not a definitive restoration; for early childhood caries or provided in non-office setting. Exfoliation is not imminent. |
D2950 | CORE BUILDUP INCLUDING ANY PINS | none | There are no time limits on replacement or re- cementations when medical necessity can be documented. Not same day as D2952, D2954. | Diagnostic radiographs | Tooth meets criteria for full coverage restoration. |
D2951 | TOOTH PIN RETENTION | none | There are no time limits on replacement or re- cementations when medical necessity can be documented. | Diagnostic radiographs | Tooth to receive direct restoration 3 or more surfaces as definitive restoration. |
D2952 | CAST POST AND CORE IN ADDITION TO CROWN | none | There are no time limits on replacement or re- cementations when medical necessity can be documented. | Diagnostic radiographs of clinically acceptable post-op RCT not same day as D2952, D2954. | Evidence of clinically acceptable post-treatment view of RCT and restorable tooth; post should extend at least 1/2 (preferably 2/3) length of root; does not include crown; meets clinical criteria for a crown. |
D2953 | EACH ADDTIONAL CAST POST | none | There are no time limits on replacement or re- cementations when medical necessity can be documented. | Diagnostic radiographs of clinically acceptable post-op RCT not same day as D2952, D2954. | Evidence of clinically acceptable post-treatment view of RCT and restorable tooth; post should extend at least 1/2 (preferably 2/3) length of root; does not include crown; meets clinical criteria for a crown for molars only. |
D2954 | PREFABRICATED POST/CORE IN ADDITION TO CROWN | none | There are no time limits on replacement or re- cementations when medical necessity can be documented. | Diagnostic radiographs of clinically acceptable post-op RCT not same day as D2952, D2954. | Evidence of clinically acceptable post-treatment view of RCT and restorable tooth; post should extend at least 1/2 (preferably 2/3) length of root; does not include crown; meets clinical criteria for a crown. |
D2955 | POST REMOVAL | none | AMN | 诊断射线照片展示失败endo or restoration Is included in service and reimbursement for endodontic retreatment codes, but can be billed as separate rate when different provider is doing retreatment. | Failure of RCT requires post removal for retreatment. Post is not clinically acceptable. |
D2957 | EACH ADDTIONAL PREFABRICATED POST | none | There are no time limits on replacement or re- cementations when medical necessity can be documented. | Diagnostic radiographs of clinically acceptable post-op RCT not same day as D2952, D2954. | Evidence of clinically acceptable post-treatment view of RCT and restorable tooth; post should extend at least 1/2 (preferably 2/3) length of root; does not include crown; meets clinical criteria for a crown. |
D2971 |
ADDITIONAL PROCEDURE TO CONSTRUCT NEW CROWN UNDER RPD |
none |
There are no time limits on replacement or re- cementations when medical necessity can be documented. |
BR。Diagnostic radiographs, presence of removable partial denture (RPD). |
Tooth will receive crown (to be billed separately) and serve as abutment to existing functional RPD. Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics. |
D2975 |
COPING |
none |
There are no time limits on replacement or re- cementations when medical necessity can be documented. |
Diagnostic radiographs, planned full-coverage restoration. |
Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics. |
D2980 |
CROWN REPAIR |
none |
There are no time limits on replacement or re- cementations when medical necessity can be documented. |
BR; diagnostic image. |
Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics. Existing crown is otherwise clinically acceptable. |
D2981 | INLAY REPAIR | none | There are no time limits on replacement or re- cementations when medical necessity can be documented | BR; diagnostic image. | Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics. Existing inlay is otherwise clinically acceptable. |
D2982 |
ONLAY REPAIR |
none |
There are no time limits on replacement or re- cementations when medical necessity can be documented. |
BR; diagnostic image. |
Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics. Existing onlay is otherwise clinically acceptable. |
D2983 |
单板维修 |
none |
There are no time limits on replacement or re- cementations when medical necessity can be documented. |
BR; diagnostic image. |
Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics. Existing veneer is otherwise clinically acceptable. |
D2999 |
UNSPECIFIED RESTORATIVE PROCEDURE |
none |
BR。DMN; diagnosis, clinical presentation of provided service. |
Service not described by CDT code. |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D3220 |
THERAPUTIC PULPOTOMY |
none |
Once per tooth |
Emergency procedure |
For pain relief; primary or permanent tooth; not first stage of RCT or for apexogenesis. Tooth is restorable. |
D3221 | GROSS PULPAL DEBRIDEMENT | none | Once per tooth | Emergency procedure not same DOS as RCT performed in one visit. | For pain relief; primary or permanent tooth; not first stage of RCT or for apexogenesis. Tooth is restorable. |
D3222 |
PART PULPOTOMY FOR APEXOGENESIS |
To age 19 |
Once per tooth |
Diagnostic radiographs |
Restorable permanent tooth with incomplete root formation; open apex. |
D3230 |
PULPAL THERAPY ANTERIOR PRIM ARY TOOTH |
none |
Once per tooth |
Diagnostic radiographs |
Restorable tooth, good prognosis; space preservation. |
D3240 |
PULPAL THERAPY POSTERIOR PRI MARY TOOTH |
none |
Once per tooth |
Diagnostic radiographs |
Restorable tooth, good prognosis; space preservation. |
D3310 |
ENDO THERAPY ANTERIOR TOOTH |
none |
Once per tooth |
Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs included in reimbursement. |
Tooth is restorable, in occlusion or will be utilized as an abutment to a prosthesis; crown/root ratio of at least 50%; without mobility. Also includes clinical criteria for D2710. Exposed pulp or carious involved pulp, pulpal necrosis, PAP. |
D3320 |
ENDO THERAPY PREMOLAR TOOTH |
none |
Once per tooth |
Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs included in reimbursement. |
Tooth is restorable, in occlusion or will be utilized as an abutment to a prosthesis; crown/root ratio of at least 50%; without mobility. Also includes clinical criteria for D2710. Exposed pulp or carious involved pulp, pulpal necrosis, PAP. |
D3330 |
ENDO THERAPY MOLAR TOOTH |
none |
Once per tooth |
Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs included in reimbursement. |
Tooth is restorable, in occlusion or will be utilized as an abutment to a prosthesis; crown/root ratio of at least 50%; without mobility. Also includes clinical criteria for D2710. Exposed pulp or carious involved pulp, pulpal necrosis, PAP. |
D3331 |
NON SURGICAL TREATMENT ROOT CANAL OBSTRUCTION |
none |
Once per tooth |
BR。To include diagnostic image. |
Tooth is restorable, canal(s) blocked by calcification or foreign body for at least 50% of length. Pulpal exposure or caries. |
D3332 |
INCOMPLETE ENDODONTIC TREATMENT |
none |
Once per tooth |
BR。To include diagnostic image. |
Tooth found to be unrestorable during the course of RCT. |
D3333 |
INTERNAL ROOT REPAIR |
none |
Once per tooth |
BR。To include diagnostic image. |
To correct resorption or carious perforation; not iatrogenic. |
D3346 |
RETREAT ROOT CANAL ANTERIOR |
none |
Once per tooth |
Not benefited to same provider of D3310 within 36 months; there is no timeframe for consideration of an endodontic retreatment. |
Tooth is restorable; canal fill appears to be shorter than 2mm from apex or significantly beyond apex; fill appears to be incomplete or poor condensation, periapical pathology; tooth is sensitive to pressure or otherwise symptomatic. |
D3347 |
RETREAT ROOT CANAL PREMOLAR |
none |
Once per tooth |
Not benefited to same provider of D3320 within 36 months; there is no timeframe for consideration of an endodontic retreatment. |
Tooth is restorable; canal fill appears to be shorter than 2mm from apex or significantly beyond apex; fill appears to be incomplete or poor condensation, periapical pathology; tooth is sensitive to pressure or otherwise symptomatic. |
D3348 |
RETREAT ROOT CANAL MOLAR |
none |
Once per tooth |
Not benefited to same provider of D3330 within 36 months; there is no timeframe for consideration of an endodontic retreatment. |
Tooth is restorable; canal fill appears to be shorter than 2mm from apex or significantly beyond apex; fill appears to be incomplete or poor condensation, periapical pathology; tooth is sensitive to pressure or otherwise symptomatic. |
D3351 |
APEXIFICATION/R ECALCIFICATION INITIAL |
none |
Once per tooth |
Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs included in reimbursement. |
Vital pulp, insufficient apical development. |
D3352 |
APEXIFICATION/R ECALC INTERIM MEDICATION REPLACEMENT |
none |
Once per tooth includes all visits |
Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs |
Vital pulp, insufficient apical development. |
D3353 |
APEXIFICATION/R ECALCIFICATION FINAL |
none |
Once per tooth |
BR。To include diagnostic image. |
Vital pulp, insufficient apical development |
D3355 |
PULPAL REGENERATION INITIAL |
none |
Once per tooth |
Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs included in reimbursement. |
Permanent tooth; necrotic pulp, insufficient apical development. |
D3356 |
PULPAL REGENERATION INTERIM |
none |
Once per tooth |
Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs included in reimbursement. |
Permanent tooth; necrotic pulp, insufficient apical development. |
D3357 | PULPAL REGENERATION COMPLETE | none | Once per tooth | Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs included in reimbursement. | Permanent tooth; necrotic pulp, insufficient apical development. |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D3410 |
APICOECTOMY- ANTERIOR |
none |
Once per tooth |
Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs included in reimbursement. there is no timeframe for consideration of service. |
Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Restorable tooth; calcification prevents adequate fill to apex; failed retreatment; accessory canals; marked over extension of fill material preventing healing; tooth is sensitive to pressure or otherwise symptomatic. |
D3421 |
APICOECTOMY PREMOLAR (FIRST ROOT) |
none |
One treatment per initial root treated; all subsequent roots to be considered as D3426. |
Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs included in reimbursement. |
Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Restorable tooth; calcification prevents adequate fill to apex; failed retreatment; accessory canals; marked over extension of fill material preventing healing; tooth is sensitive to pressure or otherwise symptomatic. |
D3425 | APICOECTOMY MOLAR (FIRST ROOT) | none | One treatment per initial root treated; all subsequent roots to be considered as D3426. | Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs included in reimbursement. | Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion,or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Restorable tooth; calcification prevents adequate fill to apex; failed retreatment; accessory canals; marked over extension of fill material preventing healing; tooth is sensitive to pressure or otherwise symptomatic. |
D3426 |
APICOECTOMY EACH ADDITIONAL ROOT |
none |
One treatment per additional tooth root(s) |
Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs included in reimbursement. |
Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Restorable tooth; calcification prevents adequate fill to apex; failed retreatment; accessory canals; marked over extension of fill material preventing healing; tooth is sensitive to pressure or otherwise symptomatic. |
D3428 |
BONE GRAFT PERI RADICULAR PER TOOTH |
none |
One treatment allowed per tooth |
BR; Provided w/D3427; includes non- autogenous graft material. |
To repair perforation, resorption, fracture, removal of foreign material or seal accessory canals. |
D3429 |
BONE GRAFT PERI RADICULAR EACH ADDL TOOTH |
none |
One treatment allowed per tooth |
BR; Provided w/D3427; includes non- autogenous graft material. |
To repair perforation, resorption, fracture, removal of foreign material or seal accessory canals. |
D3430 |
RETROGRADE FILLING –PER ROOT |
none |
One treatment per tooth root |
Provided w/ D3410, D3421, D3425, D3426. |
To repair perforation, resorption, fracture, removal of foreign material or seal accessory canals. |
D3450 |
ROOT AMPUTATION |
none |
Once per root |
Restorative treatment plan, full mouth radiographs. |
Presence of root fracture, caries or resorption; bone support and crown: root ratio both at least 50%; remaining root(s) functional and restorable with good long term prognosis. |
D3471 |
SURGICAL REPAIR OF ROOT RESORPTION - ANTERIOR |
none |
One treatment allowed per tooth |
Restorative treatment plan, full mouth radiographs. Surgery on root of anterior tooth; does not include restoration. |
Radiographic evidence of root resorption; both bone support and crown to root ratio at least 50%; tooth is restorable and will be in function with good long term prognosis. |
D3472 |
SURGICAL REPAIR OF ROOT RESORPTION - PREMOLAR |
none |
One treatment allowed per tooth |
Restorative treatment plan, full mouth radiographs. Surgery on root of premolar tooth; does not include restoration. |
Radiographic evidence of root resorption; both bone support and crown to root ratio at least 50%; tooth is restorable and will be in function with good long term prognosis. |
D3473 |
SURGICAL REPAIR OF ROOT RESORPTION - MOLAR |
none |
One treatment allowed per tooth |
Restorative treatment plan, full mouth radiographs. Surgery on root of molar tooth; does not include restoration. |
Radiographic evidence of root resorption; both bone support and crown to root ratio at least 50%; tooth is restorable and will be in function with good long term prognosis. |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D3501 |
SURGICAL EXPOSURE OF ROOT SURFACE WITHOUT APICOECTOMY OR REPAIR OF ROOT RESORPTION - ANTERIOR |
none |
One treatment allowed per tooth. No other services (excepting diagnostic) to be performed on same DOS. |
BR Clinical findings, differential diagnosis, restorative treatment plan, recent radiograph of involved tooth, full mouth radiographs. |
History of pain or discomfort which could not be diagnosed from clinical evaluation or radiographic images; exploratory procedure. Conforms to CDT descriptor. |
D3502 |
SURGICAL EXPOSURE OF ROOT SURFACE WITHOUT APICOECTOMY OR REPAIR OF ROOT RESORPTION – PREMOLAR |
none |
One treatment allowed per tooth. No other services (excepting diagnostic) to be performed on same DOS. |
BR Clinical findings, differential diagnosis, restorative treatment plan, recent radiograph of involved tooth, full mouth radiographs. |
History of pain or discomfort which could not be diagnosed from clinical evaluation or radiographic images; exploratory procedure. Conforms to CDT descriptor. |
D3503 |
SURGICAL EXPOSURE OF ROOT SURFACE WITHOUT APICOECTOMY OR REPAIR OF ROOT RESORPTION – MOLAR |
none |
One treatment allowed per tooth. No other services (excepting diagnostic) to be performed on same DOS. |
BR Clinical findings, differential diagnosis, restorative treatment plan, recent radiograph of involved tooth, full mouth radiographs. |
History of pain or discomfort which could not be diagnosed from clinical evaluation or radiographic images; exploratory procedure. Conforms to CDT descriptor. |
D3910 |
SURGICAL ISOLATION- TOOTH W/ RUBBER DAM |
none |
Once per tooth |
BR。To include diagnostic image. |
Insufficient supra-osseous tooth structure to retain rubber dam clamp. |
D3920 |
TOOTH SPLITTING |
none |
Once per tooth |
Diagnostic full mouth radiographs; does not include RCT. |
Hemisection; tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Restorable tooth; calcification prevents adequate fill to apex; failed retreatment; accessory canals; marked over extension of fill material preventing healing; tooth is sensitive to pressure or otherwise symptomatic tooth is restorable and required for occlusal function or as an abutment. |
D3950 | CANAL PREP/ FITTING OF DOWEL | none | Once per tooth | Diagnostic periapical, restorative treatment plan; not to same provider as D2952, D2953, D2954, D2957. | Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Restorable tooth; calcification preventsadequate fill to apex; failed retreatment; accessory canals; marked over extension of fill material preventing healing; tooth is sensitive to pressure or otherwise symptomatic. |
D3999 |
UNSPECIFIED ENDODONTIC PROCEDURE |
none |
BR。DMN; diagnosis, clinical presentation of provided service. |
Service not described by CDT code. |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D4210 | GINGIVECTOMY/ PLASTY 4 OR MORE TEETH | none | Periodontal surgical procedures will be allowed every 3 years. | Based on number of involved restorable teeth in quadrant. Full mouth x-rays or photos and narrative if SHCN member; perio charting; case type; oral hygiene status; occlusal trauma; mobility; at least four weeks after scaling, excepting OR cases. Units reimbursable per DOS will be limited to 2 quadrants unless services are provided in an operating room or for a developmentally disabled or SHCN member. | Recent history of scaling and root planning or periodontal maintenance; documentation of bone loss and pocket depth exceeding 5 mm.; documentation of caries control; documentation of drug induced gingival hyperplasia, where applicable. |
D4211 | GINGIVECTOMY/ PLASTY 1 TO 3 TEETH | none | Periodontal surgical procedures will be allowed every 3 years. | Based on number of involved restorable teeth in quadrant. Full mouth x-rays or photos and narrative if SHCN member; perio charting; case type; oral hygiene status; occlusal trauma; mobility; at least four weeks after scaling, excepting OR cases. Units reimbursable per DOS will be limited to 2 quadrants unless services are provided in an operating room or for a developmentally disabled or SHCN member. | Recent history of scaling and root planning or periodontal maintenance; documentation of bone loss and pocket depth exceeding 5 mm.; documentation of caries control; documentation of drug induced gingival hyperplasia, where applicable. |
D4212 | GINGIVECTOMY/ PLASTY ACCESS FOR RESTORATION | none | Periodontal surgical procedures will be allowed every 3 years. | Diagnostic periapical or bitewing radiograph, restorative treatment plan. | To allow visualize & access for placement of restoration. |
D4240 | 牙龈皮瓣手术W /根PLANING 4 OR MORE TEETH | Age 18 and older | Periodontal surgical procedures will be allowed every 3 years. | Based on number of involved restorable teeth in quadrant. Full mouth x-rays or photos and narrative if SHCN member; perio charting; case type; oral hygiene status; occlusal trauma; mobility; at least four weeks after scaling, excepting OR cases. Units reimbursable per DOS will be limited to 2 quadrants unless services are provided in an operating room or for a developmentally disabled or SHCN member, there is no requirement for prior scaling and root planning. | Recent history of scaling and root planning or periodontal maintenance; documentation of bone loss and pocket depth exceeding 5 mm.; documentation of caries control; documentation of drug induced gingival hyperplasia, where applicable without recent history of scaling and root planning. |
D4241 | GINGIVAL FLAP W/ ROOT PLANING 1 -3 TEETH | Age 18 and older | Periodontal surgical procedures will be allowed every 3 years. | Based on number of involved restorable teeth in quadrant. Full mouth x-rays or photos and narrative if SHCN member; perio charting; case type; oral hygiene status; occlusal trauma; mobility; at least four weeks after scaling, excepting OR cases. Units reimbursable per DOS will be limited to 2 quadrants unless services are provided in an operating room or for a developmentally disabled or SHCN member, there is no requirement for prior scaling and root planning. | Recent history of scaling and root planning or periodontal maintenance; documentation of bone loss and pocket depth exceeding 5 mm.; documentation of caries control; documentation of drug induced gingival hyperplasia, where applicable. |
D4245 | APICALLY POSITIONED FLAP | Age 18 and older | Once per tooth | Full mouth x-rays or photos, perio charting, oral hygiene status. To preserve keratinized gingiva surrounding natural teeth or implant(s). | |
D4249 | CLINICAL CROWN LENGTHENING HARD TISSUE | Age 18 and older | Once per tooth | Diagnostic periapical or bitewing radiograph, restorative treatment plan | To restore clinically acceptable crown root ratio or to create proper biologic width for crown margin; tooth has good long term prognosis and periodontium is healthy; RCT if present is clinically acceptable. |
D4260 | OSSEOUS SURGERY 4 OR MORE TEETH | Age 18 and older | Periodontal surgical procedures will be allowed every 3 years. | Based on number of involved restorable teeth in quadrant. Full mouth x-rays or photos and narrative if SHCN member; perio charting; case type; oral hygiene status; occlusal trauma; mobility; at least four weeks after scaling, excepting OR cases. Units reimbursable per DOS will be limited to 2 quadrants unless services are provided in an operating room or for a developmentally disabled or SHCN member. Periodontal surgical procedures will be allowed every 3 years. | Recent history of scaling and root planning or periodontal maintenance; documentation of bone loss and pocket depth exceeding 5 mm.; documentation of caries control; documentation of drug induced gingival hyperplasia, where applicable. |
D4261 | OSSEOUS SURGERY 1 TO 3 TEETH | Age 18 and older | Periodontal surgical procedures will be allowed every 3 years. | Based on number of involved restorable teeth in quadrant. Full mouth x-rays or photos and narrative if SHCN member; perio charting; case type; oral hygiene status; occlusal trauma; mobility; at least four weeks after scaling, excepting OR cases. Units reimbursable per DOS will be limited to 2 quadrants unless services are provided in an operating room or for a developmentally disabled or SHCN member. Periodontal surgical procedures will be allowed every 3 years. | Recent history of scaling and root planning or periodontal maintenance; documentation of bone loss and pocket depth exceeding 5 mm.; documentation of caries control; documentation of drug induced gingival hyperplasia, where applicable. |
D4263 | BONE REPLACE GRAFT FIRST SITE IN QUAD | Age 18 and older | Once per tooth (each tooth = 1 site) | Full mouth x-rays or photos and narrative if SHCN; perio charting; case type; oral hygiene status; occlusal trauma; mobility; at least four weeks after scaling, excepting SHCN OR cases. Not with implant cases; does not include entry and closure, wound debridement, osseous contouring, biologic materials or barrier membranes. Other procedures on same DOS documented by their own codes. | 通过牙周再生骨丢失disease to correct a deformity or defect; not for edentulous spaces or extraction sites. For retained natural tooth, presence of bone loss. |
D4264 | BONE REPLACE GRAFT EACH ADDITIONAL SITE IN A QUADRANT | Age 18 and older | Once per tooth | Full mouth x-rays or photos and narrative if SHCN; perio charting; case type; oral hygiene status; occlusal trauma; mobility; at least four weeks after scaling, excepting SHCN OR cases Not with implant cases. Performed with one or more bone replacement grafts; number of sites to be Documented | 通过牙周再生骨丢失disease to correct a deformity or defect; not for edentulous spaces or extraction sites. For retained natural tooth, presence of bone loss. |
D4265 |
BIOLOGIC MATERIALS TO AID SOFT TISSUE/ OSSEOUS REGENERATION |
Age 18 and older |
Once per tooth |
Recent diagnostic images and periodontal charting. Used alone or with other regenerative materials such as bone and barrier membranes; does not include surgical entry and closure, debridement, osseous contouring or placement of graft related materials and or membranes. Other procedures provided on same DOS to be reported with own 有限公司des. |
For the correction of periodontal defects involving restorable teeth in occlusion, presence of bone loss. |
D4266 |
GUIDED TISSUE REGENERATION RESORBABLE |
Age 18 and older |
Once per tooth (each tooth = 1 site) |
Recent diagnostic images and periodontal charting. Does not include surgical entry and closure, wound debridement, osseous contouring or placement of barrier membranes or graft materials; other procedures provided on same DOS reported using their own codes |
For correction of periodontal and peri-implant defects involving restorable teeth or implant in occlusion presence of bone loss. |
D4267 |
GUIDED TISSUE REGENERATION NONRESORBABLE |
Age 18 and older |
Once per tooth (each tooth = 1 site) |
Full mouth x-rays or photos and narrative if SHCN; perio charting; case type; oral hygiene status; occlusal trauma; mobility; at least four weeks after scaling, excepting SHCN OR cases. Not with implant cases; does not include entry and closure, wound debridement, osseous contouring, biologic materials or barrier membranes. Other procedures on same DOS documented by their own codes. |
For correction of periodontal and peri-implant defects involving restorable teeth or implant in occlusion presence of bone loss. |
D4268 |
SURGICAL REVISION PROCEDURE, PER TOOTH |
Age 18 and older |
Once per tooth |
Full mouth x-rays or photos and narrative if SHCN; perio charting; case type; oral hygiene status; occlusal trauma; mobility; at least four weeks after scaling, excepting SHCN OR cases. Not with implant cases; does not include entry and closure, wound debridement, osseous contouring, biologic materials or barrier membranes. Other procedures on same DOS documented by their own codes. |
To refine results of previous surgical procedure; presence of bone loss, may modify irregular contours of soft or hard tissue; muccoperiosteal flap to access alveolar bone; flap(s) replaced or repositioned and sutured. |
D4270 |
PEDICLE SOFT TISSUE GRAFT PROCEDURE |
Age 18 and older |
Once per tooth |
Recent perio charting, diagnostic radiographs and/or photographs, narrative. |
Adjacent gingiva is used to replace absent alveolar mucosa as marginal tissue; for root coverage or correct gingival defects on prominent teeth. |
D4273 |
AUTO TISSUE GRAFT FIRST TOOTH |
Age 18 and older |
Once per tooth |
Recent perio charting, diagnostic radiographs and/or photographs, narrative. |
For correction of gingival defects of tooth, implant or dental ridge; utilizes donor site. |
D4274 |
MESIAL/DISTAL WEDGE PROCEDURE |
Age 18 and older |
Once per tooth |
Recent perio charting, diagnostic radiographs and/or photographs, narrative. |
To reduce pocket depth in edentulous area adjacent to erupted tooth. |
D4275 |
NON-AUTOGEOUS GRAFT FIRST TOOTH |
Age 18 and older |
Once per tooth |
Recent perio charting, diagnostic radiographs and/or photographs, narrative. |
For correction of gingival defects of tooth (including recession), implant or dental ridge; eliminate pull of frena and muscle attachments; no donor site. |
D4276 |
CONNECTIVE TISSUE AND DOUBLE PEDICLE GRAFT |
Age 18 and older |
Once per tooth |
Recent perio charting, diagnostic radiographs and/or photographs, narrative. |
For advanced gingival recession, utilizes combined tissue grafting procedures. |
D4277 |
SOFT TISSUE GRAFT FIRSTTOOTH |
Age 18 and older |
Once per tooth |
Recent perio charting, diagnostic radiographs and/or photographs, narrative. |
For correction of gingival defects of tooth, implant or dental ridge; utilizes donor site. |
D4278 |
SOFT TISSUE GRAFT ADDITIONAL TOOTH |
Age 18 and older |
Once per tooth |
Recent perio charting, diagnostic radiographs and/or photographs, narrative. |
For correction of gingival defects of tooth, implant or dental ridge; utilizes donor site. |
D4283 |
AUTO TISSUE GRAFT ADDITIONAL TOOTH |
Age 18 and older |
Once per tooth |
Recent perio charting, diagnostic radiographs and/or photographs, narrative. |
For correction of gingival defects of tooth, implant or dental ridge; utilizes donor site. |
D4285 |
NON-AUTO GRAFT ADDITIONAL TOOTH |
Age 18 and older |
Once per tooth |
Recent perio charting, diagnostic radiographs and/or photographs, narrative. |
For correction of gingival defects of tooth (including recession), implant or dental ridge; eliminate pull of frena and muscle attachments; no donor site; same graft site, used in conjunction with D4275. |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D4322 | SPLINT – INTRA- CORONAL; NATURAL TEETH OR PROSTHETIC CROWNS | none | AMN | Full mouth x-rays or photos and narrative if SHCN; perio charting to include level of bone support, presence of occlusal trauma and/or mobility; treatment plan: per tooth | For interim stabilization of periodontally involved teeth; not for stabilization post- trauma (see D7270) presence of bone loss. |
D4323 | SPLINT – EXTRA- CORONAL; NATURAL TEETH OR PROSTHETIC CROWNS | none | AMN | Full mouth x-rays or photos and narrative if SHCN; perio charting to include level of bone support, presence of occlusal trauma and/or mobility; treatment plan: per tooth | For interim stabilization of periodontally involved teeth; not for stabilization post- trauma (see D7270) presence of bone loss. |
D4341 | PERIODONTAL SCALING & ROOT PLANING 4 OR MORE TEETH | Age 18 and older unless SHCN | Allowed every 3 years; can be considered once a year with DMN for SHCN members | Recent full mouth perio charting and radiographs; narrative and photos if bone loss not visible on x-rays or for SHCN Member, LTCF resident or member who cannot tolerate radiographs. | Documentation of pocket depth, presence of bone loss inflammation, medical history or mobility supports procedure; pocket depths of 5mm. or greater. |
D4342 | PERIODONTAL SCALING 1-3 TEETH | Age 18 and older unless SHCN | Allowed every 3 years; can be considered once a year with DMN for SHCN members. | Recent full mouth perio charting and radiographs; narrative and photos if bone loss not visible on x-rays or for SHCN Member, LTCF resident or member who cannot tolerate radiographs | Documentation of pocket depth, presence of bone loss inflammation, medical history or mobility supports procedure; pocket depths of 5mm. or greater. |
D4346 | SCALING W/GINGIVAL INFLAMATION | Age 10 and older (unless SHCN) | Once per RY; up to four times per RY for SHCN with documentation of medical necessity. | Recent full mouth perio charting and radiographs; narrative and photos if bone loss not visible on x-rays or for SHCN Member, LTCF resident or member who cannot tolerate radiographs; not allowed within 6 months of D4341, D4342, D4355, D4210, D4211, D4910. | Pocket depths of 4mm. or greater without bone loss; presence of inflammation; medical history. |
D4355 | FULL MOUTH DEBRIDEMENT | none | Once per 3 years. Allowed once per year for SHCN members and LTCF residents. | DMN; Code cannot be billed on same DOS with D0150, D0160 or D0180 or with prophylaxis – adult or child (D1110, D1120) or any other periodontal code unless service is provided in OR setting for SHCN member. | Removal of heavy plaque and/or calculus deposits required to perform oral evaluation. |
D4381 | LOCALIZED DELIVERY OF ANTIMICROBIAL AGENTS | none | One placement per tooth per DOS per 12 month period; not same DOS as D1110, D4346, or D4355. | Narrative report, recent full mouth perio charting. May be provided on same DOS as D4341, D4342 or D4910. | Minimum 6mm probing depth; presence of bone loss. Patient must have completed root planning, or periodontal surgical procedure in same quadrant, and have documented regular recall visits. |
D4910 | PERIODONTAL MAINTENANCE | none | May be provided twice a RY and for members with SHCN additional visits can be considered in a RY with documentation of medical necessity. For periodontal maintenance on a 3 month cycle additional service will be considered as prophylaxis | Recent full mouth charting and radiographs, documentation of recent provision of other periodontal therapy, improved oral hygiene and periodontal prognosis with documented caries control. | Recent provision of periodontal therapy presence of bone loss. |
D4999 | UNSPECIFIED PERIODONTAL PROCEDURE | none | DMN; diagnosis, clinical presentation of provided service; BR. | Service not described by CDT code. |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D5110 | COMPLETE DENTURE MAXILLARY | none | 7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed through MCO of enrollment. | Full mouth radiographs or photographs, charting of dentition, planned surgical procedures. Replacements: Documentation of physical changes, post denture insertion extractions or planned extractions, broken or lost dentures and other extenuating circumstances. Date of previous denture(s) not required.; includes adjustments for first six months post-insertion, relines and rebases not covered 6 months post insertion. |
Edentulous arch or planned full arch extractiontd> |
D5120 | COMPLETE DENTURE MANDIBULAR | none | 7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed through MCO of enrollment. | Full mouth radiographs or photographs, charting of dentition, planned surgical procedures. Replacements: Documentation of physical changes, post denture insertion extractions or planned extractions, broken or lost dentures and other extenuating circumstances. Date of previous denture(s) not required.; includes adjustments for first six months post-insertion, relines and rebases not covered 6 months post insertion. |
Edentulous arch or planned full arch extraction. |
D5130 | IMMEDIATE DENTURE MAXILLARY | none | Once per lifetime | Full mouth radiographs or photographs, charting of dentition, planned surgical procedures. Adjustments, relines/rebases are included for the 1st 6 months post insertion. |
Remaining teeth have poor to hopeless prognosis; extractions (to include teeth #s 05-12) performed on date of insertion. |
D5140 | IMMEDIATE DENTURE MANDIBULAR | none | Once per lifetime | Full mouth radiographs or photographs, charting of dentition, planned surgical procedures. Adjustments, relines/rebases are included for the 1st 6 months post insertion. |
Remaining teeth have poor to hopeless prognosis; extractions (to include teeth #s 21-28) performed on date of insertion. |
D5211 | MAXILLARY PARTIAL DENTURE RESIN BASE | none | 7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed through MCO of enrollment. | Full mouth radiographs or photographs, charting of dentition, planned surgical procedures. | At least one missing anterior tooth; less than 8 points of contact that establish functional and balanced occlusion; all procedures to be provided before impressions; remaining teeth have at least fair prognosis; design allows for addition of teeth; adjustments, relines, rebases included 6 mos. post insert. If denture is less than 7.5 years old, documentation to support loss, inability to repair or multiple planned extractions will be provided. |
D5212 | MANDIBULAR PARTIAL DENTURE RESIN BASE | none | 7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed through MCO of enrollment. | Full mouth radiographs or photographs, charting of dentition, planned surgical procedures. | At least one missing anterior tooth; less than 8 points of contact that establish functional and balanced occlusion; all procedures to be provided before impressions; remaining teeth have at least fair prognosis; design allows for addition of teeth; adjustments, relines, rebases included 6 mos. post insert. If denture is less than 7.5 years old, documentation to support loss, inability to repair or multiple planned extractions will be provided. |
D5213 | MAXILLARY PARTIAL DENTURE CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING RETENTIVE/CLASP ING MATERIALS, RESTS AND TEETH) | none | 7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed through MCO of enrollment. | Full mouth radiographs or photographs, charting of dentition, planned surgical procedures. | At least one missing anterior tooth; less than 8 points of contact that establish functional and balanced occlusion; all procedures to be provided before impressions; remaining teeth have at least fair prognosis; design allows for addition of teeth; adjustments, relines, rebases included 6 mos. post insert. If denture is less than 7.5 years old, documentation to support loss, inability to repair or multiple planned extractions will be provided. |
D5214 | MANDIBULAR PARTIAL DENTURE CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING RETENTIVE/CLASP ING MATERIALS, RESTS AND TEETH) | none | 7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed through MCO of enrollment. | Full mouth radiographs or photographs, charting of dentition, planned surgical procedures. | At least one missing anterior tooth; less than 8 points of contact that establish functional and balanced occlusion; all procedures to be provided before impressions; remaining teeth have at least fair prognosis; design allows for addition of teeth; adjustments, relines, rebases included 6 mos. post insert. If denture is less than 7.5 years old, documentation to support loss, inability to repair or multiple planned extractions will be provided. |
D5225 | MAXILLARY PARTIAL DENTURE FLEXIBLE BASE | none | 7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed through MCO of enrollment. | Full mouth radiographs or photographs, charting of dentition, planned surgical procedures. | Additional retention required; at least one missing anterior tooth; less than 8 points of contact that establish functional and balanced occlusion; all procedures to be provided before impressions; remaining teeth have good prognosis; adjustments, relines, rebases included 6 mos. post insert. If denture is less than 7.5 years old, documentation to support loss, inability to repair or multiple planned extractions will be provided. |
D5226 | MANDIBULAR PARTIAL DENTURE FLEXIBLE BASE | none | 7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed through MCO of enrollment. | Full mouth radiographs or photographs, charting of dentition, planned surgical procedures. | Additional retention required; at least one missing anterior tooth; less than 8 points of contact that establish functional and balanced occlusion; all procedures to be provided before impressions; remaining teeth have good prognosis; adjustments, relines, rebases included 6 mos. post insert. If denture is less than 7.5 years old, documentation to support loss, inability to repair or multiple planned extractions will be provided. |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D5410 | DENTURES ADJUST CMPLT MAXILLARY | none | AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function. | Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these services. | Necessity to restore form, function and to relieve sore spots and over-extensions causing tissue damage by existing denture. |
D5411 | DENTURES ADJUST COMPLETE MANDIBULAR | none | AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function. | Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these services. | Necessity to restore form, function and to relieve sore spots and over-extensions causing tissue damage by existing denture. |
D5421 | DENTURES ADJUST PARTIAL MAXILLARY | none | AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function. | Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these services. | Necessity to restore form, function and to relieve sore spots and over-extensions causing tissue damage by existing denture |
D5422 | DENTURES ADJUST PARTIAL MANDBLULAR | none | AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function. | Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these services. | Necessity to restore form, function and to relieve sore spots and over-extensions causing tissue damage by existing denture. |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D5511 | REPAIR BROKEN COMPLETE DENTURE BASE MANDIBULAR | none | AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function. | Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these services. | To restore denture function and retention. |
D5512 | REPAIR BROKEN COMPLETE DENTURE BASE MAXILLARY | none | AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function. | Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these services. | To restore denture function and retention. |
D5520 | REPLACE DENTURE TEETH COMPLETE | none | AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function. | Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these services. | To restore function and occlusion. |
D5611 | REPAIR RESIN PARTIAL DENTURE BASE MANDIBULAR | none | AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function. | Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these services. | To restore denture function and retention. |
D5612 | REPAIR RESIN PARTIAL DENTURE BASE MAXILLARY | none | AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function. | Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these services. | To restore denture function and retention. |
D5621 | REPAIR CAST PARTIAL DENTURE FRAME MANDIBULAR | none | AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function. | Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these services. | To restore denture function and retention. |
D5622 | REPAIR CAST PARTIAL DENTURE FRAME MAXILLARY | none | AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function. | Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these services. | To restore denture function and retention. |
D5630 | REPAIR PARTIAL DENTURE CLASP | none | AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function. | Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these services. | To restore denture function and retention. |
D5640 | REPLACE PARTIAL DENTURE TEETH | none | AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function. | Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these services. | To restore function and occlusion; replacement of denture tooth. |
D5650 | ADD TOOTH TO PARTIAL DENTURE | none | AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function. | Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these services. | To restore function and occlusion; replacement of a missing natural tooth. |
D5660 | ADD CLASP TO PARTIAL DENTURE | none | AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function. | Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these services. | To restore denture function and retention. |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D5710 | DENTURES REBASE COMPLETE MAXILLARY | none | Every 3 years | Narrative to DMN; photograph. | Necessity to restore form, function and to relieve sore spots and over-extensions causing tissue damage by existing denture; restore denture fit and retention. |
D5711 | DENTURES REBASE COMPLETE MANDIBULAR | none | Every 3 years | Narrative to DMN; photograph. | Necessity to restore form, function and to relieve sore spots and over-extensions causing tissue damage by existing denture; restore denture fit and retention. |
D5720 | DENTURES REBASE PARTIAL MAXILLARY | none | Every 3 years | Narrative to DMN; photograph. | Necessity to restore form, function and to relieve sore spots and over-extensions causing tissue damage by existing denture; restore denture fit and retention. |
D5721 | DENTURES REBASE PARTIAL MANDIBULAR | none | Every 3 years | Narrative to DMN; photograph. | Necessity to restore form, function and to relieve sore spots and over-extensions causing tissue damage by existing denture; restore denture fit and retention. |
D5725 | REBASE HYBRID PROSTHESIS | none | Every 2 years | Narrative to DMN; photograph. | Necessity to restore form, function and to relieve sore spots and over-extensions causing tissue damage by existing implant supported complete denture; restore complete denture fit and retention. |
D5730 | DENTURE RELNE COMPLETE MAXIL CHAIRSIDE | none | Once per RY | Documentation of ill- fitting denture. | 恢复功能,保留了重修的。 |
D5731 | DENTURE RELNE COMPLETE MAND CHAIRSIDE | none | Once per RY | Documentation of ill- fitting denture. | 恢复功能,保留了重修的。 |
D5740 | DENTURE RELINE PARTIAL MAXIL CHAIRSIDE | none | Once per RY | Documentation of ill- fitting denture. | 恢复功能,保留了重修的。 |
D5741 | DENTURE RELINE PARTIAL MAND CHAIRSIDE | none | Once per RY | Documentation of ill- fitting denture. | 恢复功能,保留了重修的。 |
D5750 | DENTURE RELINE COMPLETE MAX LAB | none | Once per RY | Documentation of ill- fitting denture. | 恢复功能,保留了重修的。 |
D5751 | DENTURE RELINE COMPLETE MAND LAB | none | Once per RY | Documentation of ill- fitting denture. | 恢复功能,保留了重修的。 |
D5760 | DENTURE RELINE PARTIAL MAXIL LAB | none | Once per RY | Documentation of ill- fitting denture. | 恢复功能,保留了重修的。 |
D5761 | DENTURE RELINE PARTIAL MAND LAB | none | Once per RY | Documentation of ill- fitting denture. | 恢复功能,保留了重修的。 |
D5850 | DENTURE TISSUE CONDITIONING MAXILLA | none | Once per RY | DMN; history of dentures includes adjustments to same provider for 6 months. | To heal soft tissue and ridge before definitive treatment; evidence of inflammation or tissue irritation. |
D5851 | DENTURE TISSUE CONDITIONING MANDBLE | none | Once per RY | DMN; history of dentures includes adjustments to same provider for 6 months. | To heal soft tissue and ridge before definitive treatment; evidence of inflammation or tissue irritation. |
D5862 | PRECISION ATTACHMENT | none | There are no time limits on replacement or re- cementations when medical necessity can be documented. | Diagnostic full mouth images, treatment plan | Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement. Documented caries control; RCT (if present) is clinically acceptable. |
D5863 | OVERDENTURE COMPLETE MAXILLARY | none | 7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed through MCO of enrollment. | Full mouth radiographs or photographs, charting of dentition, planned surgical procedures. Planned extraction with natural roots retained for arch integrity. | Planned extractions with specific roots retained to limit future arch resorption and improve denture retention. Retained roots have at least 50% bone support |
D5864 | OVERDENTURE PARTIAL MAXILLARY | none | 7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed through MCO of enrollment. | Full mouth radiographs or photographs, charting of dentition, planned surgical procedures. Planned extraction with natural roots retained for arch integrity. | At least one natural root or teeth retained for arch integrity and one missing anterior tooth; less than 8 points of contact that establish functional and balanced occlusion; all procedures to be provided before impressions; remaining teeth have at least fair prognosis; design allows for addition of teeth; adjustments, relines, rebases included 6 mos. post insert. If denture is less than 7.5 years old, documentation to support loss, inability to repair or multiple planned extractions will be provided. Retained roots have at least 50% bone support |
D5865 | OVERDENTURE COMPLETE MANDIBULAR | none | 7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed through MCO of enrollment. | Full mouth radiographs or photographs, charting of dentition, planned surgical procedures. Planned extraction with natural roots retained for arch integrity. | Planned extractions with specific roots retained to limit future arch resorption and improve denture retention. Retained roots have at least 50% bone support |
D5866 | OVERDENTURE PARTIAL MANDIBULAR | none | 7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed through MCO of enrollment. | Full mouth radiographs or photographs, charting of dentition, planned surgical procedures. Planned extraction with natural roots retained for arch integrity. | At least one natural root or teeth retained for arch integrity and one missing anterior tooth; less than 8 points of contact that establish functional and balanced occlusion; all procedures to be provided before impressions; remaining teeth have at least fair prognosis; design allows for addition of teeth; adjustments, relines, rebases included 6 mos. post insert. If denture is less than 7.5 years old, documentation to support loss, inability to repair or multiple planned extractions will be provided. Retained roots have at least 50% bone support |
D5867 | REPLACEMENT OF PRECISION ATTACHMENT | none | There are no time limits on replacement or re- cementations when medical necessity can be documented. | Image of abutment, narrative. | Failed attachment; can be replacement of male and/or female component(s). Same periodontal criteria as for D2710; good prognosis for abutment and denture. |
D5875 | PROSTHESIS MODIFICATION | none | Once per lifetime of prosthesis | BR; dental records. For implant cases only. | For existing prosthesis following implant surgery. |
D5899 | UNSPECIFIED REMOVABLE PROSTHODONTIC PROCEDURE | none | BR。DMN; diagnosis, clinical presentation of provided service. | Service not described by CDT code. |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D5911 | FACIAL MOULAGE SECTIONAL | none | AMN | BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. | Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5912 | FACIAL MOULAGE COMPLETE | none | AMN | BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. | Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5913 | NASAL PROSTHESIS | none | AMN | BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. | Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5914 | AURICULAR PROSTHESIS | none | AMN | BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. | Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5915 | ORBITAL PROSTHESIS | none | AMN | BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. | Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5916 | OCULAR PROSTHESIS | none | AMN | BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. | Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5919 | FACIAL PROSTHESIS | none | AMN | BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. | Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5922 | NASAL SEPTAL PROSTHESIS | none | AMN | BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. | Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5923 | OCULAR PROSTHESIS INTERIM | none | AMN | BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. | Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5924 | CRANIAL PROSTHESIS | none | AMN | BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. | Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5925 | FACIAL AUGMENTATION IMPLANT | none | AMN | BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. | Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5926 | REPLACEMENT NASAL PROSTHESIS | none | AMN | BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. | Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5927 | AURICULAR REPLACEMENT | none | AMN | BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. | Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5928 | ORBITAL REPLACEMENT | none | AMN | BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. | Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5929 | FACIAL REPLACEMENT | none | AMN | BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. | Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5931 | SURGICAL OBTURATOR | none | AMN | BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. | Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5932 | POSTSURGICAL OBTURATOR | none | AMN | BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. | Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5933 | REFITTING OF OBTURATOR | none | AMN | BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. | Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5934 | MANDIBULAR FLANGE PROSTHESIS | none | AMN | BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. | Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5935 | MANDIBULAR DENTURE PROSTHESIS | none | AMN | BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. | Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5936 | TEMPORARY OBTURATOR PROSTHESIS | none | AMN | BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. | Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5937 | TRISMUS APPLIANCE | none | AMN | BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. | Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5951 | FEEDING AID | none | AMN | BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes | Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5952 | PEDIATRIC SPEECH AID | Under age 19 | AMN | BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. | Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5953 | ADULT SPEECH AID | 19岁以上 | AMN | BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. | Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5954 |
PALATAL AUGMENTATION PROSTHESIS |
none |
AMN |
BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. |
Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5955 |
PALATAL LIFT PROSTHESIS, DEFINITIVE |
none |
AMN |
BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. |
Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5958 |
PALATAL LIFT PROSTHESIS INTERIM |
none |
AMN |
BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. |
Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5959 |
PALATAL LIFT PROSTHESIS, MODIFACATION |
none |
AMN |
BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. |
Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5960 |
MODIFY SPEECH AID PROSTHESIS |
none |
AMN |
BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. |
Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5982 |
SURGICAL STENT |
none |
AMN |
BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes |
Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5983 | RADIATION APPLICATOR | none | AMN | BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. | Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5984 |
RADIATION SHIELD |
none |
AMN |
BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. |
Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5985 |
RADIATION CONE LOCATOR |
none |
AMN |
BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. |
Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5986 |
FLUORIDE CARRIER |
none |
AMN |
BR; dental records. |
Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5987 | COMMISURE SPLINT | none | AMN | BR; dental records | Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5988 |
SURGICAL SPLINT |
none |
AMN |
Treatment plan, narrative |
Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5991 |
VESICULO BULLOUS DISEASE MED CARRIER |
none |
AMN |
Treatment plan, narrative |
Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5992 |
ADJUST MAXILLOFACIAL PROSTHETIC APPLIANCE |
none |
AMN |
Treatment plan, narrative |
Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5993 |
MAINTAIN/CLEAN MAXILLOFACIAL PROSTHESIS |
none |
AMN |
BR; indicate type of prosthesis and description of service provided/planned. |
Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor. |
D5999 |
UNSPECIFIED MAXILLOFACIAL PROSTHESIS |
none |
BR。DMN; diagnosis, clinical presentation of provided service; |
Service not described by CDT code. |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D6010 | ENDOSTEAL IMPLANT | none | Maximum 4 per arch | Diagnostic radiographic images of implant sites as appropriate, number of and area where implants are to be placed, dental history to indicate date of denture fabrication, two years of difficulty with denture retention and provider’s attempts to improve or correct retention of denture are required. Service is only considered with PA for denture(s) for edentulous arch(es) and complete implant treatment plan. | Patient is unable to function with conventional complete denture due to lack of retention due to insufficient bone. |
D6011 |
SECOND STAGE IMPLANT SURGERY |
none |
Maximum 4 per arch |
Recent diagnostic radiographic images of implants. Service is only considered with PA for denture(s) for edentulous arch(es). |
Implant body(ies) require surgical exposure to continue case. |
D6055 |
IMPLANT CONNECTING BAR |
none |
Once per arch |
BR。To include diagnostic radiographs of implants showing successful osteointegration, Service is only considered with PA for denture(s) for edentulous arch(es) or narrative describing modification to functional preexisting dentures. Paid as case rate for entire arch. |
Patient is unable to function with conventional complete denture due to lack of retention due to insufficient bone. |
D6080 |
IMPLANT MAINTENANCE PROCEDURES |
none |
Twice per RY |
BR; for debridement and evaluation of entire arch prostheses and its associated implants. Prosthesis is removed and reinserted. |
Evidence of plaque, stains, calculus on implant structure. Ensure occlusion and stability of prosthesis. |
D6081 |
SCALE & DEBRIDE, SINGLE IMPLANT |
none |
Once every 3 years |
Recent images of implants, narrative to document inflammation; not on same DOS as D1110, D4910 or D4346 D6101, D6102, D6103. |
For a single implant. Documentation of inflammation, medical history supports procedure. |
D6090 | REPAIR IMPLANT SUPPORTED PROSTHESIS | none | AMN There are no frequencies or time limits when DMN shows failure of material. | BR。照片、文档的临床结果and description of planned repair to include if it will be lab or in-office service. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or damage by patient can be documented. Documentation that existing denture is serviceable and functional. | For repair of implant supported prosthesis. |
D6091 |
REPLACE SEMI/PRECISION ATTACH OF IMPLANT SUPPORTED PROSTHESIS |
none |
AMN There are no frequencies or time limits when DMN shows failure of material. |
Photograph, clinical findings and description of planned repair to include if it will be lab or in-office service If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or damage by patient can be documented. Documentation that existing denture is serviceable and functional. |
Direct replacement of preexisting failed/defective semi-precision attachments; can be male and/or female component(s). Applies to replaceable male or female component of attachment. |
D6092 |
RECEMENT ABUTMENT SUPPORTED CROWN |
none |
AMN There are no frequencies or time limits when DMN shows failure of material. |
For single implant crowns. Recent, diagnostic radiograph or panoramic image. |
Recementation of undamaged implant crown. Associated denture must be functional. |
D6095 |
REPAIR IMPLANT ABUTMENT |
none |
AMN There are no frequencies or time limits when DMN shows failure of material. |
BR。Photograph, narrative. Submit denture repair on same PA when applicable. |
Repair of any part of implant abutment. |
D6096 |
REMOVE BROKEN IMPLANT RETAIN SCREW |
none |
Once per implant |
BR。To include diagnostic radiographs and narrative. |
Failed implant screw. |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D6100 | REMOVAL OF IMPLANT | none | Once per implant | BR。To include diagnostic radiographs and narrative. | Implant failure |
D6101 |
DEBRIDEMENT OF A PERIIMPLANT DEFECT |
none |
Once every 3 years; per implant |
Diagnostic x-rays or photos and narrative to include oral hygiene status; occlusal trauma; mobility; Includes entry and closure. Not on same DOS as D6081. |
For debridement and correction of peri-implant defect(s). |
D6102 |
DEBRIDEMENT & CONTOURING OF A PERI-IMPLANT DEFECT |
none |
Once every 3 years; per implant |
Diagnostic x-rays or photos and narrative to include oral hygiene status; occlusal trauma; mobility; Includes entry and closure. Not on same DOS as D6081. |
For debridement and correction of peri-implant osseous defect(s). |
D6103 |
植骨修复PERIMPLANT |
none |
Once every 3 years; per implant |
Diagnostic x-rays or photos and narrative; to include oral hygiene status; occlusal trauma; mobility. Does not include entry and closure, wound debridement, osseous contouring, biologic materials or barrier membranes. Other procedures on same DOS documented by their own code on same PA. Not on same DOS as D6081. |
For regeneration of bone loss associated with peri-implant osseous defect(s), to correct a deformity or defect. |
D6110 |
IMPLANT/ABUT REMOVEABLE DENTURE FOR EDENTULOUS ARCH-MAXILLARY |
none |
7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed through MCO of enrollment. |
BR。To include diagnostic radiographs. Include all associated implant services on same PA. |
Inability to function with conventional complete maxillary denture due to ridge resorption and lack of retention for at least 2 years. |
D6111 | IMPLANT/ABUT REMOVEABLE DENTURE FOR EDENTULOUS ARCH MANDIBULAR | none | 7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed through MCO of enrollment. | BR。To include diagnostic radiographs. Include all associated implant services on same PA. | Inability to function with conventional complete mandibular denture due to ridge resorption and lack of retention for at least 2 years |
D6191 | SEMI-PRECISION ABUTMENT PLACEMENT | none | Initial placement or replacement. Once per implant body; maximum 4 per arch | Diagnostic radiographs of implants showing successful osteointegration, photograph, clinical findings and description of planned repair if applicable. Service is only considered for complete denture(s). | Patient is unable to function with conventional complete denture due to lack of retention and insufficient bone. Include reason for replacement if applicable. |
D6192 | SEMI-PRECISION ATTACHMENT PLACEMENT | none | Initial placement or replacement. Once per implant body; maximum 4 per arch | Diagnostic radiographs of implants showing successful osteointegration, photograph, clinical findings and description of planned repair to include denture modification if applicable. Service is only considered for complete denture(s). | Patient is unable to function with conventional complete denture due to lack of retention and insufficient bone. Include reason for replacement if applicable. |
D6199 | UNSPECIFIED IMPLANT PROCEDURE | none | BR。DMN; diagnosis, clinical presentation, description of service to be provided. | Service not described by CDT code. |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D6210 | HIGH NOBLE METAL PONTIC | none | Replacement criteria based on N.J.A.C. 10:56 -2.13 Prosthodontic treatment (a) and (b). | Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | 最初的更换:单个前牙for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met. |
D6211 | PONTIC BASE METAL CAST | none | Replacement criteria based on N.J.A.C. 10:56 -2.13 Prosthodontic treatment (a) and (b). | Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | 最初的更换:单个前牙for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met. |
D6212 | PONTIC NOBLE METAL CAST | none | Replacement criteria based on N.J.A.C. 10:56 -2.13 Prosthodontic treatment (a) and (b). | Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | 最初的更换:单个前牙for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met. |
D6240 | PONTIC PORCELAIN HIGH NOBLE | none | Replacement criteria based on N.J.A.C. 10:56 -2.13 Prosthodontic treatment (a) and (b). | Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | 最初的更换:单个前牙for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met. |
D6241 | PONTIC PORCELAIN BASE METAL | none | Replacement criteria based on N.J.A.C. 10:56 -2.13 Prosthodontic treatment (a) and (b). | Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | 最初的更换:单个前牙for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met. |
D6242 | PONTIC PORCELAIN NOBLE METAL | none | Replacement criteria based on N.J.A.C. 10:56 -2.13 Prosthodontic treatment (a) and (b). | Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | 最初的更换:单个前牙for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met. |
D6250 | PONTIC RESIN W/HIGH NOBLE | none | Replacement criteria based on N.J.A.C. 10:56 -2.13 Prosthodontic treatment (a) and (b). | Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | 最初的更换:单个前牙for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met. |
D6251 | PONTIC RESIN BASE METAL | none | Replacement criteria based on N.J.A.C. 10:56 -2.13 Prosthodontic treatment (a) and (b). | Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | 最初的更换:单个前牙for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met. |
D6252 | PONTIC RESIN W/NOBLE METAL | none | Replacement criteria based on N.J.A.C. 10:56 -2.13 Prosthodontic treatment (a) and (b). | Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | 最初的更换:单个前牙for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met. |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D6545 | RETAINER CAST METAL | none | Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion. There are no frequencies or time limits when DMN shows failure of material or carious lesion. | Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | 最初的更换:单个前牙for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met. |
D6720 | RETAINER CROWN RESIN W HI NBLE | none | Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion. There are no frequencies or time limits when DMN shows failure of material or carious lesion. | Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | 最初的更换:单个前牙for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met. |
D6721 | RETAINER CROWN RESIN W/BASE METAL | none | Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion. There are no frequencies or time limits when DMN shows failure of material or carious lesion. | Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | 最初的更换:单个前牙for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met. |
D6722 | RETAINER CROWN RESIN W/NOBLE METAL | none | Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion. There are no frequencies or time limits when DMN shows failure of material or carious lesion. | Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | 最初的更换:单个前牙for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met. |
D6750 | RETAINER CROWN PORCELAIN HIGH NOBLE METAL | none | Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion. There are no frequencies or time limits when DMN shows failure of material or carious lesion. | Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | 最初的更换:单个前牙for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met. |
D6751 | RETAINER CROWN PORCELAIN BASE METAL | none | Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion. There are no frequencies or time limits when DMN shows failure of material or carious lesion. | Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | 最初的更换:单个前牙for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met. |
D6752 | RETAINER CROWN PORCELAIN NOBLE METAL | none | Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion. There are no frequencies or time limits when DMN shows failure of material or carious lesion. | Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | 最初的更换:单个前牙for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met. |
D6790 | RETAINER CROWN FULL HIGH NOBLE METAL | none | Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion. There are no frequencies or time limits when DMN shows failure of material or carious lesion. | Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | 最初的更换:单个前牙for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met. |
D6791 | RETAINER CROWN FULL BASE METAL CAST | none | Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion. There are no frequencies or time limits when DMN shows failure of material or carious lesion. | Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | 最初的更换:单个前牙for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met. |
D6792 | RETAINER CROWN FULLNOBLE METAL CAST | none | Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion. There are no frequencies or time limits when DMN shows failure of material or carious lesion. | Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | 最初的更换:单个前牙for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met. |
D6920 | DENTAL CONNECTOR BAR | none | Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion. There are no frequencies or time limits when DMN shows failure of material or carious lesion. | BR。To include diagnostic radiographs. | Device attached to abutment crown or coping to stabilize removable overdenture prosthesis. |
D6930 | RECEMENT/BOND FIXED PARTIAL DENTURE | none | No frequency or time limits. | Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | Recement functional and undamaged fixed partial denture; includes all retainers/abutments. |
D6940 | STRESS BREAKER | none | Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion | BR。To include diagnostic radiographs. | Used to decrease occlusal forces on abutment teeth. |
D6950 | PRECISION ATTACHEMENT | none | Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion. | Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented. | Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement. Documented caries control; RCT (if present) is clinically acceptable. Separate from prosthesis. |
D6980 | FIXED PARTIAL DENTURE REPAIR | none | Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion | BR。To include diagnostic radiographs | Repair of functional fixed partial denture. |
D6985 | PEDIATRIC PARTIAL DENTURE FIXED | Under age 21 | PA required | Diagnostic views of upper anterior region. | Premature loss or extraction of maxillary incisor(s) or when eruption of permanent teeth is not imminent. May be required for proper function and/or enunciation. |
D6999 | UNSPECIFIED FIXED PROSTHODONTIC PROCEDURE | none | BR。DMN; diagnosis, clinical presentation, description of service to be provided. | Service not described by CDT code. |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D7111 | EXTRACTION CORONAL REMNANTS | none | Once per tooth | Diagnostic radiographs | Primary tooth remnants |
D7140 | EXTRACT ERUPTED TOOTH/EXPOSED ROOT | none | Once per tooth | Diagnostic radiographs Extraction of teeth that are restorable, asymptomatic, not causing tissue damage or are not being removed to prevent a future condition will not be covered Extraction of restorable teeth at the request of an orthodontist as part of an orthodontic treatment plan or for treatment of crowding are allowed and the dentist doing the exactions should retain the request for extractions or document this in the dental records. | Unrestorable tooth with or without pulpal involvement. |
D7210 | REM OVAL ERUPTED TOOTH W/ MUCOPERIOSTEA L FLAP | none | Once per tooth | Diagnostic radiographs Extraction of teeth that are restorable, asymptomatic, not causing tissue damage or are not being removed to prevent a future condition will not be covered Extraction of restorable teeth at the request of an orthodontist as part of an orthodontic treatment plan or for treatment of crowding are allowed and the dentist doing the exactions should retain the request for extractions or document this in the dental records. | Conforms to CDT descriptor. |
D7220 | IMPACTED TOOTH REMOVALE SOFT TISSUE | none | Once per tooth | Diagnostic radiographs Extraction of teeth that are restorable, asymptomatic, not causing tissue damage or are not being removed to prevent a future condition will not be covered Extraction of restorable teeth at the request of an orthodontist as part of an orthodontic treatment plan or for treatment of crowding are allowed and the dentist doing the exactions should retain the request for extractions or document this in the dental records. | Occlusal surface of tooth covered by soft tissue; requires mucoperiosteal flap elevation. Conforms to CDT descriptor. |
D7230 | IMPACTED TOOTH REMOVAL PARTIAL BONY | none | Once per tooth | Diagnostic radiographs Extraction of teeth that are restorable, asymptomatic, not causing tissue damage or are not being removed to prevent a future condition will not be covered Extraction of restorable teeth at the request of an orthodontist as part of an orthodontic treatment plan or for treatment of crowding are allowed and the dentist doing the exactions should retain the request for extractions or document this in the dental records. | Part of crown covered by bone; requires mucoperiosteal flap elevation. Conforms to CDT descriptor. |
D7240 | IMPACTED TOOTH REMOVAL COMPLETELY BONY | none | Once per tooth | Diagnostic radiographs Extraction of teeth that are restorable, asymptomatic, not causing tissue damage or are not being removed to prevent a future condition will not be covered Extraction of restorable teeth at the request of an orthodontist as part of an orthodontic treatment plan or for treatment of crowding are allowed and the dentist doing the exactions should retain the request for extractions or document this in the dental records. | Most or all of crown covered by bone; requires mucoperiosteal flap elevation and bone removal. Conforms to CDT descriptor |
D7241 | IMPACTED TOOTH REMOVAL BONY IMPACTION W/UNUSUAL COMPLICATIONS | none | Once per month | BR。Diagnostic radiographs Extraction of teeth that are restorable, asymptomatic, not causing tissue damage or are not being removed to prevent a future condition will not be covered Extraction of restorable teeth at the request of an orthodontist as part of an orthodontic treatment plan or for treatment of crowding are allowed and the dentist doing the exactions should retain the request for extractions or document this in the dental records. | Most or all of crown covered by bone; unusually difficult or complicated due to factors such as nerve dissection required, separate closure of maxillary sinus required or aberrant tooth position. Conforms to CDT descriptor. |
D7250 | TOOTH ROOT REMOVAL | none | Once per tooth | Diagnostic radiographs | Includes cutting of soft tissue and bone, removal of tooth structure and closure. Conforms to CDT descriptor. |
D7251 | CORONECTOMY | none | once per tooth | Diagnostic radiographs | Intentional partial removal of impacted tooth performed when neurovascular complication likely with complete removal. Conforms to CDT descriptor. |
D7260 | ORAL ANTRAL FISTULA CLOSURE | none | AMN | Diagnostic radiographs, dental records. | To provide primary closure between maxillary sinus and oral cavity. Conforms to CDT descriptor. |
D7261 | PRIMARY CLOSURE SINUS PERFORATION | none | AMN | Diagnostic radiographs, dental records; same DOS as surgery in upper posterior region | To repair sinus perforation. Conforms to CDT descriptor. |
D7270 | TOOTH REIMPLANTATION AND STABILIZATION | none | Once per tooth | Diagnostic radiographs, dental records; post dental/facial trauma includes splinting and/or stabilization not for periodontal splinting (see D4320, D4321: full mouth x-rays or photos and narrative if SHCN; perio charting to include presence of occlusal trauma and/or mobility, treatment plan (per tooth.). | Restorable tooth which had been in occlusion. Conforms to CDT descriptor. |
D7280 | EXPOSURE OF UNERUPTED TOOTH | Under age 21 | Once per tooth | Diagnostic radiographs, dental records, narrative, treatment plan; approved PA for associated orthodontic service(s). | To aid in eruption of permanent teeth into functional position. |
D7282 | MOBILIZE ERUPTED/MALPO SITIONED TOOTH | Under age 21 | Once per tooth | Diagnostic radiographs, dental records, narrative, treatment plan, approved PA for associated orthodontic services. | To aid in eruption of permanent tooth. |
D7283 | PLACE DEVICE FOR IMPACTED TOOTH ERRUPTION | Under age 21 | Once per tooth | Diagnostic radiographs, dental records, narrative, treatment plan, approved PA for associated orthodontic services. | To aid in eruption of permanent tooth. |
D7285 | BIOPSY OF ORAL TISSUE HARD | none | no limits | Lab report, progress notes, area of mouth pathology report. | Per site Abnormal radiographic finding. Conforms to CDT descriptor. |
D7286 | BIOPSY OF ORAL TISSUE SOFT | none | No Limits | Lab report, progress notes, area of mouth pathology report. | Abnormal appearance of soft tissue; for diagnosis and treatment. Conforms to CDT descriptor. |
D7287 | EXFOLIATIVE CYTOLOG COLLECTION | none | No Limits | Lab report, progress notes, area of mouth pathology report. | Abnormal appearance of soft tissue; for diagnosis and treatment. Conforms to CDT descriptor. |
D7288 | BRUSH BIOPSY | none | No limits | Lab report, progress notes, area of mouth pathology report. | Abnormal appearance of soft tissue; for diagnosis and treatment. Conforms to CDT descriptor. |
D7290 | REPOSITIONING OF TEETH | Under age 21 | Once per tooth | BR; Treatment plan, full mouth radiographs/panoramic image, narrative. Submitted on same PA with any associated grafting procedures. | Malposed tooth that is restorable has adequate bone support and is in occlusion; with ongoing orthodontic treatment or approved PA for orthodontic services. Conforms to CDT descriptor. |
D7291 | TRANSSEPTAL FIBEROTOMY | Under age 21 | Once per area | BR; Treatment plan, recent diagnostic radiographs and photographs. | To facilitate tooth movement of permanent tooth; with ongoing orthodontic treatment or approved PA for orthodontic services. Conforms to CDT descriptor. |
D7292 | SCREW RETAINED PLATE | Under age 21 | Once per area | BR; Treatment plan, recent diagnostic radiographs and photographs. Includes placement and removal. | To facilitate tooth movement of permanent tooth; with ongoing orthodontic treatment or approved PA for orthodontic services. Conforms to CDT descriptor |
D7293 | TEMPORARY ANCHORAGE DEVICE W/ FLAP | Under age 21 | Once per area | BR; Treatment plan, recent diagnostic radiographs and photographs. Includes placement and removal. | To facilitate tooth movement of permanent tooth; with ongoing orthodontic treatment or approved PA for orthodontic services. Conforms to CDT descriptor |
D7294 | TEMPORARY ANCHORAGE DEVICE W/O FLAP | Under age 21 | Once per area | BR; Treatment plan, recent diagnostic radiographs and photographs Includes placement and removal. | To facilitate tooth movement of permanent tooth; with ongoing orthodontic treatment or approved PA for orthodontic services. Conforms to CDT descriptor |
D7295 | BONE HARVEST, AUTO GRAFT PROCEDURE | none | AMN | BR; Treatment plan, full mouth radiographs/panoramic image, narrative. Include on same PA with other autogenous graft placement procedures which do not include harvesting of bone. | DMN Bone defect. |
D7298 | REMOVAL OF TEMPORARY ANCHORAGE DEVICE [SCREW RETAINED PLATE, REQUIRING FLAP | Under age 21 | Once per area | BR; Treatment plan, recent diagnostic radiographs and photographs. D7292 in history. | Based on completion of treatment or defective or damaged anchorage device. |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D7310 | ALVEOPLASTY W/EXTRACTION 4 OR MORE TEETH | none | Once per quadrant | Treatment plan, full mouth radiographs/panoramic image, narrative; Four or more teeth per quadrant. | Preprosthetic surgery or before radiation therapy or transplant surgery. Recontouring of bone in area of extractions. |
D7311 | ALVEOLOPLASTY W/EXTRACT 1-3 TEETH | none | Once per quadrant | Treatment plan, full mouth radiographs/panoramic image, narrative; One to three teeth per quadrant. | Preprosthetic surgery or before radiation therapy or transplant surgery. Recontouring of bone in area of extractions. |
D7320 | ALVEOLOPLASTY W/O EXTRACTION 4 OR MORE TEETH | none | AMN | Treatment plan, full mouth radiographs/panoramic image, narrative; Four or more teeth per quadrant. | 假前surgery or before radiation therapy or transplant surgery. Recontouring of bone i |
D7321 | ALVEOLOPLASTY NOT W/EXTRACTS 1-3 TEETH | none | AMN | Treatment plan, full mouth radiographs/panoramic image, narrative; One to three teeth per quadrant. | Preprosthetic surgery or before radiation therapy or transplant surgery. Recontouring of bone |
D7340 | VESTIBULOPLASTY RIDGE EXTENSION | none | AMN | Treatment plan, full mouth radiographs/panoramic image, narrative. | Second epithelization; preprosthetic surgery. To increase ridge height. |
D7350 | VESTIBULOPLASTY EXTENION W/ GRAFTS | none | AMN | Treatment plan, full mouth radiographs/panoramic image, narrative includes soft tissue grafts, muscle reattachments, revision of soft tissue attachment, management/removal of excessive soft tissue. | Preprosthetic surgery To increase ridge height. |
D7410 | EXCISION BENIGN LESION UP TO 1.25 CM | none | AMN | Pathology report, radiographs, dental records | Removal of abnormal soft tissue lesion or tissue overgrowth. |
D7411 | EXCISION BENIGN LESION > 1.25 C | none | AMN | Pathology report, radiographs, dental records | Removal of abnormal soft tissue lesion or tissue overgrowth. |
D7412 | EXCISION BENIGN LESION COMPLICATED | none | AMN | Pathology report, radiographs, dental records | Removal of abnormal soft tissue lesion or tissue overgrowth. |
D7413 | EXCISION MALIG LESION<= 1.25C | none | AMN | Pathology report, radiographs, dental records | Removal of cancerous soft tissue lesion. |
D7414 | EXCISION MALIG LESION>1.25 CM | none | AMN | Pathology report, radiographs, dental records | Removal of cancerous soft tissue lesion. |
D7415 | EXCISION MALIG LESION COMPLICATED | none | AMN | Pathology report, radiographs, dental record | Removal of cancerous soft tissue lesion. Conforms to CDT descriptor. |
D7440 | MALIG TUMOR EXCISION TO 1.25CM | none | AMN | Pathology report, radiographs, dental record | Removal of cancerous soft tissue lesion. Conforms to CDT descriptor. |
D7441 | MALIG TUMOR > 1.25CM | none | AMN | Pathology report, radiographs, dental record | Removal of cancerous soft tissue lesion. Conforms to CDT descriptor. |
D7450 | REMOVE ODONTOGENIC CYST TO 1.25CM | none | AMN | Pathology report, radiographs, dental records; any extractions on same DOS considered separately. | Removal of cyst Conforms to CDT descriptor. |
D7451 | REMOVE ODONTOGENIC CYST >1.25CM | none | AMN | Pathology report, radiographs, dental records; any extractions on same DOS considered separately. | Removal of cyst Conforms to CDT descriptor. |
D7460 | REMOVE NON- ODONTOGENIC CYST TO 1.25 CM | none | AMN | Pathology report, radiographs, dental record; any extractions on same DOS considered separately. | Removal of cyst Conforms to CDT descriptor. |
D7461 | REMOVE NON- ODONTOGENIC CYST >1.25 CM | none | AMN | Pathology report, radiographs, dental records; any extractions on same DOS considered separately. | Removal of cyst Conforms to CDT descriptor. |
D7465 | LESION DESTRUCTION | none | AMN | Dental records | Removal of abnormal tissue. Conforms to CDT descriptor. |
D7471 | REMOVE EXOSTOSIS ANY SITE | none | AMN | Dental records, full mouth radiographs or intraoral images. | Overgrowth of hard tissue. Conforms to CDT descriptor. |
D7472 | REMOVAL OF TORUS PALATINUS | none | AMN | Dental records, full mouth radiographs or intraoral images. | Overgrowth of palatal hard tissue. Conforms to CDT descriptor. |
D7473 | REMOVE TORUS MANDIBULARIS | none | AMN | Dental records, full mouth radiographs or intraoral images. | Overgrowth of mandibular hard tissue. Conforms to CDT descriptor. |
D7485 | SURG REDUCT OSSEOUS TUBEROSITY | none | AMN | Dental records, full mouth radiographs or intraoral images. | Need to reshape tuberosity for denture construction |
D7490 | MAXILLA OR MANDIBLR RESECTION | none | AMN | Lab report, radiographs, dental records. | Removal of lesion in mandible Conforms to CDT descriptor. |
D7510 | &D ABSCESS INTRORAL SOFT TISSUE | none | AMN | Dental records | Abscess Conforms to CDT descriptor. |
D7511 | I&D ABSCESS INTRAORAL SOFT TISSUE, COMPLICATED | none | AMN | BR, dental records. | Abscess Conforms to CDT descriptor. |
D7520 | I&D ABSCESS, EXTRAORAL | none | AMN | Dental records | Abscess Conforms to CDT descriptor. |
D7521 | 我脓肿、EXTRAORAL复杂 | none | AMN | BR, dental records. | Abscess |
D7530 | REMOVAL FOREIGN BODY SKIN/ALVEOLAR TISSUE | None | AMN | Dental records. | Foreign body Conforms to CDT descriptor. |
D7540 | REMOVAL OF FOREIGN BODY REACTION | none | AMN | Dental records | Foreign body Conforms to CDT descriptor. |
D7550 | REMOVAL OF NON-VITAL BONE | none | Once per area | Dental records | Sequestrectomy; for removal of necrotic, sloughed-off bone due to infection or reduced blood supply. Conforms to CDT descriptor. |
D7560 | MAXILLARY SINUSOTOMY | none | AMN | Dental records, diagnostic radiograph of area. | Presence of tooth fragment or foreign body. Conforms to CDT descriptor. |
D7610 | MAXILLA OPEN REDUCTION SIMPLE | none | AMN | Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider. | Maxillary fracture requiring surgical reduction Conforms to CDT descriptor. |
D7620 | CLOSED REDUCTION SIMPLE MAXILLA FRACTURE | none | AMN | Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider. | Maxillary fracture with non- surgical reduction Conforms to CDT descriptor. |
D7630 | OPEN REDUCTION SIMPLE MANDIBLE FRACTURE | none | AMN | Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider. | Mandibular fracture requiring surgical reduction Conforms to CDT descriptor. |
D7640 | CLOSED REDUCTION SIMPLE MANDIBLE FRACTURE | none | AMN | Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider. | Mandibular fracture, non- surgical reduction Conforms to CDT descriptor. |
D7650 | OPEN REDUCTION SIMPLE MALAR/ZYGOMA FRACTURE | none | AMN | Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider. | Unilateral surgical reduction Conforms to CDT descriptor. |
D7660 | CLOSED REDUCTION SIMPLE MALAR/ZYGOMA FRACTURE | none | AMN | Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider. | Unilateral non-surgical reduction Conforms to CDT descriptor. |
D7670 | CLOSED REDUCTION SLPINT ALVEOLUS | none | AMN | Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider. | One site non-surgical reduction Conforms to CDT descriptor. |
D7671 | ALVEOLUS OPEN REDUCTION | none | AMN | Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider. | Surgical reduction Conforms to CDT descriptor. |
D7680 | REDUCTION COMPLEX FACIAL BONES FRACTURE | none | AMN | Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider. | Surgical reduction Conforms to CDT descriptor. |
D7710 | MAXILLA-OPEN REDUCTION | none | AMN | Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider. | Maxillary fracture requiring surgical reduction. Conforms to CDT descriptor. |
D7720 | MAXILLA-CLOSED REDUCTION | none | AMN | Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider. | Maxillary fracture requiring non-surgical reduction. Conforms to CDT descriptor. |
D7730 | MANDIBLE-OPEN REDUCTION | none | AMN | Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider. | Mandibular fracture requiring surgical reduction. Conforms to CDT descriptor. |
D7740 | MANDIBLE- CLOSED REDUCTION | none | AMN | Dental records; diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider. | Mandibular fracture requiring non-surgical reduction. Conforms to CDT descriptor. |
D7750 | OPEN REDUCTION MALAR/ZYGOMA FRACTURE | none | AMN | Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider. | Unilateral. Requires surgical reduction. Conforms to CDT descriptor. |
D7760 | CLOSED REDUCTION MALAR/ZYGOMA FRACTURE | none | AMN | Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider. | Unilateral Non-surgical reduction Conforms to CDT descriptor. |
D7770 | ALVEOLUS-OPEN REDUCTION STABILIZE TEETH | none | AMN | Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider. | Surgical reduction Conforms to CDT descriptor. |
D7771 | ALVEOLUS - CLOSED REDUCTION STABILIZE TEETH | none | AMN | Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider. | Non-surgical reduction Conforms to CDT descriptor. |
D7780 | REDUCT COMPND FACIAL BONE FRACTURE | none | AMN | Dental records; diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider. | Surgical reduction Conforms to CDT descriptor. |
D7810 | TMJ OPEN REDUCTION- DISLOCATION | none | AMN | Dental records, clinical presentation. | Surgical reduction Conforms to CDT descriptor. |
D7820 | CLOSED REDUCTION OF DISLOCATION | none | AMN | Dental records, clinical presentation; only billed with radiographs and anesthesia codes on same DOS. | Non-surgical reduction Conforms to CDT descriptor. |
D7830 | TMJ MANUPULATION UNDER ANESTHESIA | none | AMN | Dental records, clinical presentation; only with IV sedation or GA and radiographs on same DOS. | Reduction of dislocation with general or intravenous anesthesia. Conforms to CDT descriptor. |
D7840 | CONDYLECTOMY REMOVAL OF TMJ CONDYLE | none | Once per side | Dental records, clinical presentation, diagnostic image. | Unilateral Separate procedure. Conforms to CDT descriptor. |
D7850 | TMJ SURGICAL DISECTOMY | none | Once per side | Dental records, clinical presentation, diagnostic image | Unilateral With or without implant. Conforms to CDT descriptor. |
D7852 | TMJ REPAIR OF JOINT DISC | none | Once per side | Dental records, clinical presentation, diagnostic image. | Unilateral Reposition and/or sculpting of disc. Conforms to CDT descriptor. |
D7854 | SYNOVECTOMY | none | Once per side | Dental records, clinical presentation, diagnostic image. | Unilateral Removal of all or part of membrane. Conforms to CDT descriptor. |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA | |
D7856 | TMJ CUTTING OF A MUSCLE | none | AMN | BR, dental records For therapeutic purposes; separate procedure. | Conforms to CDT descriptor. | |
D7858 | TMJ RECONSTRUCTIO N | none | Once per side | Dental records, clinical presentation, diagnostic image. | Reconstruction of hard and/or soft tissues | Conforms to CDT descriptor. |
D7860 | ARTHROTOMY | none | Once per side | Dental records, clinical presentation, diagnostic image. | Conforms to CDT descriptor. | |
D7865 | ARTHROPLASTY | none | Once per side | Dental records, clinical presentation, diagnostic image. | Separate procedure Conforms to CDT descriptor. | |
D7870 | ARTHROCENTISIS | none | AMN | Dental records, clinical presentation, diagnostic image. | Unilateral Fluid removal from joint space. Conforms to CDT descriptor. | |
D7871 | LYSIS + LAVAGE W/ CATHETERS | none | AMN | Dental records, clinical presentation, diagnostic image. | Non-arthroscopic; treatment of joint space. Conforms to CDT descriptor. | |
D7872 | TMJ DIAGNOSTIC ARTHROSCOPY | none | AMN | Dental records, clinical presentation, diagnostic image. | With or without biopsy Conforms to CDT descriptor. | |
D7873 | TMJ ARTHROSCOPY LYSIS ADHESIONS | none | AMN | Dental records, clinical presentation, diagnostic image. | Arthroscopic treatment of joint space Conforms to CDT descriptor. | |
D7874 | TMJ ARTHROSCOPY DISC REPOSITION | none | AMN | Dental records, clinical presentation, diagnostic image | Disc reposition and stabilization Conforms to CDT descriptor. | |
D7875 | TMJ ARTHROSCOPY SYNOVECTOMY | none | AMN | Dental records, clinical presentation, diagnostic image. | Partial or complete Conforms to CDT descriptor. | |
D7876 | TMJ ARTHROSCOPY DISCECTOMY | none | Once per area | BR, dental records. | For disc removal and to remodel attachment. Conforms to CDT descriptor. | |
D7877 | 颞下颌关节关节镜清创 | none | AMN | Dental records, clinical presentation, diagnostic image. | Remove pathologic tissues Conforms to CDT descriptor. | |
D7880 | OCCLUSAL ORTHOTIC APPLIANCE | none | AMN | BR; includes placement and adjustments to same provider for first 6 months. | May be Included in case rate for TMJ. | |
D7881 | OCCLUSAL ORTHOTIC DEVICE ADJUST | none | AMN | BR, dental records. | Reimbursed to other than original provider or 6 months after placement. |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D7899 | TMJ UNSPECIFIED THERAPY | none | AMN | 描述临床BR-panoramic形象,叙事findings (to include measurements), dental records and TMJ images if available; treatment plan which includes expected time of treatment. Not for bruxism; paid as case rate. | Documentation supports presence of TMJ pain and /or decreased function. |
D7910 | SUTURE RECENT WOUND TO 5 CM | none | AMN | Dental records | Conforms to CDT descriptor. |
D7911 | SUTURE WOUND TO 5 CM | none | AMN | Dental records | Conforms to CDT descriptor. |
D7912 | SUTURE COMPLICATED WOUND >5 CM | none | AMN | Dental records | Conforms to CDT descriptor. |
D7920 | DENTAL SKIN GRAFT | none | AMN | Dental records | Conforms to CDT descriptor. |
D7940 | OSTEOPLASTY FOR ORTHOGNATHIC DEFORMATIES | none | Once per area | BR; diagnostic images, dental records, treatment plan; can be uni-lateral or bi-lateral. | Congenital, developmental, traumatic or surgical deformity. Conforms to CDT descriptor. |
D7941 | OSTEOTOMY MANDIBULAR RAMI | none | Once per area | BR; diagnostic images, dental records; treatment plan; can be uni-lateral or bi-lateral BR; Diagnostic images, progress notes, treatment plan; can be uni-lateral or bi-lateral. | Conforms to CDT descriptor. |
D7943 | OSTEOTOMY W/GRAFT | none | Once per area | BR; diagnostic images, dental records; treatment plan; can be uni-lateral or bi-lateral Includes obtaining graft. | Conforms to CDT descriptor. |
D7944 | OSTEOTOMY SEGMENTED | none | Once per area | Range of tooth numbers within segment; diagnostic images, dental records, treatment plan. | Conforms to CDT descriptor. |
D7945 | OSTEOTOMY BODY MANDIBLE | none | Once per area | BR; diagnostic images, dental records, treatment plan; can be uni-lateral or bi-lateral. | Sectioning of lower jaw; includes entire procedure and follow-up care. Conforms to CDT descriptor. |
D7946 | RECONSTRUCTIO N MAXILLA TOTAL LE FORTE I | none | Once per area | Diagnostic images, approved orthodontic treatment plan if for orthognathic surgery (under age 21), operative notes. | Sectioning of upper jaw; includes all procedures and follow-up care. Conforms to CDT descriptor. |
D7947 | RECONSTRUCT MAXILLA SEGMENT LE FORTE I | none | Once per area | Diagnostic images, approved orthodontic treatment plan if for orthognathic surgery (under age 21), operative notes. | BR ; reduced reimbursement when used for surgically assisted palatal expansion Conforms to CDT descriptor. |
D7948 | LE FORTE II or LE FORTE III NO BONE GRAFT | none | Once per area | Diagnostic images, approved orthodontic treatment plan if for orthognathic surgery (under age 21), operative notes. | Sectioning of upper jaw; includes all procedures and follow-up care. Conforms to CDT descriptor. |
D7949 | LE FORTE II OR LE FORTE III W/BONE GRAFT | none | Once per area | Diagnostic images, approved orthodontic treatment plan if for orthognathic surgery (under age 21), operative notes. | Sectioning of upper jaw; includes all procedures and follow-up care. Conforms to CDT descriptor. |
D7950 | MAXILLA OR MANDIBLE GRAFT | none | AMN | Full mouth radiographic images, approved restorative/prosthetic treatment plan. | Preprosthetic surgery to increase ridge height of Maxilla or Mandible; repair of trauma or post-cancer surgery. Conforms to CDT descriptor. |
D7951 | SINUS AUGMENTATION W/ BONE OR BONE SUBSTS. LATERAL APPROACH | none | Once per area; total limit is two procedures | Full mouth radiographic images, approved restorative/prosthetic treatment plan. | Unilateral. Conforms to CDT descriptor. |
D7952 | SINUS AUGMENTATION VERTICAL APPROACH | none | Once per area | Full mouth radiographic images, approved restorative/prosthetic treatment plan. | 单边符合to CDT descriptor. |
D7955 | REPAIR MAXILLOFACIAL SOFT/HARD TISSUE DEFECTS | none | AMN | Diagnostic imaging of area, dental records. | For facial reconstruction, trauma or congenital defects not a preprosthetic procedure. Conforms to CDT descriptor. |
D7961 | BUCCAL/LABIAL FRENECTOMY (FRENULECTOM Y) | none | AMN | DMN. Narrative describing importance to success of prosthetic or orthodontic treatment. Intraoral image when available. | Aberrant muscle attachments which hinder oral function, development or treatment. Separate procedure. Conforms to CDT descriptor. |
D7962 | LINGUAL FRENECTOMY (FRENULECTOM Y) | none | AMN | PA required. If referred by PCP, narrative of medical necessity required when requested for purposes of lactation or speech. Narrative describing importance to success of prosthetic or orthodontic treatment. Intraoral image when available. | Aberrant muscle attachments which hinder oral function, development or treatment. Separate procedure. Conforms to CDT descriptor. |
D7963 | FRENULOPLASTY | none | AMN | Dental records, intraoral image. | Aberrant muscle attachments which hinder oral function, development or treatment. Conforms to CDT descriptor. |
D7970 | EXCISION HYPERPLASTIC TISSUE | none | AMN; per arch | Dental records, intraoral image. | 假前surgery Conforms to CDT descriptor. |
D7971 | EXCISION PERCORONAL GINGIVA | none | AMN for permanent teeth | Dental records, intraoral image; with other oral surgical procedure. | To remove tissue surrounding partially erupted teeth; not as periodontal therapy. Conforms to CDT descriptor. |
D7972 | SURGICAL REDUCTION FIBROUS TUBEROSITY | none | Once per area limit two per DOS | Dental records, intraoral image. | 假前surgery Conforms to CDT descriptor. |
D7979 | NON-SURGICAL SIALOLITHOTOMY | none | AMN | BR, dental records. | Medical history, clinical presentation of glandular obstruction. Conforms to CDT descriptor. |
D7980 | 外科SIALOLITHOTOMY | none | AMN | Dental records. | Salivary gland/duct stone present. Conforms to CDT descriptor. |
D7981 | EXCISION OF SALIVARY GLAND | none | Once per gland | BR; dental records | Pathology due to tumor, infection or blockage. Conforms to CDT descriptor. |
D7982 | SIALODOCHO- PLASTY | none | AMN | Dental records | Salivary gland duct defect. Conforms to CDT descriptor. |
D7983 | CLOSURE OF SALIVARY FISTULA | none | AMN | Dental records | Repair of pathological opening into oral cavity. Conforms to CDT descriptor. |
D7990 | EMERGENCY TRACHEOTOMY | none | AMN | Dental records; may be paid under medical benefit. | Blocked airway; respiratory distress Conforms to CDT descriptor |
D7991 | CORONOIDEC- TOMY | none | Once per side | Dental records, diagnostic radiograph/image of area. | Pathology resulting in need for removal of coronoid process. Conforms to CDT descriptor. |
D7993 | SURGICAL PLACEMENT OF CRANIOFACIAL IMPLANT - EXTRAORAL | none | AMN | BR; dental records. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. | To aid in retention of an auricular, nasal or orbital prosthesis. Conforms to CDT descriptor. |
D7994 | SURGICAL PLACEMENT – ZYGOMATIC IMPLANT | none | AMN | BR; dental records. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes. | To provide support and attachment of a maxillary dental prosthesis. Conforms to CDT descriptor. |
D7995 | SYNTHETIC GRAFT FACIAL BONES | none | AMN | BR; for congenital defects and/or trauma; includes allogenic material. | Loss of bone or bone defect. Conforms to CDT descriptor. |
D7996 | IMPLANT MANDIBLE AUGMENTATION | none | AMN | BR, dental records. | Loss of mandibular bone width or height, Excludes alveolar ridge Conforms to CDT descriptor. |
D7997 | APPLIANCE REMOVAL | none | Not to provider originally treating fracture(s) | Panoramic image, narrative, dental records. | Fracture of jaw(s); includes removal of arch bar; appliance non-functional, treatment complete. Conforms to CDT descriptor. |
D7999 | UNSPECIFIED ORAL SURGERY PROCEDURE | none | BR。DMN; diagnosis, clinical presentation of provided service. | Service not described by CDT code. |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D8010 | LIMITED ORTHO TX PRIMARY DENTITION | From age 4 up to age 9 | Orthodontic treatment (D8010-D8080) Based on DMN. | Narrative of clinical findings; treatment plan; estimated treatment time; diagnostic photos, x- rays or digital films, study models; PCD attestation of completed dental treatment. If re-banding or replacement of appliance is requested supporting explanation and complete treatment plan is required. | To treat any stage of dentition. When part of a comprehensive case, indicate objective and submit complete treatment plan. Reimbursement includes placement and removal of appliance(s) by same provider. Refer to MCO Provider Manual. Paid as case rate. |
D8020 | LIMITED ORTHO TX TRANSITIONAL DENTITION | From age 6 up to age 15 | Orthodontic treatment (D8010-D8080) Based on DMN. | Narrative of clinical dings; treatment plan; estimated treatment time; diagnostic photos, x-rays or digital films, study models; PCD attestation of completed dental treatment. If re-banding or replacement of appliance is requested supporting explanation and complete treatment plan is required. | To treat any stage of dentition. When part of a comprehensive case, indicate objective and submit complete treatment plan. Reimbursement includes placement and removal of appliance(s) by same provider. Refer to MCO Provider Manual. Paid as case rate. |
D8030 | LIMITED ORTHO TX ADOLESCENT DENTITION | From age 8 up to age 21 | Orthodontic treatment (D8010-D8080) Based on DMN. | Narrative of clinical findings; treatment plan; estimated treatment time; diagnostic photos, x- rays or digital films, study models; PCD attestation of completed dental treatment. If re-banding or replacement of appliance is requested supporting explanation and complete treatment plan is required. | To treat any stage of dentition. When part of a comprehensive case, indicate objective and submit complete treatment plan. Reimbursement includes placement and removal of appliance(s) by same provider. Refer to MCO Provider Manual. Paid as case rate. |
D8040 | LIMITED ORTHO TX ADULT DENTITION | From age 8 up to age 21 | Orthodontic treatment (D8010-D8080) Based on DMN. | Narrative of clinical findings; treatment plan; estimated treatment time; diagnostic photos, x- rays or digital films, study models; PCD attestation of completed dental treatment. If re-banding or replacement of appliance is requested supporting explanation and complete treatment plan is required. | To treat any stage of dentition. When part of a comprehensive case, indicate objective and submit complete treatment plan. Reimbursement includes placement and removal of appliance(s) by same provider. Refer to MCO Provider Manual. Paid as case rate. |
D8080 | COMPREHENSIVE ORTHO TX ADOLESCENT DENTITION | From age 8 up to age 21 | Orthodontic treatment (D8010-D8080) Based on DMN. | Classification of malocclusion, diagnostic radiographic images and photograph to show full view of millimeter ruler in position to show measurement, diagnostic study or digital study models, cephalometric image, completed current NJ HLD, attestation from PCD re: preventive and dental treatment services provided; treatment planned extraction(s) and/or surgical interventions and medical diagnosis. Include documentation of extenuating conditions. | Handicapping malocclusion to treat late mixed and permanent dentition. Scoring based on HLD or extenuating circumstance which meets medical necessity requirement. |
D8210 | ORTHODONTIC REMOVEABLE APPLIANCE TX | Up to age 21 | Maximum 2 per date of service | Clinical findings; treatment plan; estimated treatment time with prognosis; diagnostic photos and/or models; adjustments included to provider of placement. | Documentation of harmful habit including but not limited to thumb sucking and tongue thrust. |
D8220 | FIXED APPLIANCE THERAPY HABIT | Up to age 21 | Once without PA | Clinical findings; treatment plan; estimated treatment time with prognosis; diagnostic photos and/or models; adjustments included to provider of placement. | Documentation of harmful habit including but not limited to thumb sucking and tongue thrust. |
D8660 | PREORTHODONTI C TX VISIT | Up to age 21 | Once per year; service linked to provider | Clinical findings, diagnostic materials (current NJ HLD) required for interceptive and comprehensive treatment. | Evaluate with documentation of findings associated with orthodontic conditions. |
D8670 | PERIODIC ORTHODONTIC TX VISIT | Up to age 21 | 24 months of active treatment are expected to be adequate to complete most cases (up to 36 months). | 12日访问包含在PA D8080;PA为additional 12 visits to include treatment notes; PCD attestation; pre-and current panoramic image and/or photos; documentation of any compliance problems; initial approval if started in different NJFC program. | Case in comprehensive treatment. |
D8680 | ORTHODONTIC RETENTION | Up to age 21 | AMN | Documents completion of D8080 by provider initiating or treating case. | Treatment outcomes demonstrate completion or termination of orthodontic treatment. |
D8681 | REMOVABLE RETAINER ADJUSTMENT | Up to age 21 | Once per day of service | Narrative including Member compliance; dental records. Not to provider of original placement. | Patient in retention. |
D8695 | REMOVE FIXED ORTHO APPLIANCE (FOR REASONS OTHER THAN CASE COMPLETION) | none | DMN, AMN | BR; Non-compliance with ortho treatment, dental records, provider attestation for request; release from treatment form from parent/member to agree to removal of appliances. Includes fee for removal and retainer(s) if provided by provider of placement. | DMN; treatment is not progressing. |
D8696 | REPAIR OF ORTHODONTIC APPLIANCE- MAXILLARY | Up to age 21 | AMN | Clinical findings | For functional appliance and palatal expanders, not brackets (standard fixed ortho appliance). |
D8697 | REPAIR OF ORTHODONTIC APPLIANCE- MANDIBULAR | Up to age 21 | AMN | Clinical findings | For functional appliance and palatal expanders, not brackets (standard fixed ortho appliance). |
D8698 | RE-CEMENT OR RE-BOND FIXED RETAINER- MAXILLARY | Up to age 21 | AMN | Clinical findings | Patient in retention; may be included in case rate. Dislodged retainer that is undamaged. |
D8699 | RE-CEMENT OR RE-BOND FIXED RETAINER- MANDIBULAR | Up to age 21 | AMN | Clinical findings | Patient in retention; may be included in case rate. Dislodged retainer that is undamaged. |
D8701 | REPAIR OF FIXED RETAINER, INCLUDES REATTACHMENT- MAXILLARY | Up to age 21 | AMN | Narrative including Member compliance; dental records. | For functional appliance and palatal expanders, not brackets (standard fixed ortho appliance). |
D8702 | REPAIR OF FIXED RETAINER, INCLUDES REATTACHMENT- MANDIBULAR | Up to age 21 | AMN | Narrative including Member compliance; dental records. | For functional appliance and palatal expanders, not brackets (standard fixed ortho appliance). |
D8703 | REPLACEMENT OF LOST OR BROKEN RETAINER- MAXILLARY | Up to age 21 | AMN | Narrative including Member compliance; dental records. | Replacement of lost or broken retainer based on medical necessity. |
D8704 | REPLACEMENT OF LOST OR BROKEN RETAINER- MANDIBULAR | Up to age 21 | AMN | Narrative including Member compliance; dental records. | Replacement of lost or broken retainer based on medical necessity. |
D8999 | UNSPECIFIED ORTHODONTIC PROCEDURE | Up to age 21 | BR。DMN; diagnosis, clinical presentation of provided service. | Service not described by CDT code. |
CDT | SHORT - DESCRIPTION | AGE LIMITS | FREQUENCY LIMITS | DOCUMENTATION/ REQUIREMENTS | CLINICAL CRITERIA |
D9110 | TREATMENT DENTAL PAIN MINOR PROCEDURE | none | Once per date of service; per tooth or per site | DMN | Emergency, limited treatment for pain. |
D9210 | DENTAL ANESTHESIA W/O SURGERY | none | Twice per year per provider with PA; not with dental procedure | Narrative, radiographs and/or photos not with D9211, D9212. | For diagnostic purposes only |
D9211 | REGIONAL BLOCK ANESTHESIA | none | Twice per year per provider with PA; not with dental procedure | Narrative, radiographs and/or photos not with D9210, D9212. | For diagnostic purposes only |
D9212 | TRIGEMINAL BLOCK ANESTHESIA | none | Twice per year per provider with PA; not with dental procedure | Narrative, radiographs and/or photos not with D9210, D9211. | For diagnostic purposes only |
D9222 | DEEP SEDATION GENERAL ANESTHESIA 1st 15 MINUTES | none | AMN | Dental records, radiographs, anesthesia record; Not with D9230 | In conjunction with removal of impacted teeth; multiple extractions, complex OMFS procedure; SHCN for dental services; situational anxiety. |
D9223 | DEEP SEDATION GENERAL ANESTHESIA EACH SUBSEQUENT 15 MINUTES | none | AMN | Dental records, radiographs, anesthesia record; Maximum 7 units per DOS. Not with D9230, D9243, D9239, D9248. | In conjunction with removal of impacted teeth; multiple extractions, complex OMFS procedure; SHCN for dental services; situational anxiety. |
D9230 | ANALGESIA (NITROUS OXIDE | none | AMN | Dental records, clinical presentation; One unit per DOS; not with D9222, D9223, D9239, D9243. | Situational anxiety during dental treatment. |
D9239 | IV MODERATE SEDATION, 1st 15 MINUTES | none | AMN | Dental records, radiographs, anesthesia record; Maximum 7 units per DOS. Not with D9230, D9243, D9239, D9248. | In conjunction with removal of impacted teeth; multiple extractions, complex OMFS procedure; SHCN for dental services; situational anxiety. |
D9243 | IV MODERATE SEDATION EACH SUBSEQUENT 15 MINUTES | none | AMN | Dental records, radiographs, anesthesia record; Maximum 7 units per DOS. Not with D9230, D9243, D9239, D9248. | In conjunction with removal of impacted teeth; multiple extractions, complex OMFS procedure; SHCN for dental services; situational anxiety. |
D9248 | NON-IV CONSCIOUS SEDATION | none | Four times per RY | Dental records, clinical presentation; not with D9222, D9223, D9239, D9243; may be billed with D9230. | Situational anxiety during dental treatment. |
D9310 | CONSULTATION | none | AMN | Dental records, clinical presentation; not with D9420. Only to be billed with diagnostic services on same DOS. | DMN; Used for: consultation by specialist with referral from general dentist or physician; or, general dentist consultation with referral from physician; or orthodontic evaluation when treatment is not imminent Cannot be used for 2nd opinion between general dentists. (For non-specialty dental second opinions D0140, D0160 may be used as appropriate). |
D9311 | CONSULT W/MEDICAL HEALTH CARE PROFFESSIONAL | none | Two per RY | Medical history, clinical presentation; to licensed clinicians only. | Presence of appropriate medical diagnosis Conforms to CDT descriptor |
D9410 | DENTAL HOUSE CALL | none | Once per LTC facility per DOS; billed on one claim | Limited to visits at a LTC facility, institution, or homebound; in addition to services rendered | Patient in LTC facility, institution or home bound. |
D9420 | HOSPITAL/ASC CALL | none | AMN | Hospital call requiring dental evaluation Once per date of service; only when services rendered outside of office/clinic; not with D9310. Scheduled visit in the OR of a hospital or ASC when medical necessity or age of patient requires this place of service | Patient meets criteria for receiving dental services in a hospital OR or ASC; patient confined to hospital. (Refer to DMAHS Newsletter Vol. 22, No. 18). |
D9430 | OFFICE VISIT DURING HOURS OBSERVATION | none | No other services on same DOS; not for suture removal | Post OMFS surgical case evaluation; no other services performed. | Recently received OMFS procedure from same provider/group. |
D9610 | THERAPEUTIC PARENTERAL DRUG SINGLE ADMIN | none | AMN | Narrative, dental records; not with D9222, D9223, D9239, D9243. | Not for sedatives, anesthetic or reversal agents. Appropriate diagnosis; Conforms to CDT descriptor |
D9612 | THERAPUTIC PARENTERAL DRUGS 2 OR > ADMIN | none | AMN | Narrative, dental records; not with D9222, D9223, D9239, D9243. | Not for sedatives, anesthetic or reversal agents. Appropriate diagnosis; Conforms to CDT descriptor |
D9613 | INFILTRATION OF SUSTAINED RELEASE THERAPUTIC DRUG, PER QUADRANT | none | AMN | Narrative, dental records must include dose administered. | For long acting pain control at surgical site after oral surgical procedure. Must be submitted with surgical procedures provided on same DOS. Not employed as local anesthesia. May be covered under medical benefit. Confirms to CDT descriptor. |
D9630 | DRUGS/MEDS DISPENSED FOR HOME USE | none | AMN | BR。To include name of product, strength and dosage administered. | Oral antibiotics, analgesics, topical fluoride; not for written prescriptions. |
D9910 | APPLICATION DESENSITIZING MEDICAMENT | Age 16 and older | Once per 12 months | Per visit; narrative, dental records. | For root/tooth sensitivity, sensitive dentin. |
D9911 | APPLICATION DESENSITIZING RESIN | Age 16 and older | Once per 12 months | Per tooth; narrative, dental records; not with D9910. | Application of adhesive resin to sensitive dentin for root/tooth sensitivity. |
D9920 | BEHAVIOR MANAGEMENT | none | AMN | Clinical presentation and documentation of medical necessity; One unit = 15 minutes; 2 units per DOS allowed. Not on same DOS as: D9222, D9223, D9239, D9243, D9248 or D9420 | DMN to include inability to cooperate with dental treatment due to behavioral health condition, intellectual, developmental or other disability, members with SHCN, children and individuals with situational anxiety. |
D9930 | TREATMENT OF COMPLICATIONS POST SURGICAL | none | AMN | 叙述,牙科记录。 | Recent complex surgical procedure by same provider or group. |
D9941 | 运动护齿套的制造 | Ages 12 through 18 | Once per 12 months | Narrative in dental record documenting need for appliance. | To prevent or mitigate injury to teeth and dental/oral hard and soft tissue due to trauma during contact sports activities. |
D9943 | OCCLUSAL GUARD ADJUSTMENT | none | AMN | 叙述,牙科记录。Paid to provider who did not place occlusal guard. | DMN Sore/high spots, areas of roughness. |
D9944 | OCCLUSAL GUARD-HARD APPLIANCE, FULL ARCH | Age 18 and older | Once per 24 months | 叙述,牙科记录。 | For bruxism or other occlusal factors; not for TMJ; includes all adjustments; paid as case rate. Does not include athletic mouth guards (D9941) which are presently not covered services. |
D9945 | OCCLUSAL GUARD-SOFT APPLIANCE, FULL ARCH | Age 18 and older | Once per 24 months | Narrative, dental records; FMX demonstrate occlusal wear. | For bruxism or other occlusal factors; not for TMJ; includes all adjustments; paid as case rate. Does not include athletic mouth guards (D9941) which are presently not covered services. |
D9947 | CUSTOM SLEEP APNEA APPLIANCE FABRICATION AND PLACEMENT | none | AMN | Pulmonologist referral, sleep study (with interpretation), documented failure of CPAP | Case rate; may be covered under medical plan. Includes adjustment and follow-up visits six months post insertion. |
D9948 | ADJUSTMENT OF CUSTOM SLEEP APNEA APPLIANCE | none | AMN | Dental records to document prior placement of sleep apnea appliance and to DMN for procedure. | Not reimbursable to provider of placement if within six months of insertion.. |
D9949 | REPAIR OF CUSTOM SLEEP APNEA APPLIANCE | none | AMN | Dental records to document prior placement of sleep apnea appliance and to DMN for procedure. | Not reimbursable to provider of placement if within one year of insertion. |
D9951 | LIMITED OCCLUSAL ADJUSTMENT | none | AMN | Per visit; narrative, dental records. For permanent teeth; not same DOS with a restorative, endodontic or prosthetic service | Occlusal equilibration to create more harmonious tooth contact. Conforms to CDT descriptor |
D9952 | COMPLETE OCCLUSAL ADJUSTMENT | none | Once | 叙述,牙科记录。Diagnostic casts should be available upon request. For permanent teeth; not same DOS with a restorative, endodontic or prosthetic service; may require several appointments; includes all visits. | In conjunction with extensive restorative treatment, periodontics, orthognathic surgery dysfunctional occlusion or past jaw trauma. Not in conjunction with orthodontics. Conforms to CDT descriptor |
D9971 | ODONTOPLASTY 1-2 TEETH | none | Once per location | 叙述,牙科记录。恒牙;有限公司mpleted in one visit; not same DOS with a restorative, endodontic or prosthetic procedure. | Enamel projections irregular tooth morphology. |
D9974 | INTERNAL BLEACHING PER TOOTH | none | Once per permanent tooth | Narrative, radiographs and/or photos. | 脱色的蚂蚁ior tooth, previous endodontics |
D9999 | UNSPECIFIED ADJUNCTIVE PROCEDURE | none | BR。DMN; diagnosis, clinical presentation of provided service. | For service not described by CDT code. Code may be used by MCO (in addition to dental services) when dental services are provided in the OR of a hospital or in an ASC. When the code is used for this service, the clinical criteria for D9420 must be met. Medical necessity or age of patient requires in-patient or out-patient dental services be rendered at a hospital or ASC (Refer to DMAHS Newsletter Vol. 22, No. 18). |
1
NJ FamilyCare Dental Services Clinical Criteria Policy
Introduction and Purpose:
The NJFC program has established a clinical criteria policy for dental services to establish a single set of
clinical guidelines to be used by the State and the MCOs and their third party administrators and vendors
in the processing of claims and the review of prior authorizations for treatment requests based on medical
necessity or where applicable within the established frequencies.
The reviewing consultant should use these policies and their clinical judgement along with any submitted
documentation and diagnostic materials when reviewing treatment requests for medical necessity.
Consideration for prior authorization of services should consider the overall general health, patient
有限公司mpliance and dental history, condition of the oral cavity, long-term prognosis and complete treatment
plan that is both judicious in the use of program funds and provides a clinically acceptable treatment
outcome.
The MCO must monitor their consultants or those of the third party vendor each calendar year to ensure
prior authorization decisions and claim payments are being made in accordance with the clinical criteria
policy. The monitoring outcomes will be available to the State upon request.
Guidelines and Criteria for Complete Treatment Plan Submission:
Submission of a complete treatment plan is required where requests for complex cases with multiple root
canals, crowns (single or abutment), partial denture(s) and/or multiple surgical periodontal procedures are
being considered. A complete treatment plan may be required and the provider may be asked to
sequentially submit several prior authorization requests, one for each of the various stages of the
treatment. Each prior authorization should be submitted as the provider is about to initiate that
stage. This will ensure that the prior authorization will remain active during the stage of
treatment.
使用首字母缩略词:
o AMN ? As Medically Necessary
o BR ? By Report
o CRA ? Caries Risk Assessment
o CY ? Calendar Year
o DMN ? Documentation of Medical Necessity
o DOS ? Date of Service
o ECC ? Early Childhood Caries
o EPSDT ? Early and Periodic Screening, Diagnostic and Treatment
o FX ? Fracture
o LTCF ? Long Term Care Facility
(o HLD) - NJ国防部新泽西矫正评估Tool for Comprehensive Treatment Index
(most recent version)
o PA ? Prior Authorization
o RCT ? Root Canal Treatment
o RY ? Rolling Year (1 year from the date of service)
o SHCN ? Special Health Care Needs member
2
Format:
The document is in a grid format and follows the listing sequence by category of service as found in the
American Dental Association CDT book and includes the following headers: CDT code, short description
(nomenclature with abbreviations), age limits, frequency limits, documentation requirements and clinical
criteria. A provider may refer to an individual servicing provider or provider group. For completed
nomenclature and descriptor of a CDT code, please refer to the current CDT book published by the
American Dental Association.
The policy will be updated annually based on CDT revisions and DMAHS decisions. (A complete list of
有限公司des and services included in the NJ FamilyCare program?s benefit package may be found on the New
Jersey Medicaid Management Information System website: https://www.njmmis.com/hospitalinfo.aspx.)
Early and Periodic Screening, Diagnostic and Treatment:
Please note that EPSDT guidelines for medically necessary services to children ages 0 through 20
supersede any restrictions included in the Clinical Criteria Grid, based on the following:
o Under Medicaid regulations a State must cover necessary health care, diagnostic services,
treatment and other measures to correct or ameliorate defects and physical and mental illness
and conditions.
o Services must be covered if they correct, compensate for, improve a condition, or prevent a
有限公司ndition from worsening-even if the condition cannot be prevented or cured. Based on this
lifetime limits cannot be applied to limit the frequency for services provided to children under the
age of 21. As a result the CC Grid cannot indicate once per lifetime and multiple requests for
AMN services with supporting documentation cannot be denied.
Patient Records:
Dental diagnosis is to be documented for all treatment rendered on that DOS as per N.J.A.C. 10:56-1.9.
This applies to units of behavior management which also requires medical diagnosis and clinical
presentation be documented.
CDT (Current Dental Procedure Codes):
The current CDT Dental Procedure Codes from the American Dental Association (ADA) should be used
as a reference for procedure code selection as the Clinical Criteria Grid is a quick reference guide for the
NJ FamilyCare Program and uses abbreviations. The CDT provides the Nomenclature (written title of a
procedure code) and Descriptor (narrative that further defines the nature of the intended use of a single
有限公司de) and is updated annually by the ADA to provide additions, deletions and revisions.
Please note that many services such as complex oral and maxillofacial surgical procedures and
maxillofacial prosthetics may be reimbursed by MCOs using the appropriate medical CPT codes. Either a
CPT or a CDT code may be billed. Contact the MCO of enrollment for additional information.
Posting of the Clinical Criteria Grid:
The MCO shall post the Clinical Criteria Grid on their website and reference the location or provide a link
供应商手册中。应当在更新the first quarter of the calendar year based on
information provided by DMAHS.