NEW YORK STATEMEDICAID PROGRAM

DENTALPOLICY AND PROCEDURE CODEMANUALDental Policy and Procedure Code Manual

Table of Contents
SECTION I - REQUIREMENTS FOR PARTICIPATION IN MEDICAID ..........................4QUALIFICATIONS OF SPECIALISTS ................................................................................................................................. 4
GROUP P ROVIDERS ....................................................................................................................................................... 5
APPLICATION OF FREE CHOICE ..................................................................................................................................... 5
CREDENTIAL VERIFICATION REVIEWS .......................................................................................................................... 5

SECTION II - DENTAL SERVICES..............................................................................7
CHILDREN’S DENTAL SERVICES.................................................................................................................................... 7
STANDARDS OF QUALITY.............................................................................................................................................. 7
SCOPE OF HOSPITALIZATION SERVICES ........................................................................................................................ 7
CHILD/TEEN HEALTH PROGRAM................................................................................................................................... 7
CHILD HEALTH PLUS PROGRAM ................................................................................................................................... 8
DENTAL MOBILE VAN .................................................................................................................................................. 8
REQUIREMENTS AND EXPECTATIONS OF DENTAL CLINICS........................................................................................... 8
SERVICES NOT WITHIN THE SCOPE OF THE MEDICAID PROGRAM .............................................................................. 10
SERVICES WHICH DO NOT MEET EXISTING STANDARDS OF PROFESSIONAL PRACTICE ARE NOT REIMBURSABLE 10
OTHER NON-REIMBURSABLE SERVICES ..................................................................................................................... 11
RECORD KEEPING ...................................................................................................................................................... 11
LOCUM TENENS ARRANGEMENTS ............................................................................................................................... 12
MISCELLANEOUS ISSUES ............................................................................................................................................ 13

SECTION III - BASIS OF PAYMENT FOR SERVICES PROVIDED ............................ 14
PAYMENT FOR SERVICES NOT LISTED ON THE DENTAL FEE SCHEDULE..................................................................... 14
PAYMENT FOR SERVICES EXCEEDING THE PUBLISHED FREQUENCY LIMITATIONS ..................................................... 14
PAYMENT FOR ORTHODONTIC CARE .......................................................................................................................... 14
MANAGED CARE ......................................................................................................................................................... 14
DENTAL SERVICES INCLUDED IN A FACILITY RATE ................................................................................................... 15
PAYMENT IN FULL ...................................................................................................................................................... 16
PREPAYMENT R EVIEW ............................................................................................................................................... 16
THIRD-PARTY INSURERS ............................................................................................................................................. 17
UNSPECIFIED PROCEDURE CODES .............................................................................................................................. 17
PRIOR APPROVAL / PRIOR AUTHORIZATION REQUIREMENTS ...................................................................................... 17
RECIPIENT RESTRICTION PROGRAM ............................................................................................................................ 20
UTILIZATION THRESHOLD .......................................................................................................................................... 20

SECTION IV - DEFINITIONS..................................................................................... 21
ATTENDING DENTIST ................................................................................................................................................. 21
REFERRAL .................................................................................................................................................................. 21

SECTION V - DENTAL PROCEDURE CODES .......................................................... 22
GENERAL INFORMATION AND INSTRUCTIONS ............................................................................................................. 22

FEE 27
I. DIAGNOSTIC D0100 - D0999 ................................................................................. 27
II. PREVENTIVE D1000 - D1999 ............................................................................... 32
III. RESTORATIVE D2000 - D2999 ............................................................................ 38
IV. ENDODONTICS D3000 - D3999 ........................................................................... 41
V. PERIODONTICS D4000 - D4999 ........................................................................... 44

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VI. PROSTHODONTICS (REMOVABLE) D5000 - D5899 ........................................... 46
VII. MAXILLOFACIAL PROSTHETICS D5900 - D5999 .............................................. 50
VIII. IMPLANT SERVICES D6000 - D6199 ................................................................. 51
IX. PROSTHODONTICS, FIXED D6200 - D6999 ........................................................ 57
X. ORAL AND MAXILLOFACIAL SURGERY D7000 - D7999 .................................... 60
XI. ORTHODONTICS D8000 - D8999 ........................................................................ 70
XII. ADJUNCTIVE GENERAL SERVICES D9000 - D9999 ......................................... 81

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Section I - Requirements for Participation in Medicaid
Dental providers must be licensed and currently registered by the New York State
Education Department (NYSED), or, if in practice in another state, by the appropriate
agency of that state, and must be enrolled as providers in the New York State Medicaid
program.
No provider who has been excluded from the Medicaid program may receive
reimbursement by the Medicaid program, either directly or indirectly, while such sanctions arein effect.

Qualifications of Specialists
A specialist is one who:•

Is a diplomat of the appropriate American Board; or,•Is listed as a specialist in the American Dental Directory of the American Dental
Association section on “character of practice”; or,•Is listed as a specialist on the roster of approved dental specialists of the New YorkState Department of Health (DOH).

All dental providers enrolled in the Medicaid program are eligible for reimbursement for
all types of services except for orthodontic care, dental anesthesia and those procedures
where a specialty is indicated. There is no differential in levels of reimbursement
between general practitioners and specialists.
•

Orthodontic care is reimbursable only when provided by a board certified or board
eligible orthodontist or an Article 28 facility which have met the qualifications of the
DOH and are enrolled with the appropriate specialty code.

•

General anesthesia, parenteral and enteral conscious sedation are reimbursable
only when provided by a qualified dental provider who has the appropriate level ofcertification in dental anesthesia by the NYSED. The NYSED issues five separate
certificates:i.
General Anesthesia Certificate, which authorizes a licensed dentist to
employ conscious (moderate) sedation (enteral or parenteral route with orwithout inhalation agents), deep sedation, and general anesthesia;ii.
Dental Parenteral Conscious (Moderate) Sedation for patients 13
years old and older, which authorizes a licensed dentist to employ
conscious (moderate) sedation (enteral or parenteral route with or without
inhalation agents) on all patients 13 years old and older;iii.
Dental Parenteral Conscious (Moderate) Sedation for patients 12
years old and younger, which authorizes a licensed dentist to employ
conscious (moderate) sedation (enteral or parenteral route with or without
inhalation agents) on all patients;

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iv.

v.

Dental, Enteral Conscious (Moderate) Sedation for patients 13 years
old and older, which authorizes a licensed dentist to employ conscious(moderate) sedation (enteral route only with or without inhalation agents)
on all patients 13 years old and older; andDental Enteral Conscious (Moderate) Sedation for patients 12 years
old and younger, which authorizes a licensed dentist to employ
conscious (moderate) sedation (enteral route only with or without
inhalation agents) on all patients.

Additional information is located on the New York State Education Department
website (NYSED.gov):
http://www.op.nysed.gov/prof/dent/dentanesthes.htm

Group Providers
A group of practitioners is defined in 18 NYCRR 502.2 as:“…two or more health care practitioners who practice their profession at acommon location (whether or not they share common facilities, common
supporting staff, or common equipment).”
Regardless of the arrangement among practitioners (associates, employer-employee,
principal-independent contractor), practitioners who practice in a group setting are
required to enroll as a group and to comply with the requirements associated with grouppractices.
Regardless of the nature of the practice (group, employer-employee, associate, etc.), thename, NPI and other required information of the dentist actually providing the service
or treatment must be entered in the “Servicing Provider” or “Treating Dentist” field on all
claims and prior approval requests. Except for FEE-FOR-SERVICE (FFS) billing byinstitutions, including Article 28, and Diagnostic and Treatment centers , all private FFS
dental claims should list the treating or servicing dentist as the biller when submitting forservices rendered. Payments can be designated to be made to a group, if desired, byentry of the group information in a separate field. Please refer to the section“Requirements and Expectations of Dental Clinics” for Institutional FFS billing.
Initial and periodic exam (D0120, D0145, and D0150) frequency limitations will be applied
to a claim based on the member’s exam history within the group when the servicing
provider has a group affiliation.

Application of Free Choice
A Medicaid member is guaranteed free choice of a dental provider in obtaining the dental careavailable under the New York State Medicaid program.

Credential Verification Reviews

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Credential Verification Reviews (CVRs) are periodic onsite visits of a provider’s place ofbusiness to ensure overall compliance with Medicaid regulations. These visits are
conducted by the Medicaid program and the Office of the Medicaid Inspector General(OMIG), and assess such areas as:•••

provider and staff identification and credentialing
physical attributes of the place of businessrecordkeeping protocols and procedures regarding Medicaid claiming.

CVRs are conducted for such sites as:••••

medical and dental offices
pharmacies
durable medical equipment retailers, andpart time clinics.
CVRs are not performed at hospitals, nursing homes, etc.

Every effort is made to conduct these visits in a professional and non-obtrusive manner.
Investigators conducting these reviews will have a letter of introduction signed by the
Office of the Medicaid Inspector General and a photo identification card.
Should providers, or their staff, have questions regarding these Credential Verification
Reviews, they can contact:
The New York State Office of the Medicaid Inspector General
Bureau of Medicaid Investigations(518) 402-1837

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Section II - Dental Services
Dental Care in the Medicaid program shall include only ESSENTIAL SERVICES rather thancomprehensive care. The provider should use this Manual to determine when the
Medicaid program considers dental services "essential". The application of standards
related to individual services is made by the DOH when reviewing individual cases.

Children’s Dental Services
A child is defined as anyone under age 21 years.

Standards of Quality
Services provided must conform to acceptable standards of professional practice.
Quality of Services Provided
Dental care provided under the Medicaid program must meet as high a standard of quality as
can reasonably be provided to the community-at-large. All materials and therapeutic
agents used or prescribed must meet the minimum specifications of the American Dental
Association, and must be acceptable to the State Commissioner of Health. Experimental
procedures are not reimbursable in the Medicaid program.

Scope of Hospitalization Services
Medicaid members are provided a full range of necessary diagnostic, palliative andtherapeutic inpatient hospital care, including but not limited to dental, surgical, medical,
nursing, radiological, laboratory and rehabilitative services.
Limitations of Hospitalization
Medicaid utilization review (UR) agents are authorized to review the necessity andappropriateness of hospital admissions and lengths of stay, and to determine Medicaid
benefit coverage. These review agents will review inpatient dental services both on a preadmission and retrospective basis. Emergency admissions may be reviewed
retrospectively for necessity and appropriateness.
If you have any questions regarding specific Medicaid hospital review requirements, you
may contact the DOH, Bureau of Hospital and Primary Care Services at:(518) 402-3267

Child/Teen Health Program
Please refer to the New York Medicaid Child/Teen Health Program (C/THP) Provider
Manual Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) available atthe following website:
https://www.emedny.org/ProviderManuals/index.aspx

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Dental Policy and Procedure Code ManualChild Health Plus Program
The goal of the Child Health Plus Program is to improve child health by increasing
access to primary and preventive health care through a subsidized insurance program.
A child eligible for Medicaid is not eligible for Child Health Plus.
For more information on benefits, contact the Child Health Plus Program at:(800) 698-4543

Dental Mobile Van
The use of mobile vans to provide the operatories for the provision of dental services iscommonplace. All claims for services rendered in a mobile unit must have thecorresponding Place of Service code which identifies this type of location. That is, theuse of a mobile unit (POS - 15). The correct POS code must be reported on every claim.
Reporting the incorrect place of service could result in inaccurate payment, audit review
and/ or ensuing disallowances.
Please refer to the Centers for Medicare and Medicaid Services website (CMS.gov) for
additional information:
Place of Service Code Set - Centers for Medicare & Medicaid Services

Requirements and Expectations of Dental Clinics
 Dental clinics licensed under Article 28 reimbursed on a rate basis or through
APG’s (i.e., hospital outpatient departments, diagnostic and treatment centers, anddental schools) are required to follow the policies stated in the Dental Policy andProcedure Code Manual and should use this Manual to determine when dental
services are considered "essential" by the Medicaid program.
 Except for implants, implant related services and orthodontic treatment, clinics andschools are exempt from the prior approval procedure because of internal quality
assurance processes that insure their compliance with existing Medicaid policy.
 The provision of dental care and services are limited to those procedures presented
in the Dental Policy and Procedure Code Manual and are to be provided within thestandards and criteria listed in the procedure code descriptions.
 Dental care provided under the Medicaid program includes only essential services(rather than “comprehensive” services).
 Non-emergency initial visits should include a cleaning, radiographic images (ifrequired), and a dental examination with a definitive treatment plan. Generally, thisshould be accomplished in one visit. However, in rare instances, a second visit
may be needed for completion of these services. A notation in the record toindicate the necessity for a second visit should be made.

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Public health programs in schools, Head-Start Centers, dental schools, clinics
treating those individuals identified with a recipient exception code of RE 81 (“TBI
Eligible”) or RE 95 (“OPWDD/Managed Care Exemption”) and other settings are
exceptions that may require more than one visit to complete the above mentioned
services.
 Quadrant dentistry should be practiced, wherever practicable, and the treatment
plan followed in normal sequence.
 Procedures normally requiring multiple visits (i.e., full dentures, partial dentures,root canals, crowns, etc.) should be completed in a number of visits that would beconsidered consistent with the dental community at large and the scope of practice ofthe provider. If additional visits are required, a notation in the member’s treatment
record to indicate the necessity for each additional visit must be made.
 Procedures normally completed in a single visit (examination, prophylaxis, x-rays, etc.)
but which require additional visits must include a notation in the member’streatment record documenting the justification for the additional visit.
 When billing:•

For article 28 and diagnostic and treatment centers (D&TC) facilities, theinstitution may be the billing provider, but the rendering /treating provider mustbe listed on the claim in the appropriate field;•

Other than orthodontic services (D8000 – D8999) and implant and implant
related services (D6010 -D6199) there is NO FEE-FOR-SERVICE (FFS)BILLING; “Except for FEE-FOR-SERVICE (FFS) billing by institutions,
including Article 28, and Diagnostic and Treatment centers, all private FFS
dental claims should list the treating or servicing dentist as the biller whensubmitting for services rendered. Payments can be designated to be made toa group, if desired, by entry of the group information in a separate field.
Please refer to the section “Requirements and Expectations of Dental Clinics”
for Institutional FFS billing;•

For article 28 and D&TC facilities, the institution may be the billing provider,but the servicing/treating provider must be listed on the claim in theappropriate field. The supervising provider at a dental school must be a
Medicaid enrolled provider who will be responsible for the treatment
rendered. This individual could be an attending clinical instructor, dental
department chair, or dean of a dental school;•

Prior approval is required for orthodontic services and implants and implant
related services;•

Certify that the services were provided;•

For specific instructions, please refer to the Dental Billing Guidelines at:https://www.emedny.org/ProviderManuals/Dental/index.aspx

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Dental Policy and Procedure Code ManualServices Not Within the Scope of the Medicaid Program
These services include but are not limited to: Fixed bridgework, except for cleft palate stabilization, or when a removable
prosthesis would be contraindicated; Immediate full or partial dentures;
 Molar root canal therapy for members 21 years of age and over, except when
extraction would be medically contraindicated or the tooth is a critical abutment for an
existing serviceable prosthesis; Crown lengthening; Replacement of partial or full dentures prior to required time periods unlessappropriately documented and justified as stated in the Manual; Dental work for cosmetic reasons or because of the personal preference of themember or provider; Periodontal surgery, except when associated with implants or implant related
services; Gingivectomy or gingivoplasty, except for the sole correction of severe hyperplasia or
hypertrophy associated with drug therapy, hormonal disturbances or congenital
defects;
 Adult orthodontics, except in conjunction with, or as a result of, approved
orthognathic surgery necessary in conjunction with an approved course oforthodontic treatment or the on-going treatment of clefts;
 Placement of sealants for members under 5 or over 15 years of age; Improper usage of panoramic images (D0330) along with intraoral complete seriesof images (D0210).

Services Which Do Not Meet Existing Standards of Professional
Practice Are Not Reimbursable
These services include but are not limited to: Partial dentures provided prior to completion of all Phase I restorative treatment
which includes necessary extractions, removal of all decay and placement of
permanent restorations; Other dental services rendered when teeth are left untreated; Extraction of clinically sound teeth;

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Dental Policy and Procedure Code Manual Treatment provided when there is no clinical indication of need noted in thetreatment record. Procedures should not be performed without documentation ofclinical necessity. Published “frequency limits” are general reference points on the
anticipated frequency for that procedure. Actual frequency must be based on theclinical needs of the individual member; Restorative treatment of teeth that have a hopeless prognosis and should be
extracted;
 Taking of unnecessary or excessive radiographic images;
 Services not completed and, “Unbundling” of procedures.

Other Non-Reimbursable Services
 Treatment of deciduous teeth when exfoliation is reasonably imminent.
 Extraction of deciduous teeth without clinical necessity.
• Claims submitted for the treatment of deciduous cuspids and molars forchildren ten (10) years of age or older, or for deciduous incisors in children five(5) years of age or older will be pended for professional review. As a condition
for payment, it may be necessary to submit, upon request, radiographic images andother information to support the appropriateness and necessity of these
restorations.
 Services associated with a non-approved procedure will not be considered forreimbursement.

Record Keeping
Health professionals are required to maintain records for each patient that accuratelyreflect the evaluation and treatment of the patient according to section 29.2(a)(3) of theRules of the Board of Regents. Recipient medical histories should be updated periodically(annually at a minimum) and be maintained as part of the recipient’s dental records. The
treating practitioner should refer to the recipient’s medical/dental history and treatment record
to avoid unnecessary repetition of services. Please refer to NYSED.gov for further
information:
NYS Rules of the Board of Regents: Part 29
The patient’s Dental Record is to include: Medical History;
 Dental History (including dated treatment plans, identification of all pathology
present);

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Dental Policy and Procedure Code Manual Dental Charting; Radiographs;
 Study Models (if taken); Copies of all prescriptions and invoices (pharmacy / lab); All correspondences; Consultation and referral reports; and,
 Signed consent and HIPAA forms.
Treatment notes are to include the following for each dental appointment:
 Detailed description of all services rendered including the identification of thehealthcare professional providing the service(s); Date (and time when appropriate) of visit and signature or initials of the teammember writing the entry;
 Instructions to the patient; Drugs administered / prescription (includes all anesthesia provided); Unusual reactions; Cancellations / missed appointments;
 Telephone conversations (date and time);
 Patient comments and complaints;
 Referrals made; Referrals not followed or refused; and,
 General anesthesia / I.V. sedation reports.
Note: Reports must include start and stop times for:
 Anesthetic provided; and,
 Operative treatment provided.

Locum Tenens Arrangements
Federal law requires that payment for services be made to the provider of service. An
exception to this requirement may be made when one dentist arranges for anotherdentist to provide services to his/her patients under a locum tenens arrangement.
The law allows such locum tenens arrangements:• On an informal, reciprocal basis for periods not to exceed 14 days, or;• For periods of up to 90 days with a more formal agreement.

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Record of either arrangement must be maintained in writing to substantiate locum
tenens payment.
Locum tenens arrangements should not be made with any dentists who are not enrolled
or have been disqualified by the New York State Medicaid program.

Miscellaneous Issues
 Radiographic images should be clear and allow for diagnostic assessment. They
are performed based on need, age, prior dental history and clinical findings. Allradiographic images, whether digitalized or conventional, must be of good
diagnostic quality, properly dated and positionally mounted including accurate
right/left orientation, and identified with the member's name and provider name andaddress. The cost of all materials and equipment used shall be included in the fee
for the image.
Medicaid claims payment decisions for types, numbers and frequency of images
will be related to the needs of the individual member, dental age, past dental history
and, most importantly, clinical findings. Guidelines on the selection of members
for Dental radiographic examination can be obtained from the “American Dental
Association (ADA)” or the “U.S. Department of Health and Human Services, Foodand Drug Administration (FDA)”.
Good quality, diagnostic, duplicate radiographic images, must be made available
for review upon request of the Department of Health or the Office of the Medicaid
Inspector General. There is no reimbursement for duplication of images. If original
radiographs are submitted, they will be returned after each review. Other types ofimages that can be readily reproduced will not be returned. All images must be
retained by the provider for a minimum of six years, or the minimum durationprescribed by law, from the date of payment.
 Facilities should use the NYS Medicaid Exclusion List when checking and verifying thecredentials of the dental professionals that make up their staff. The NYS Medicaid
Exclusion List is currently available at NYS Office of the Medicaid Inspector
General (OMIG) website:
NYS Medicaid Exclusion List

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Section III - Basis of Payment for Services Provided
It is the provider’s responsibility to verify each member’s eligibility at EVERY
appointment. Even when a service has been prior approved / prior authorized, theprovider must verify a member’s eligibility via the MEVS before the service isprovided and comply with all other service delivery and claims submission
requirements described in each related section of the provider manual.
Payment for dental services is limited to the lower of the usual and customary fee charged to
the general public or the fee developed by the DOH and approved by the New York State
Director of the Budget. The Dental Fee Schedule is available online:
http://www.emedny.org/ProviderManuals/Dental/index.aspx
Claims must be submitted when the product or service is completed and delivered to themember with the appropriate procedure code using the date that the service is actuallycompleted and delivered as the date of service.

Payment for Services Not Listed on the Dental Fee Schedule
If an "essential" service is rendered that is not listed in the fee schedule, the fee will be
determined by the DOH, which will use the most closely related service or procedure in
the fee schedule as the basis for determining such fee.

Payment for Services Exceeding the Published Frequency Limitations
Reimbursement for services that exceed the published frequency limitations but that are
determined to be medically necessary following professional review may be considered.

Payment for Orthodontic Care
When Prior Approval is obtained for orthodontic care for severe physically handicapping
malocclusions, the care will be reimbursed for an eligible member for a maximum of three
years of active orthodontic care plus one year of retention care. Cleft palate or approved
orthognathic surgical cases may be approved for additional treatment time. Treatment
not completed within the maximum allowed period must be continued to completion
without additional compensation from the NYS Medicaid program, the member or family.

Managed Care
If a member is enrolled in a managed care plan which covers the specific care or services
being provided, it is inappropriate to bill such services to the Medicaid program on a feefor-service basis whether or not prior approval has been obtained.

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Dental Services Included in a Facility Rate
Article 28 facilities must adhere to the program policies as outlined in this manual.
 Hospital In-Patient
The “professional component” for dental services can be reimbursed on a fee-forservice basis. Payment for those services requiring prior approval / priorauthorization is dependent upon obtaining approval from the Department of Health or
the Medicaid Managed Care Plan. Refer to the prior approval section of thismanual and the Prior Approval Guidelines located on the eMedNY.org website for
additional information on how to obtain prior approval:
eMedNY : Provider Manuals : Dental
 Out-Patient Services
ClinicDental services rendered in outpatient clinics are reimbursed using an“Ambulatory Patient Groups (APG)” payment methodology and include both thefacility and professional reimbursement. There is no fee-for-service billing
allowed.
Ambulatory Surgery and Emergency Room
The “professional component” for dental services can be reimbursed on afee-for-service basis. Payment for those services requiring prior approval /prior authorization is dependent upon obtaining approval from the
Department of Health or the Medicaid Managed Care Plan. Refer to the priorapproval section of this manual and the Prior Approval Guidelines locatedon the eMedNY.org website for additional information on how to obtain priorapproval.
 OMH Psychiatric Centers
Dental services are included in the facility rates. Payment for services in such
facilities will not be made on a fee-for-service basis.
It is the responsibility of the facility to make arrangements for the provision of alldental services listed in the Provider Manual either within the facility or with area
providers. Claims should not be submitted by either the provider(s) or facility forcovered dental services or for transportation.
 Intermediate Care Facilities (ICF)-DDICF-DD providers should contact OPWDD for guidance on billing for dental
services for their residents.
 Residential Health Care Facilities (RHCF’s) In
State
Dental services are included in the facility rates. Payment for services toresidents of such facilities will not be made on a fee-for-service basis.
It is the responsibility of the facility to make arrangements for the provisionof all dental services listed in the Provider Manual either within the facility
or with area providers. Claims should not be submitted by either theprovider(s) or facility for covered dental services or for transportation.

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Out of State
It is the responsibility of the out-of-state RHCF to inform the provider if
dental services are included in the rate.

Payment in Full
Fees paid by the Medicaid program shall be considered full payment for services
rendered. Except for appropriate co-pay’s, no additional charge may be made by aprovider.
Medicaid members cannot be charged for broken or missed appointments.
Providers are prohibited from charging any additional amount for a service billed to theMedicaid program.
A dentist may enter into a private pay agreement with a Medicaid member. Thisagreement must be in writing and mutually agreed upon prior to the start of treatment;these guidelines must be followed:
 The member must be informed of alternative treatment plans, including
procedures covered by the Medicaid Program or procedures that require priorauthorization by the NYS DOH or Medicaid Managed Care Plan, the advantages
and disadvantages of each, as well as the expense and financial responsibilities ofeach (If any of the procedures in the treatment plan require prior approval from theMedicaid Program, the provider is encouraged to submit the necessary forms anddocumentation for review and determination, which may eliminate the need for a
private payment agreement and Medicaid could cover the procedure(s) in full); The NYS DOH (Medicaid Program) will not review a prior approval request, orrender any opinion, associated with a private pay agreement after treatment has
been started; The member must have full understanding and consent that there may beservice(s) or alternatives that could be provided through Medicaid coverage
without any expense to them; The member is responsible for 100% of the entire fee. There cannot be any
payment from Medicaid; The provision of this service might alter future benefits available throughMedicaid (e.g. if payment is made through a private payment agreement for root
canal(s) therapy, the member might not qualify for a partial denture and/or crowns
for these teeth either now or in the future that they might otherwise be eligible for);and, The member may be responsible for any subsequent or associated expenses.

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

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Third-Party Insurers
Third-party insurers (including Medicare) provide reimbursement for various dental
procedures. Since Medicaid is the payer of last resort, the provider must bill themember’s third-party payers prior to requesting payment from Medicaid. Prior toinitiating treatment which has been approved by a third-party insurance plan, theprovider should obtain a prior approval from Medicaid to ensure that the treatment plan
falls within the current guidelines of the Medicaid Program. Failure to do so may resultin the denial of Medicaid benefits for these services.
If the third party is a commercial plan, Medicaid will reimburse the difference only if thetotal third-party payment(s) is (are) less than the lesser of the provider’s fee charged to
the general public or the fee developed by the DOH for the specific procedure code. If
the third party is a Medicare Advantage plan, Medicaid will reimburse one hundred
percent (100%) of the deductible and eighty-five percent (85%) of thecoinsurance/copay.

Unspecified Procedure Codes
Unspecified procedure codes at the end of each section of the fee schedule are
miscellaneous codes applicable to procedures within the scope of the Medicaid program, but
for which suitable procedure codes do not currently exist.

Prior Approval / Prior Authorization Requirements
Prior approval / prior authorization does not ensure payment. The provider mustverify a member’s eligibility before every appointment and comply with all otherservice delivery and claims submission requirements described in each related
section of the provider manual.
Claims for fixed and removable prosthetics (including implant related prosthetics) andendodontics are not to be submitted until the approved procedure code is completed.
Prior authorization is required through the use of the Dispensing Validation System (DVS)
when specified. These specifications are indicated after the procedure code description
by the following: (DVS REQUIRED)
When DVS is required providers must place the DVS prior authorization number on theclaim. If DVS rejects the request due to service limits exceeded, a prior approval isrequired. The prior approval request must include medical documentation as to why theservice limit needs to be exceeded. Prior approval requests received where the provider
has not requested prior authorization through DVS will be rejected and returned to theprovider.
Procedures that require prior approval, or where a DVS over-ride is required, must not
begin until the provider has received approval from the DOH. When any portion of atreatment plan requires prior approval, the complete treatment plan listing all necessary
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procedures, whether or not they require prior approval, must be listed and coded on theprior approval request form. Any completed treatment which is not evident on submitted
images should be noted. No treatment other than provision of symptomatic relief of pain
and/or infection is to be instituted until such time as cases have been reviewed and a priorapproval determination made.
All prior approval requests must include accurate pretreatment charting clearly
depicting all existing restorations and missing natural teeth. Any existing fixed or
removable prosthetic appliances should be noted and their current conditions described
and the date of initial placement noted. If applicable, a complete medical history,
nutritional assessment, certification of employment and any other pertinent informationthat will assist in determining the necessity and appropriateness of the proposed
treatment plan should be submitted.
The approved treatment plan, in its entirety, must be adhered to. Any alteration of theapproved course of treatment may render the entire approval null and void and subject torecoupment. Changes to an approved course of treatment should be submitted to the
DOH by using a “prior approval change request form”.
If a change is needed or there is a disagreement with a prior approval review and you
would like to challenge a determination rendered by the DOH on an existing finalized priorapproval, a request may be submitted with supporting documentation and a detailed
report using a “Prior Approval Change Request Form”. This form may be submitted preoperatively or post-operatively. If the requested change is submitted post-operatively acopy of the treatment notes should be included with the request.
The Prior Approval Change Request Form can be obtained by clicking on the link
below or by calling eMedNY at 1-800-343-9000.
eMedNY: Information: Paper Forms

The minimum number of pre-treatment radiographic images needed to clearly show all
current conditions and which allow for the proper evaluation and diagnosis of theentire dentition must accompany all requests for prior approval. Radiographic images
are not routinely required to obtain prior approval for replacement full dentures, sealants,
denture re-base etc. The previously referenced guidelines on the selection of members
for radiographs should be followed.
Payment for multiple restorations which are placed in teeth subsequently determined toneed extraction as part of an approved prosthetic treatment plan is not acceptable if therestorations were provided less than six months prior to the date of the prior approval
request for the prosthesis.
When a treatment plan has been denied, services that were a portion of that plan may
not be reimbursable, or subsequently prior approved.
For non-emergency treatment, the same prior approval guidelines apply when treatment
is being rendered by a specialist. If the member is referred to a specialist for treatment
requiring prior approval, the referring provider can obtain the prior approval for use by the
specialist, or the specialist can submit his/her own request.

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When Prior Approval is required
For professional dental services, payment for those listed procedures where theprocedure code number is underlined and listed as (PA REQUIRED) is dependent upon
obtaining the approval of the Department of Health or the Medicaid Managed Care Planprior to performance of the procedure. If such prior approval is not obtained, noreimbursement will be made. For information on completion and submission of priorapproval requests refer to the Prior Approval Guidelines:
https://www.emedny.org/ProviderManuals/Dental/index.aspx
Prior approval does not guarantee payment. It should be noted that:• Prior approval requests will automatically be rejected if there is no response toa request for additional information and the provider notified. The request will
be reactivated without submitting a new request provided that the information isreturned using the “Return Information Routing Sheet” provided with the original
request for information;• Prior approval requests may be denied if there is incomplete or insufficient
response to a request for additional information;• Dental providers may submit documents stored in a digitized format (x-rays,
treatment plans, charting, photographs, etc.) as electronic attachments to dental
prior approval requests when submitted through ePACES. This enhanced
feature is currently only available through ePACES. The following file formats are
JPEG; TIF; PDF: PNG; and GIF. For morecurrently supported:
information on ePACES, or to enroll, please contact the eMedNY Call Center at(800) 343-9000;• Back-dated prior approval can be issued on an exception basis, such as when
eligibility has been back-dated and treatment requiring prior approval has
already been rendered. The following guidelines apply:o The request must be received within 90 days of the date of treatment;o There is NO guarantee that the request will be approved or back-dated
even if treatment has already begun and / or completed;o Treatment already rendered will NOT change the review criteria.
Approval will not be issued that wouldn't have been approved
otherwise;o The same documentation must be submitted as any other request(complete treatment plan, sufficient radiographic images to allow for
the evaluation of the entire dentition, charting etc.) as appropriate forthe case;o Appropriate documentation must be submitted showing that
extenuating circumstances existed warranting back-dating of therequest as well as the date that the service(s) was (were) performed;
o Actions of either the provider or member do not commit the DOH to
any particular course of treatment;o Approvals will NOT be issued for the convenience of the provider ormember, or because the provider forgot or didn't realize that priorapproval was required.
Emergency Treatment

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The provider should refer to the billing guidelines on the eMedNY.org website for claim
submission instructions for emergency services when there is a severe, life threatening,or potentially disabling condition that required immediate intervention:
https://www.emedny.org/ProviderManuals/Dental/index.aspx

Recipient Restriction Program
Medicaid members with any coverage type (i.e. managed care, fee-for-service) will be
reviewed and those who have been found to have a demonstrated pattern of abusive
behavior will be placed in the recipient restriction program in an effort to control the abuse.
Restricted members are monitored by the Office of the Medicaid Inspector General(OMIG). When the member’s benefit is administered by a Managed Care Organization(MCO), the MCO is responsible for identifying and restricting the member who is abusing their
Medicaid benefit. The MCO is required to report any new, re-restricted or modified
restrictions to OMIG for tracking. The recipient restriction program follows the member
when a member’s coverage changes. If a member is switched to a different managed
care plan OMIG will notify the new managed care plan of the existence of the restriction.
The restriction process does not force the member to be enrolled in a Medicaid Managed Care
Plan.

Utilization Threshold
The Utilization Threshold Program (UT) is a post payment review of services and procedures
provided to members that evaluates medical necessity while maintaining fiscal responsibility to
the Medicaid Program. For additional information please see the General Providers Policy
Manual at:https://www.emedny.org/ProviderManuals/AllProviders/PDFS/Information_for_All_ProvidersGeneral_Policy.pdf

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Section IV - Definitions
For the purposes of the Medicaid program and as used in this Manual, the following terms
are defined to mean:

Attending Dentist
The attending dentist is the dentist who is primarily and continuously responsible for thetreatment rendered.

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

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Section V - Dental Procedure Codes
General Information and Instructions
This section lists those procedure codes and nomenclature listed in the “Current Dental
Terminology (CDT®)” as published by the “American Dental Association (ADA®)” which
are covered services by the NYS Medicaid program. Some procedure descriptions areincluded for clarification of Medicaid policy. The CDT should be referenced for a fulldescriptor of each procedure.
The dental procedure codes are grouped into sections as follows:
Section
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
X.
XI.
XII.

Code Series

Diagnostic
Preventive
Restorative
Endodontics
Periodontics
Prosthodontics, removable
Maxillofacial Prosthetics
Implant Services
Prosthodontics, fixed
Oral and Maxillofacial Surgery
Orthodontics
Adjunctive General Services

D0100-D0999
D1000-D1999
D2000-D2999
D3000-D3999
D4000-D4999
D5000-D5899
D5900-D5999
D6000-D6199
D6200-D6999
D7000-D7999
D8000-D8999
D9000-D9999

Miscellaneous Procedures

Q3014

Local anesthesia is considered to be part of the procedure(s) and is not payable
separately.
1.

“(REPORT NEEDED)” / “BY REPORT (BR)” PROCEDURES:
Procedures that do not have a published fee are indicated as “(BR)”. Procedureswith or without a published fee that are listed as “(REPORT NEEDED)” require
professional review for validation and/or pricing. All claims for these proceduresmust be submitted with supporting documentation.
Information concerning the nature, extent and need for the procedure or service,
the time, the skill and the equipment necessary, must be furnished. Appropriate
documentation (e.g., operative report, procedure description, and/or itemized
invoices and name/dosage of therapeutic agents) is required. To ensure
appropriate payment in the context of current Medicaid fees, bill your usual andcustomary fee charged to the general public. Claims should only be submitted
AFTER treatment is completed.
Operative reports must include the following information:a.

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b.
c.
d.
e.
f.
g.

Size, location and number of lesion(s) or procedure(s) where appropriate;
Major surgical procedure and supplementary procedure(s);Whenever possible, list the nearest similar procedure by code number;
Estimated follow-up period;
Operative time;
Specific details regarding any anesthesia provided (this should include start- stop times and all medications administered).

If documentation needs to be submitted in support of any “(REPORT NEEDED)” /“By Report (BR)” procedure, the claim MUST be submitted on a paper claim form
‘A’ with the documentation as an attachment. Attachments must be on paper thesame size as the claim form. This documentation must be maintained in themember’s record and made available upon request.
DO NOT SEND RADIOGRAPHIC IMAGES AS A CLAIM ATTACHMENT
If radiographs are needed DOH or OMIG will request that you submit them directly
to the reviewing unit.
Claim Form ‘A’ can be obtained from eMedNY by calling (800) 343-9000.
2.

DENTAL SITE IDENTIFICATION:
Certain procedure codes require specification of surface, tooth, quadrant or archwhen billing. These specifications are indicated after the procedure code
description by the following abbreviations:
Specify surface: (SURF)
Specify tooth:(TOOTH)Specify quadrant: (QUAD)
Specify arch:(ARCH)
 When more than one specification is required, both specifications areincluded, for example: (SURF/TOOTH).
 Only the dental site information required should be provided. Prior approval
requests and/or claims may be rejected when extraneous or incorrect site
information is included. Multiple submission of codes that do not requiresite designation should be entered on a single line with the site designation(e.g. tooth, arch, quad) left blank and the number of times performed
entered. A report or narrative should be submitted where applicable.
 “Unspecified” procedure codes at the end of each section should not be
used for supernumerary teeth.
 Refer to the Dental Billing Guidelines, Appendix B, “Code Sets” found athttps://www.emedny.org/ProviderManuals/Dental/index.aspx
for
valid
values.

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2. “ESSENTIAL” SERVICES:
When reviewing requests for services the following guidelines will be used:
Treatment will not be routinely approved when functional replacement with lesscostly restorative materials, including prosthetic replacement, is possible.
Caries index, periodontal status, recipient compliance, dental history, medical
history and the overall status and prognosis of the entire dentition, among otherfactors, will be taken into consideration. Treatment is not considered appropriate
when the prognosis of the tooth is questionable or when a reasonable alternative
course of treatment would be extraction of the tooth and replacement. Treatment
such as endodontics or crowns will not be approved in association with an existingor proposed prosthesis in the same arch, unless the tooth is a critical abutment fora prosthesis provided through the NYS Medicaid program, or unless replacementby addition to an existing prosthesis or new prosthesis is not feasible. If the total
number of teeth which require or are likely to require treatment would be considered
excessive or when maintenance of the tooth is not considered essential or appropriate
in view of the overall dental status of the recipient, treatment will not be covered.
Treatment of deciduous teeth when exfoliation is imminent will not be routinely
reimbursable. Claims submitted for the treatment of deciduous cuspids and molars
for children ten (10) years of age or older, or for deciduous incisors in children five(5) years of age or older will be pended for professional review. As a condition for
payment, it may be necessary to submit, upon request, radiographic images andother information to support the appropriateness and necessity of these
restorations. Extraction of deciduous teeth will only be reimbursed if injection of a
local anesthetic is required.
Eight (8) posterior natural or prosthetic teeth (molars and/or bicuspids) in occlusion(four (4) maxillary and four (4) mandibular teeth in functional contact with eachother) will be considered adequate for functional purposes. Requests will be
reviewed for necessity based upon the presence/absence of eight (8) points ofnatural or prosthetic occlusal contact in the mouth (bicuspid/molar contact).
One (1) missing maxillary anterior tooth or two (2) missing mandibular anterior
teeth may be considered an esthetic problem that warrants a prosthetic
replacement.

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3.

INTERRUPTED TREATMENT:
Claims must be submitted when the product or service is completed anddelivered to the member with the appropriate procedure code using the date thatthe service is actually completed and delivered as the date of service.
However, in those cases involving multiple appointments to complete the service
or product, and the service or product cannot be completed or delivered, or themember loses eligibility prior to the completion of the service or delivery of the
product, then the appropriate billing code listed below may be used with the dateof the “decisive appointment” as the date of service.
If the "decisive appointment" (listed below) has not been met, or the member was
not eligible on the date of the "decisive appointment", no compensation isavailable.
Medicaid Fee-For-Service Providers:
The "billing code" in the chart on page 26 can be used with the date of the "decisive
appointment" as the date of service if:• The service is completed and delivered, but the member lost fee-for-service
Medicaid eligibility after the date of the "decisive appointment" (e.g. lost
Medicaid entirely or was switched to a managed care plan) but prior to thedate of delivery; or,• The service is NOT completed and delivered (e.g. member died, detained
for an indefinite period, etc.) after the date of the decisive appointment. It
must be documented that every reasonable attempt was made to complete anddeliver the service.
All claims submitted using the interrupted treatment billing codes will be pended
for manual review. Payment in full may be considered if the supporting
documentation demonstrates that the service was completed and delivered.
Payment, either in full or pro-rated, may be considered if the service is NOT
completed and delivered. The amount of compensation will be determined basedon the documentation provided.
Managed Care Plans:
All Medicaid Managed Care plans, and Essential Plans offering dental services,must continue to cover any remaining treatments required to complete theprocedures listed below if a managed care enrollee is disenrolled from the plan for
any reason (including, but not limited to, losing Medicaid eligibility, transferring toanother plan or voluntary disenrollment) after a decisive appointment. Suchcoverage is required even if the member does not qualify for guaranteed eligibility.

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Type of Service

Decisive Appointment

Approved Multiple
Visit Procedures
D1510, D1516,
D1517, D1575
D2710-D2792
D2794, D2952

Billing
Code
D0999

Root Canal Therapy

D3310-D3348

D3999

Complete Dentures
Partial Dentures

D5110-D5120
D5211-D5214
D5225, D5226
D5510-D5660

D5899
D5899

D5710-D5721
D5750-D5761
D5820-D5821

D5899

Acceptance of the prosthesis
for repair
Final impression

D5899

Final impression

D5911-D5988

D5999

Final impression

D6052-D6067,
D6094, D6095,
D6110- D6113
D6090, D6091

D6199

Final impression for the
specific procedure code

D6199

D6210-D6252
D6545-D6792
D6794
D8680
D9944, D9945,
D9946

D6999

Acceptance of prosthesis forrepairPreparation and impression of
all abutment teeth

Space Maintainers
Crowns, Posts

Denture Repair
Denture Rebase or
Relining
Other Prosthetic
Services
Maxillofacial
Prosthetics
Implant Services
Implant Services
Fixed Prosthetics
Orthodontic Retention
Occlusal Guards

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D2999

D5899

D8999
D9999

Tooth preparation
Tooth preparation or final post
pattern fabrication and final
impression
Pulp extirpation or
debridement to at least theapical 1/3 of all canals
Final impression
Final impression

Final impression
Final impression

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CODE

DESCRIPTION
Fee

I. DIAGNOSTIC D0100 - D0999
CLINICAL ORAL EVALUATIONS
The codes in this section recognize the cognitive skills necessary for patient evaluation. The
collection and recording of some data and components of the dental examination may
be delegated; however, the evaluation, which includes diagnosis and treatment
planning, is the responsibility of the dentist and must be documented in the treatment
record. As with all ADA procedure codes, there is no distinction made between theevaluations provided by general practitioners and specialists. Report additional
diagnostic and/or definitive procedures separately.
Initial and periodic exam (D0120, D0145, and D0150) frequency limitations will beapplied to a claim based on the member’s exam history within the group when theservicing provider has a group affiliation.
Includes charting, history, treatment plan, and completion of forms.
Orthodontist should ONLY use procedure code D8660 for examinations prior to starting
active care.
Periodic oral evaluation - established patient$25.00An evaluation performed on a patient of record to determine any changes in thepatient’s dental and medical health status since a previous comprehensive or
periodic evaluation. This includes an oral cancer evaluation, periodontal
screening where indicated, and may require interpretation of informationacquired through additional diagnostic procedures. The findings are discussedwith the patient. Report additional diagnostic procedures separately.
Reimbursement is limited to once per six-month period.
D0140
Limited oral evaluation - problem focused$14.00
Not used in conjunction with a regular appointment. Cannot be billed with anyother evaluation procedure, including but not limited to D9310 and D9430. Not
intended for follow-up care.
Oral evaluation for a patient under three years of age andD0145$30.00counseling with primary caregiver
Diagnostic services performed for a child under the age of three, preferably
within the first six months of the eruption of the first primary tooth, including
recording the oral and physical health history, evaluation of caries susceptibility,
development of an appropriate preventive oral health regimen andcommunication with and counseling of the child’s parent, legal guardian and/or
primary caregiver.
D0150
Comprehensive oral evaluation – new or established patient $30.00
Can only be billed once per provider-member relationship.
Detailed and extensive oral evaluation - problem focused,
(BR)
D0160
by report (REPORT NEEDED)This procedure will not be reimbursed if performed within ninety days of aconsultation or any other evaluation by the same provider.
D0120

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CODE

DESCRIPTIONDIAGNOSTIC IMAGING
The following ADA / DOHHS recommendations for “prescribing dental radiographs”
should be followed:
http://www.ada.org/~/media/ADA/Publications/ADA%20News/Files/Dental_Radiograp
hic_Examinations_2012.pdf?la=en
All images taken should be medically necessary and of diagnostic quality, properly
identified and dated. Claims for dental radiographs may be pended for professional
review and are subject to denial unless there is a documented need of medical
necessity.
If you are ordering a CT, CTA, MRI, MRA, Cardiac Nuclear, or PET procedure, you or
your office staff are required to obtain an approval number through the radiology priorapproval program. For additional information refer to:
http://www.emedny.org/ProviderManuals/Radiology/index.html
Note: The radiology prior approval program does not include procedure code D0367,
cone beam computed tomography. For more information see description of D0367.
$50.00Intraoral - complete series of radiographic images
A radiographic survey of the whole mouth, usually consisting of 14-22 periapical andposterior bitewing images intended to display the crowns and roots of all teeth,
periapical areas and alveolar bone.
D0220 Intraoral - periapical first radiographic image$8.00
To be billed only for the FIRST periapical image and ONLY when periapicalimages are taken. Cannot be used in conjunction with any other type of images
on the same date of service (e.g. bitewing, occlusal, panoramic etc.). If anothertype of radiograph is taken on the same day, all the periapical films must bereported as D0230 (intraoral – periapical each additional radiographic image).
D0230 Intraoral - periapical each additional radiographic image$5.00
When periapical images are taken in conjunction with bitewing(s), occlusal or
panoramic images, use procedure code D0230 for ALL periapical images
including the first periapical image.
The total fee for ALL intraoral radiographic images (including the first
periapical image) may not exceed the total fee allowed for a complete
intraoral series.
D0240 Intraoral - occlusal radiographic image (ARCH)$15.00One maxillary and one mandibular radiographic image are allowed within three
years. May be supplemented by necessary intraoral periapical or bitewing
images.
D0250 Extra-oral - 2D projection radiographic image created using $25.00
a stationary radiation source, and detector
These images include but are not limited to: Lateral Skull; Posterior-Anterior
Skull; Submentovertex; Waters; Reverse Tomes; Oblique Mandibular Body;
Lateral Ramus. Not reimbursable for Temporomandibular Joint images.
D0210

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CODE
D0251

DESCRIPTION
Extra-oral posterior dental radiographic image$12.00
Image is limited to exposure of complete posterior teeth in both dental arches.
This is a unique image that is not derived from another image.
Maximum of two images.
Not reimbursable for Temporomandibular Joint images.

Bitewings are allowed no more than once in six months for each member.
The procedure code is an indication of the number of images performed. Leave the“Times Performed” on the claim form blank or enter “1”.
Bitewing – single radiographic image$8.00
Bitewings – two radiographic images$14.00
Bitewings – three radiographic images$20.00
Bitewings – four radiographic images$24.00$41.00Sialography
Temporomandibular joint arthrogram, including injection$174.00$29.00
Other temporomandibular joint radiographic images, byreport (PER JOINT) (REPORT NEEDED)
D0330 Panoramic radiographic image$35.00Reimbursable every three years if clinically indicated. For use in routine caries
determination, diagnosis of periapical or periodontal pathology only when
supplemented by other necessary radiographic intraoral images (bitewing and/or
periapical), completely edentulous cases, diagnosis of impacted teeth, oral
surgery treatment planning, or diagnosis of children with mixed dentition.
Postoperative panoramic images are reimbursable for post-surgical evaluationof fractures, dislocations, orthognathic surgery, osteomyelitis, or removal ofunusually large and/or complex cysts or neoplasms. Panoramic radiographic
images are not required or reimbursable for post orthodontic documentation.
Panoramic images are not reimbursable when an intraoral complete series orpanoramic image has been taken within three years, except for the diagnosis ofa new condition (e.g., traumatic injury, orthodontic evaluation).
D0340 2D cephalometric radiographic image – acquisition,$55.00measurement and analysis
I mage of the head made using a cephalostat to standardize anatomic
p sitioning, and with reproducible x-ray beam geometry.
R eimbursable every three years if clinically indicated. Reimbursement is limitedt o enrolled orthodontists or oral and maxillofacial surgeons for the diagnosing
a d treatment of a physically handicapping malocclusion.
Cephalometricimages are not required by the DOH for routine post-orthodontic documentationa d are not routinely reimbursable. A tracing and analysis are required and is
n t payable separately. Use D0250 if a tracing and analysis is not performed.
D0270
D0272
D0273
D0274
D0310
D0320
D0321

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CODE
D0350

DESCRIPTION
2D oral/facial photographic image obtained intra-orally or$12.00extra-orally
Photographs are reimbursable when associated with procedures describedunder sections: V. PERIODONTICS, limited to gingivectomy or gingivoplasty,
procedure codes D4210, D4211
 VIII. IMPLANTS XI. ORTHODONTICS
 When requested by the Department Health; and,
 The fee includes all intra-oral and extra-oral images taken on thesame date of service.

CONE BEAM CT CAPTURE
 Includes axial, coronal and sagittal data.
 Includes all interpretation.
 There is no professional reimbursement for facility place of service.
Facility reimbursement is through APG.
 For treatment not involving implants or implant-related services, a
panoramic radiograph (D0330) or similar film, along with documentationof medical necessity, must be submitted with requests for prior approval.
Approval is limited to those cases demonstrating significant risk for acomplication such as nerve injury or jaw fracture as well as pathology ortrauma workups.
 For treatment involving implants or implant-related services, refer tosection VIII. IMPLANTS.
D0364
D0365
D0366

Cone beam CT capture and interpretation with limited fieldof view – less than one whole jaw (PA REQUIRED)
Cone beam CT capture and interpretation with field of viewof one full dental arch - mandibular (PA REQUIRED)
Cone beam CT capture and interpretation with field of viewof one full dental arch – maxilla, with or without cranium$279.00$279.00$279.00(PA REQUIRED)

Cone beam CT capture and interpretation with field of view$279.00of both jaws; with or without cranium (PA REQUIRED)
D0368 Cone beam CT capture and interpretation for TMJ series$279.00
including two or more exposures (PA REQUIRED)
D0470 Diagnostic casts$34.00Reimbursement is limited to enrolled orthodontists or oral and maxillofacial
surgeons. Includes both arches when necessary.
D0367

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CODE

DESCRIPTIONORAL PATHOLOGY LABORATORY
These are procedures generally performed in a pathology laboratory and do not include theremoval of the tissue sample from the patient. For removal of tissue sample, see codes
D7285 and D7286.
Reimbursement for procedure codes D0470, D0485 and D0502 are limited to enrolled
Oral Pathologists.
D0474
D0485
D0502
D0999

Accession of tissue, gross and microscopic examination,
including assessment of surgical margins for presence ofdisease, preparation and transmission of written report.
Consultation, including preparation of slides from biopsy
material supplied by referring source
Other oral pathology procedures, by report (REPORT NEEDED)
Unspecified diagnostic procedure, by report(REPORT NEEDED)

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CODE

DESCRIPTION

II. PREVENTIVE D1000 - D1999
DENTAL PROPHYLAXIS
Dental prophylaxis is reimbursable in addition to an initial dental examination and recall
examinations once per six (6) month period. Prophylaxis cannot be used in conjunction
with periodontal maintenance (D4910) or in conjunction with scaling and root planning(D4341) on the same date of service.
Prophylaxis – adult$45.00
Removal of plaque, calculus and stains from tooth structures and implants in thepermanent and transitional dentition. It is intended to control local irritational
factors. For members 13 years of age and older.
D1120 Prophylaxis – child$43.00
Removal of plaque, calculus and stains from tooth structures and implants in the
primary and transitional dentition. It is intended to control local irritational factors.
For members under 13 years of age.
D1110

An additional prophylaxis may be considered within a twelve-month period for thoseindividuals identified with a recipient exception code of RE 81 (“TBI Eligible”) or RE 95(“OPWDD/Managed Care Exemption”). The additional prophylaxis should be submittedusing procedure code D1999. Documentation supporting necessity must be submittedwith the claim. Reimbursement will not be considered if performed within a four-monthinterval of D1110, D1120, D1999 (used as an additional prophylaxis), or D4910.
TOPICAL FLUORIDE TREATMENT (OFFICE PROCEDURE)
Topical fluoride treatment is reimbursable when professionally administered in accordancewith appropriate standards. Benefit is limited to gel, foam, and varnish. There must be aminimum interval of three (3) months between all fluoride treatments (D1206 and/or
D1208).
Fluoride treatments that are not reimbursable under the program include: Treatment that incorporates fluoride with prophylaxis paste; Topical application of fluoride to the prepared portion of a tooth prior to restoration;
 Fluoride rinse or “swish”; and,
 Treatment for desensitization.
D1206

Topical application of fluoride varnish$30.00Reimbursable once per three (3) month period for members between 6 months and20 years of age (inclusive). For individuals 21 years of age and older D1206 is
only approvable for those individuals identified with a recipient exception code of
RE 81 (“TBI Eligible”) or RE 95 (“OPWDD/Managed Care Exemption”), or, in cases
where salivary gland function has been compromised through surgery, radiation,or disease. Reimbursable to physicians and nurse practitioners under CPT code
99188.

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CODE
D1208

DESCRIPTION
Topical application of fluoride – excluding varnish$14.00Reimbursable once per six (6) month period for members between 1 and 20 yearsof age (inclusive). Fluoride must be applied separately from prophylaxis paste. For
individuals 21 years of age and older D1208 is only approvable for those individuals
identified with a recipient exception code of RE 81 (“TBI Eligible”) or RE
95 (“OPWDD/Managed Care Exemption”), or, in cases where salivary gland
function has been compromised through surgery, radiation, or disease.

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CODE

DESCRIPTIONOTHER PREVENTIVE SERVICES
D1320

Tobacco counseling for the control and prevention of oraldisease.

$10.00Tobacco prevention and cessation services reduce patient risks of developing
tobacco-related oral diseases and conditions and improves prognosis forcertain dental therapies.
Reimbursement for smoking cessation counseling (SCC) must meet the following
criteria:• SCC must be provided face-to-face by either a dentist or by adental hygienist that is supervised by the dentist;• SCC must be billed by either an office-based dental practitioner
or by an Article 28 clinic that employs a dentist;• Dental practitioners can only provide individual SCC services,which must be greater than three minutes in duration, NO
group sessions are allowed;• Dental claims for SCC must include the CDT procedure code
D1320 (tobacco counseling for the control and prevention oforal disease);• In a dental office or an Article 28 clinic, SCC should only takeplace during a dental visit as an adjunct when providing adental service and NOT billed as a stand-alone service;• Smoking Cessation Counseling complements existing
Medicaid covered benefits for prescription and nonprescription smoking cessation products including nasal
sprays, inhalers, Zyban (bupropion), Chantix (varenicline),
over-the counter nicotine patches and gum;
• To receive reimbursement for SCC services the following
information must be documented in the patient’s dental record: At least 4 of 5 A’s: smoking status and if yes,
willingness to quit; If willing to quit, offer medication as needed,
target date for quitting, and follow-up date (withdocumentation in the record that the follow-up
occurred); If unwilling to quit, the patient’s expressed
roadblocks;
 Referrals to the New York State Smoker’s
Quitline and/or community services to address
roadblocks and for additional cessation
resources and counselling, if needed.
Smoking cessation services are included in the prospective payment system (PPS)
rate for those FQHCs that do not participate in APG reimbursement.

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Dentists should be aware of the following guideline for smoking cessation
counseling:
The Clinical Practice Guideline, “Treating Tobacco Use and Dependence: 2008
Update” demonstrated that efficacious treatments for tobacco users exist and should
become a part of standard care giving.
This guideline recommends that a practitioner should follow the “5 A’s” of treating
tobacco dependence, which include:
1. Ask: Ask the patient about tobacco use at every visit anddocument the response.
2. Advise: Advise the patient to quit in a clear andpersonalized manner.
3. Assess: Assess the patient’s willingness to make a quit
attempt at this time.
4. Assist: Assist the patient to set a quit date and make aquit plan; offer medication as needed.
5. Arrange: Arrange to follow-up with the patient within thefirst week, either in person or by phone, and takeappropriate action to assist them.
For patients not ready to make a quit attempt, clinicians should use a brief
intervention designed to promote the motivation to quit. Content areas that should
be addressed can be captured by the “5 R’s”:
1. Relevance: Encourage the patient to state why quitting
is relevant to them, being as specific as possible.
2. Risks: Ask the patient to identify potential negative
consequences of their tobacco use, including acute,environmental, and long-term risks.
3. Rewards: Ask the patient to identify potential benefits,
such as improved health, saving money, setting a good
example for children, and better physical performance.
4. Roadblocks: Ask the patient to identify barriers (e.g.,fear of withdrawal, weight gain, etc.), and provide
treatment and resources to address them.
5. Repetition: The motivational intervention should be
repeated every time the patient is seen.
Research suggests that the “5 R’s” enhance future quit attempts. Additional
information is available in Chapter 3 of the guideline, titled Clinical Interventions for
Tobacco Use and Dependence.

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D1351

DESCRIPTION
Sealant – per tooth (TOOTH) (DVS REQUIRED)$35.00Mechanically and/or chemically prepared enamel surface sealed to prevent decay.

Refer to the “Prior Approval/Prior Authorization Requirements” section for use of DVS.

Application of sealant is restricted to previously unrestored permanent first andsecond molars that exhibit no signs of occlusal or proximal caries for members
between 5 and 15 years of age (inclusive). Buccal and lingual grooves areincluded in the fee. The use of opaque or tinted sealant is recommended for ease ofchecking bond efficacy. Reapplication, if necessary, is permitted once every
five (5) years.
D1354 Application of caries arresting medicament – per tooth$15.00(TOOTH)
Conservative treatment of an active, non-symptomatic carious lesion by topicalapplication of a caries arresting or inhibiting medicament and without mechanicalremoval of sound tooth structure - Limited to Silver Diamine Fluoride
Clinical criteria for the use of silver diamine fluoride:• Stabilize non-symptomatic teeth with active carious lesion and no pulpal
exposure• High caries risk (e.g. xerostomia, severe early childhood caries)• Treatment challenged by behavioral or medical management• Difficult to treat carious lesions

Criteria for reimbursement:• Benefit covers 0-20 years of age inclusive• For individuals 21 years of age and older “D1354” is only approvable forthose individuals identified with a recipient exception code of “RE 81” (“TBI
Eligible”) or “RE 95” (OPWDD/Managed Care Exemption”)• Covered two (2) times per tooth within a 12-month period with a total of four(4) times per lifetime of the tooth.
• Covered with topical application of fluoride (“D1206” or “D1208”) when
they are performed on the same date of service if “D1354” is being used
to treat caries and “D1206” or “D1208” is being used to prevent caries.
• Silver diamine fluoride may be applied to five (5) teeth on the same date ofservice with more teeth considered in exceptional circumstances.
Documentation supporting necessity must be submitted with the claim.
Providers are required to:• Fully disclose the risks and benefits of silver diamine fluoride use and to
discuss treatment alternatives where appropriate.
• Obtain written consent.

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CODE

DESCRIPTIONSPACE MAINTENANCE (PASSIVE APPLIANCES)
Only fixed appliances are reimbursable. Documentation including pre-treatment images
to justify all space maintenance appliances must be available upon request. Space
maintenance should not be provided as an isolated service. All carious teeth must be
restored before placement of any space maintainer. The member should be practicing asufficient level of oral hygiene to ensure that the space maintainer will not become asource of further carious breakdown of the dentition. All permanent teeth in the area ofspace maintenance should be present and developing normally.
Space maintenance in the deciduous dentition (defined as prior to the interdigitation of thefirst permanent molars) can generally be considered.
Space maintenance in the mixed dentition initiated within one month of the necessary
extraction will be reimbursable on an individual basis. Space maintenance in the mixed
dentition initiated more than one month after the necessary extraction, with minimum
space loss apparent, may be reimbursable.
Space maintainer – fixed, unilateral – per quadrant (QUAD)$116.00
Excludes a distal shoe space maintainer.
D1516 Space maintainer – fixed – bilateral, maxillary$174.00
D1517 Space maintainer – fixed – bilateral, mandibular$174.00
D1551 Re-cement or re-bond bilateral space maintainer - maxillary$19.00
D1552 Re-cement or re-bond bilateral space maintainer $19.00
mandibular
D1553 Re-cement or re-bond unilateral space maintainer – per$19.00
quadrant (QUAD)
D1575 Distal shoe space maintainer – fixed, unilateral – per$116.00
quadrant (QUAD)
Fabrication and delivery of fixed appliance extending subgingivally and distally to
guide the eruption of the first permanent molar.
D1999 Unspecified preventive procedure, by report
(BR)
D1510

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III. RESTORATIVE D2000 - D2999
The cost of analgesic and anesthetic agents is included in the reimbursement forthe dental service. The administration of nitrous oxide is not separately reimbursable.
The maximum fee for restoring a tooth with either amalgam or composite resin material
will be the fee allowed for placement of a four-surface restoration. With the exception of
the placement of reinforcement pins (use code D2951), fees for amalgam and composite
restorations include tooth preparation, all adhesives (including amalgam and composite
bonding agents), acid etching, cavity liners, bases, curing and pulp capping.
Restorations placed solely for the treatment of abrasion, attrition, erosion or abfraction
and are not associated with the treatment of any other pathology are beyond the scopeof the program and will not be reimbursed. Restorative procedures should not be
performed without documentation of clinical necessity. Published “frequency limits” aregeneral reference points on the anticipated frequency for that procedure. Actual
frequency must be based on the clinical needs of the individual member.
If a non-covered surgical procedure (e.g. crown lengthening, D4249) is required toproperly restore a tooth, any associated restorative or endodontic treatment will NOT be
considered for reimbursement.
For codes D2140, D2330 and D2391, only a single restoration will be reimbursable per
surface. Occlusal surface restorations including all occlusal pits and fissures will bereimbursed as one-surface restorations whether or not the transverse ridge of an upper
molar is left intact. Codes D2150, D2160, D2161, D2331, D2332, D2335, D2781, D2392,
D2393, and D2394 are compound restorations encompassing 2, 3, 4 or more contiguous
surfaces. Restorations that connect contiguous surfaces must be billed using the appropriate
multi-surface restorative procedure code.
AMALGAM RESTORATIONS (INCLUDING POLISHING)
D2140
D2150
D2160

Amalgam - one surface, primary or permanent (SURF/TOOTH)
Amalgam - two surfaces, primary or permanent (SURF/TOOTH)
Amalgam - three surfaces, primary or permanent$50.00$67.00$82.00

D2161

Amalgam - four or more surfaces, primary or permanent$98.00(SURF/TOOTH)(SURF/TOOTH)RESIN-BASED COMPOSITE-RESTORATIONS DIRECT
D2330
D2331

Resin-based composite - one surface, anterior (SURF/TOOTH)
Resin-based composite - two surfaces, anterior$50.00$73.00

D2332

Resin-based composite - three surfaces, anterior$87.00Resin-based composite - four or more surfaces or involving
incisal angle (anterior) (SURF/TOOTH)$98.00

D2335(SURF/TOOTH)(SURF/TOOTH)

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Resin-based composite crown, anterior (TOOTH)$98.00Resin-based composite; one surface, posterior (SURF/TOOTH) $50.00
Used to restore a carious lesion into the dentin or a deeply eroded area into thedentin. Not a preventive procedure.
D2392 Resin-based composite - two surfaces, posterior$67.00
D2390
D2391

D2393
D2394

(SURF/TOOTH)

Resin-based composite - three surfaces, posterior$82.00Resin-based composite - four or more surfaces, posterior$98.00(SURF/TOOTH)(SURF/TOOTH)

CROWNS - SINGLE RESTORATIONS ONLY
The materials used in the fabrication of a crown (e.g. all-metal, porcelain, ceramic, resin)
is at the discretion of the provider. The crown fabricated must correctly match theprocedure code approved on the Prior Approval.
Crowns will not be routinely approved for a molar tooth in those members age 21 andover which has been endodontically treated without prior approval from the Department
of Health.
Crowns include any necessary core buildups.
D2710 Crown – resin-based composite (indirect) (laboratory)(TOOTH) (PA REQUIRED)$290.00

Acrylic (processed) jacket crowns may be approved as restorations for severely
fractured anterior teeth.
D2720 Crown – resin with high noble metal (TOOTH) (PA REQUIRED)$500.00
Crown
–
resin
with
predominantly
base
metal
(TOOTH)
D2721$500.00
D2722
D2740
D2750
D2751
D2752
D2753
D2780
D2781
D2782
D2790
D2791
D2792
D2794

(PA REQUIRED)

Crown – resin with noble metal (TOOTH) (PA REQUIRED)
Crown – porcelain/ceramic (TOOTH) (PA REQUIRED)
Crown – porcelain fused to high noble metal (TOOTH)$500.00$500.00$500.00

Crown – porcelain fused to predominately base metal$500.00

Crown – porcelain fused to noble metal (TOOTH)$500.00

Crown – porcelain fused to titanium and titanium alloys$500.00

Crown – ¾ cast high noble metal (TOOTH) (PA REQUIRED)
Crown – ¾ cast predominantly base metal (TOOTH)$400.00$400.00

Crown – ¾ cast noble metal (TOOTH) (PA REQUIRED)
Crown – full cast high noble metal (TOOTH) (PA REQUIRED)
Crown – full cast predominately base metal (TOOTH)$400.00$500.00$500.00

Crown – full cast noble metal (TOOTH) (PA REQUIRED)
Crown – Titanium and titanium alloys$500.00$500.00(PA REQUIRED)(TOOTH) (PA REQUIRED)(PA REQUIRED)(TOOTH) (PA REQUIRED)(PA REQUIRED)(PA REQUIRED)

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DESCRIPTIONOTHER RESTORATIVE SERVICES
For all prefabricated crowns (D2930, D2931, D2932, D2933, D2934) there must be
supporting documentation substantiating the need for the crown (e.g. radiographic
images).
D2920

D2930
D2931

Re-cement or re-bond crown (TOOTH)$30.00Claims for recementation of a crown by the original provider within one year ofplacement, or claims for subsequent recementations of the same crown, will bepended for professional review. Documentation to justify the need andappropriateness of such recementations may be required as a condition for payment.
Prefabricated stainless steel crown - primary tooth (TOOTH)$116.00
Prefabricated stainless steel crown - permanent tooth$116.00(TOOTH)

Prefabricated resin crown (TOOTH)$116.00
This procedure is limited to one occurrence per tooth within two years.
Placement on deciduous anterior teeth is generally not reimbursable past theage of five (5) years of age.
D2933
Prefabricated stainless steel crown with resin window$130.00
D2932(TOOTH)This procedure is limited to one occurrence per tooth within two years.
Restricted to primary anterior teeth, permanent maxillary bicuspids and firstmolars. Placement on deciduous anterior teeth is generally not reimbursable
past the age of five (5) years of age.
D2934
Prefabricated esthetic coated stainless steel crown –$130.00
primary tooth (TOOTH)
This procedure is limited to one occurrence per tooth within two
years. Placement on deciduous anterior teeth is generally notreimbursable past the age of five (5) years of age.
D2951
Pin retention - per tooth, in addition to restoration (TOOTH)$29.00Reimbursement is allowed once per tooth regardless of the numbe r of pins
placed.
Post and core in addition to crown, indirectly fabricatedD2952$125.00(TOOTH)

Prefabricated post and core in addition to crown (TOOTH)
There is no separate reimbursement for the core material.
D2955
Post removal (TOOTH)
D2954$125.00$95.00

D2980

Crown repair necessitated by restorative material failure

(BR)

D2999

Unspecified restorative procedure, by report(BR)(TOOTH) (REPORT NEEDED)(REPORT NEEDED)

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DESCRIPTION

IV. ENDODONTICS D3000 - D3999
All radiographic images taken during the course of root canal therapy and all posttreatment radiographic images are included in the fee for the root canal procedure. At
least one pre-treatment radiographic image demonstrating the need for the procedure,and one post-treatment radiographic image that demonstrates the result of thetreatment, must be maintained in the member's record.
Surgical root canal treatment or apicoectomy may be considered appropriate andcovered when the root canal system cannot be acceptably treated non-surgically, thereis active root resorption, or access to the canal is obstructed. Treatment may also becovered where there is gross over or under extension of the root canal filling, periapicalor lateral pathosis persists, or there is a fracture of the root.
If a non-covered surgical procedure (e.g. crown lengthening, D4249) is required toproperly restore a tooth, any associated restorative or endodontic treatment will NOT be
considered for reimbursement.
Pulp capping, either direct or indirect, is not reimbursable.
Molar endodontic treatment, retreatment or apical surgery is not approvable as a routine
procedure. Prior approval requests will be will only be considered for members underage 21 who display good oral hygiene, have healthy mouths with a full complement of
natural teeth with a low caries index and/or who may be undergoing orthodontic
treatment. In those members age 21 and over, molar endodontic therapy will beconsidered only in those instances where the tooth in question is a critical abutment foran existing functional prosthesis and when the tooth cannot be extracted and replacedwith a new prosthesis, or; where there is a documented medical condition which
precludes extraction.
PULPOTOMY
D3220

Therapeutic pulpotomy (excluding final restoration) $87.00
removal of pulp coronal to the dentinocemental junction
and application of medicament (TOOTH)
To be performed on primary or permanent teeth up until the age of 21 years.
This is not to be considered as the first stage of root canal therapy.
Pulp capping (placement of protective dressing or cement over exposed ornearly exposed pulp for protection from injury or as an aid in healing and repair)is not reimbursable.
This procedure code may not be used when billing for an "emergency
pulpotomy", which should be billed as palliative treatment.

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CODE

DESCRIPTIONENDODONTIC THERAPY ON PRIMARY TEETH
Endodontic therapy on primary teeth with succedaneous teeth and placement ofresorbable filling. This includes pulpectomy, cleaning, and filling of canals withresorbable material.
D3230
D3240

Pulpal therapy (resorbable filling) – anterior, primary tooth(excluding final restoration) (TOOTH) (PA REQUIRED)
Pulpal therapy (resorbable filling) – posterior, primary tooth(excluding final restoration) (TOOTH) (PA REQUIRED)$150.00$235.00

ENDODONTIC THERAPY (INCLUDING TREATMENT PLAN, CLINICALPROCEDURES AND FOLLOW-UP CARE)
Includes primary teeth without succedaneous teeth and permanent teeth.
D3310 Endodontic therapy – anterior tooth (excluding final
restoration) (TOOTH) (PA REQUIRED)
D3320 Endodontic therapy – premolar tooth (excluding final
restoration) (TOOTH) (PA REQUIRED)
D3330 Endodontic therapy – molar tooth (excluding final
restoration) (TOOTH) (PA REQUIRED)$250.00$300.00$400.00

ENDODONTIC RETREATMENT
D3346

Retreatment of previous root canal therapy - anterior$250.00

D3347

Retreatment of previous root canal therapy - premolar$300.00

Retreatment of previous root canal therapy - molar (TOOTH)$400.00

D3348(TOOTH) (PA REQUIRED)(TOOTH) (PA REQUIRED)(PA REQUIRED)APEXIFICATION / RECALCIFICATION PROCEDURES
D3351

Apexification / recalcification - initial visit (apicalclosure/calcific repair of perforations, root resorption, etc.)$82.00(TOOTH)

Includes opening tooth, pulpectomy, preparation of canal spaces, first placementof medication and necessary radiographic images.
(This procedure includes first phase of complete root canal therapy.)
D3352 Apexification / recalcification - interim medication$80.00replacement (TOOTH)
For visits in which the intra-canal medication is replaced with new medication.
Includes any necessary radiographs.
There may be several of these visits.
The published fee is the maximum reimbursable amount regardless of thenumber of visits.

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D3353

DESCRIPTION
Apexification / recalcification - final visit (includes$103.00
completed root canal therapy – apical closure/calcific repairof perforations, root resorption, etc.) (TOOTH)
Includes the removal of intra-canal medication and procedures necessary toplace final root canal filling material including necessary radiographs.
(This procedure includes last phase of complete root canal therapy.)

APICOECTOMY
Periradicular surgery is a term used to describe surgery to the root surface (e.g.,apicoectomy), repair of a root perforation or resorptive defect, exploratory curettage tolook for root fractures, removal of extruded filling materials or instruments, removal of
broken root fragments, sealing of accessory canals, etc. This does not include
retrograde filling material placement. Performed as a separate surgical procedure andincludes periapical curettage.
Apicoectomy - anterior (TOOTH) (PA REQUIRED)
Apicoectomy - premolar (first root) (TOOTH) (PA REQUIRED)
If more than one root is treated, see D3426.
D3425 Apicoectomy - molar (first root) (TOOTH) (PA REQUIRED)
If more than one root is treated, see D3426.
D3426 Apicoectomy (each additional root) (TOOTH) (PA REQUIRED)
D3430 Retrograde filling - per root (TOOTH) (PA REQUIRED)
D3410
D3421

$160.00$160.00$180.00$60.00$50.00OTHER ENDODONTIC PROCEDURES
D3999

Unspecified endodontic procedure, by report(REPORT NEEDED)

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DESCRIPTION

V. PERIODONTICS D4000 - D4999
For details regarding the “PERIODONTICS” codes that are associated with the implantand implant related services benefit ONLY (D4245, D4266, D4267, D4273, D4275,
D4277, D4278, D4283, D4285), see section VIII. IMPLANTS.
SURGICAL SERVICES (INCLUDING USUAL POST-OPERATIVE CARE)
D4210 and D4211 are reimbursable solely for the correction of severe hyperplasia or
hypertrophy associated with drug therapy, hormonal disturbances or congenital defects. The
provider must keep in the treatment record detailed documentation describing the needfor gingivectomy or gingivoplasty including pretreatment photographs depicting the conditionof the tissues.
D4210

Gingivectomy or gingivoplasty – four or more contiguousteeth or tooth bounded spaces per quadrant (QUAD)$100.00

Gingivectomy or gingivoplasty – one to three contiguousteeth or tooth bounded spaces per quadrant (QUAD)$65.00(REPORT NEEDED)

D4211(REPORT NEEDED)NON-SURGICAL PERIODONTAL SERVICES
D4341
D4342

Periodontal scaling and root planing – four or more teeth
per quadrant (QUAD)
Periodontal scaling and root planing – one to three teeth
per quadrant (QUAD)$45.00$30.00For periodontal scaling and root planning (D4341 and D4342) to be considered, thediagnostic materials must demonstrate the following, consistent with professional
standards:
 Clinical loss of periodontal attachment, and;•

Periodontal pockets and sub-gingival accretions on cemental surfaces in thequadrant(s) being treated, and/or;•Radiographic evidence of crestal bone loss and changes in crestal lamina
dura, and/or;•Radiographic evidence of root surface calculus.

The provider must keep in the treatment record detailed documentation describing theneed for periodontal scaling and root planing, including a copy of the pre-treatment
evaluation of the periodontium, a general description of the tissues (e.g., color, shape,and consistency), the location and measurement of periodontal pockets, the description

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DESCRIPTIONof the type and amount of bone loss, the periodontal diagnosis, the amount and locationof subgingival calculus deposits, and tooth mobility.
Treatment per quadrant is limited to once every two (2) years. For consideration of
more frequent treatment prior approval with supporting documentation is required.
Reimbursement for D4341 and/or D4342 is limited to no more than two quadrants ona single date of service.
In exceptional circumstances, consideration may be given for reimbursement for morethan two quadrants on a single date of service (e.g. treatment under anesthesia). These
claims should be submitted using procedure code D4999 with documentation supporting
both the need for treatment and the exceptional circumstances present.
Prophylaxis or periodontal maintenance (e.g. D1110, D1120, D4910) will not be
reimbursed on the same date of service as periodontal scaling and root planning (D4341,
D4342).
OTHER PERIODONTAL SERVICES
Periodontal maintenance$45.00This procedure is for members who have previously been treated for
periodontal disease with procedures such as scaling and root planing(D4341 or D4342). D4910 cannot be used in conjunction with or billed
within six (6) months of any other prophylaxis procedure (e.g. D1110).
Reimbursement for D4910 is limited to once per six (6) months andcannot be used in conjunction with D4341 or D4342 on the same dateof service.
D4999 Unspecified periodontal procedure, by report
(BR)
D4910

(REPORT NEEDED)

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VI. PROSTHODONTICS (Removable) D5000 - D5899
Full and /or partial dentures are covered by Medicaid when they are required to alleviate aserious health condition or one that affects employability. This service requires prior approval.
Complete dentures and partial dentures whether unserviceable, lost, stolen, or broken will not
be replaced for a minimum of eight years from initial placement except when determined
medically necessary by the Department or its agent. Prior approval requests for replacement
dentures prior to eight years must include a letter from the patient’s physician and dentist. A
letter from the patient’s dentist must explain the specific circumstances that necessitates
replacement of the denture. The letter from the physician must explain how dentures would
alleviate the patient’s serious health condition or improve employability. If replacement
dentures are requested within the eight-year period after they have already been replaced
once, then supporting documentation must include an explanation of preventative measuresinstituted to alleviate the need for further replacements.

General Guidelines for All Removable Prosthesis: Complete and/or partial dentures will be approved only when the existing
prosthesis is not serviceable or cannot be relined or rebased. Reline or rebase ofan existing prosthesis will not be reimbursed when such procedures are
performed in addition to a new prosthesis for the same arch within 6 months ofthe delivery of a new prosthesis. Only “tissue conditioning” (D5850 or D5851) ispayable within six (6) months prior to the delivery of a new prosthesis;
 Six (6) months of post-delivery care from the date of insertion is included in thereimbursement for all newly fabricated prosthetic appliances. This includes
rebasing, relining, adjustments and repairs.
 Cleaning of removable prosthesis or soft tissue not directly related to natural teeth is
not a covered service. Prophylaxis and/or scaling and root planing is only payable
when performed on natural dentition;
 "Immediate" prosthetic appliances are not a covered service. An appropriate
length of time for healing should be allowed before taking any final impressions.
Generally, it is expected that tissues will need a minimum of four (4) to six (6)weeks for healing. Claims for denture insertion occurring within four (4) weeks ofextraction(s) will pend for professional review;
 Claims are not to be submitted until the denture(s) are completed and delivered
to the member. The "date of service" used on the claim is the date that thedenture(s) are delivered. If the prosthesis cannot be delivered or the member has
lost eligibility following the date of the "decisive appointment," claims should besubmitted following the guidelines for "Interrupted Treatment";
 Medicaid payment is considered payment in-full. Except for members with a"spend down," members cannot be charged beyond the Medicaid fee. Deposits,
down-payments or advance payments are prohibited;

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DESCRIPTION

 All treatment notes, radiographic images, laboratory prescriptions and laboratory
invoices should be made part of the member's treatment record to be madeavailable upon request in support of any treatment provided, and;
 The total cost of repairs should not be excessive and should not exceed 50% of
the cost of a new prosthesis. If the total cost of repairs and/or relines is to exceed
50% of the cost of a new prosthesis, a prior approval request for a new prosthesis
should be submitted with a detailed description of the existing prosthesis including
why any replacement would be necessary per Medicaid guidelines and would be
more appropriate than repair of the existing prosthesis.
COMPLETE DENTURES (INCLUDING ROUTINE POST-DELIVERY CARE)Radiographs are not routinely required to obtain prior approval for full dentures. The
guidelines published by the ADA and the U.S. Department of Health and Human
Services on the use of x-rays should be followed. Additional information is found here:
http://www.ada.org/~/media/ADA/Publications/ADA%20News/Files/Dental_Radiograph
ic_Examinations_2012.pdf?la=en
D5110
D5120

Complete denture – maxillary (PA REQUIRED)
Complete denture – mandibular (PA REQUIRED)$560.00$560.00

PARTIAL DENTURES (INCLUDING ROUTINE POST-DELIVERY CARE)
Requirements for the placement of partial dentures are:
 All phase I restorative treatment which includes extractions, removalof all decay and restoration with permanent filling materials, endodontic
therapy, crowns, etc. must be completed prior to taking the final
impression(s) for partial denture(s).
 Partial dentures can be considered for ages 15 years and above; an“Interim Prosthesis” (procedure codes D5820 and/or D5821) can beconsidered for individuals 5 to 15 years of age.
D5211 Maxillary partial denture - resin base (including$350.00
retentive/clasping materials, rests, and teeth) (PA REQUIRED)
D5212 Mandibular partial denture - resin base (including$350.00
retentive/clasping materials, rests, and teeth) (PA REQUIRED)
D5213 Maxillary partial denture - cast metal framework with resin$560.00
denture bases (including retentive/clasping materials, rests
and teeth) (PA REQUIRED)
D5214 Mandibular partial denture - cast metal framework with
$560.00
resin denture bases (including retentive/clasping materials,
rests and teeth) (PA REQUIRED)
D5225 Maxillary partial denture - flexible base (including$560.00
retentive/clasping materials, rests and teeth) (PA REQUIRED)
D5226 Mandibular partial denture - flexible base (including$560.00
retentive/clasping materials, rests and teeth) (PA REQUIRED)

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DESCRIPTIONADJUSTMENTS TO DENTURES
Adjustments within six months of the delivery of the prosthesis are considered part ofthe payment for the prosthesis. Adjustments (procedure codes D5410, D5411, D5421,
and D5422) are not reimbursable on the same date of service as the initial insertion of
the prosthetic appliance OR; on the same date of service as any repair, rebase, or reline
procedure code.
D5410
D5411
D5421
D5422

Adjust complete denture - maxillary
Adjust complete denture - mandibular
Adjust partial denture - maxillary
Adjust partial denture - mandibular$25.00$25.00$25.00$25.00PROSTHETIC APPLIANCE REPAIRS
Limitation: The total cost of repairs should not be excessive and should not exceed
50% of the cost of a new prosthesis. If the total cost of repairs is to exceed 50% of thecost of a new prosthesis, a prior approval request for a new prosthesis should besubmitted with a detailed description of the existing prosthesis and why any
replacement would be necessary per Medicaid guidelines and would be more
appropriate than repair of the existing prosthesis.
REPAIRS TO COMPLETE DENTURES
D5511
D5512
D5520

Repair broken complete denture base, mandibular
Repair broken complete denture base, maxillary
Replace missing or broken teeth - complete denture (eachtooth) (TOOTH)$65.00$65.00$42.00REPAIRS TO PARTIAL DENTURES
D5611
D5612
D5621
D5622
D5630
D5640
D5650
D5660

Repair resin partial denture base, mandibular
Repair resin partial denture base, maxillary
Repair cast partial framework, mandibular
Repair cast partial framework, maxillary
Repair or replace broken retentive/clasping materials- pertooth (TOOTH)
Replace broken teeth - per tooth (TOOTH)
Add tooth to existing partial denture (TOOTH)
Add clasp to existing partial denture - per tooth (TOOTH)$67.00$67.00$120.00$120.00$130.00$60.00$65.00$102.00

DENTURE REBASE PROCEDURES
Rebase procedures are not payable within six months prior to the delivery of a new
prosthesis. Only “tissue conditioning” (D5850 and D5851) is payable within six months
prior to the delivery of a new prosthesis.
D5710 Rebase - complete maxillary denture (PA REQUIRED)$170.00
D5711 Rebase - complete mandibular denture (PA REQUIRED)$170.00
D5720 Rebase - maxillary partial denture (PA REQUIRED)$174.00
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D5721

DESCRIPTION
Rebase - mandibular partial denture (PA REQUIRED)$174.00

DENTURE RELINE PROCEDURES
Reline procedures are not payable within six months prior to the delivery of a new
prosthesis. For cases in which it is impractical to complete a laboratory reline, priorapproval for an office (“chairside” or “cold cure”) reline may be requested with credible
documentation which would preclude a laboratory reline. Only “tissue conditioning”(D5850 and D5851) is payable within six months prior to the delivery of a new
prosthesis.
D5730
D5731

Reline complete maxillary denture (direct) (PA REQUIRED)
Reline complete mandibular denture (direct)$125.00$125.00

D5740
D5741
D5750
D5751
D5760
D5761

Reline maxillary partial denture (direct) (PA REQUIRED)
Reline mandibular partial denture (direct) (PA REQUIRED)
Reline complete maxillary denture (indirect)
Reline complete mandibular denture (indirect)
Reline maxillary partial denture (indirect)
Reline mandibular partial denture (indirect)$85.00$85.00$170.00$170.00$125.00$125.00(PA REQUIRED)INTERIM PROSTHESIS
Reimbursement is limited to once per year and only for children between 5 and 15 yearsof age. Codes D5820 and D5821 are not to be used in lieu of space maintainers. All
claims will be pended for professional review prior to payment.
D5820 Interim partial denture (including retentive/clasping$174.00
materials, rests, and teeth), maxillary
D5821 Interim partial denture (including retentive/clasping$174.00
materials, rests, and teeth), mandibular
OTHER REMOVABLE PROSTHETIC SERVICES
Codes D5850 and D5851 are for treatment reline using materials designed to heal
unhealthy ridges prior to more definitive final restoration. This is the ONLY type of reline
reimbursable within six (6) months prior to the delivery of a new prosthesis. Insertion oftissue conditioning liners in existing dentures will be limited to once per denture unit.
D5850 and D5851 are not reimbursable under age 15 and should be billed one time at
the completion of treatment, regardless of the number of visits involved.
D5850
D5851

Tissue conditioning, maxillary
Tissue conditioning, mandibular$25.00$25.00

D5899

Unspecified removable prosthodontic procedure, by report(BR)(REPORT NEEDED)

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VII. MAXILLOFACIAL PROSTHETICS D5900 - D5999
D5911
D5912
D5913
D5914
D5915
D5916
D5919
D5922
D5923
D5924
D5925
D5926
D5927
D5928
D5929
D5931
D5932
D5933
D5934

Facial moulage (sectional) (REPORT NEEDED)
Facial moulage (complete) (REPORT NEEDED)
Nasal prosthesis (REPORT NEEDED)
Auricular prosthesis (REPORT NEEDED)
Orbital prosthesis (REPORT NEEDED)
Ocular prosthesis (REPORT NEEDED)
Facial prosthesis (REPORT NEEDED)
Nasal septal prosthesis (REPORT NEEDED)
Ocular prosthesis, interim (REPORT NEEDED)
Cranial prosthesis (REPORT NEEDED)
Facial augmentation implant prosthesis (REPORT NEEDED)
Nasal prosthesis, replacement (REPORT NEEDED)
Auricular prosthesis, replacement (REPORT NEEDED)
Orbital prosthesis, replacement (REPORT NEEDED)
Facial prosthesis, replacement (REPORT NEEDED)
Obturator prosthesis, surgical (REPORT NEEDED)
Obturator prosthesis, definitive (REPORT NEEDED)
Obturator prosthesis, modification (REPORT NEEDED)
Mandibular resection prosthesis with guide flange$116.00$174.00(BR)(BR)$957.00$957.00(BR)(BR)$435.00
(BR)
(BR)
(BR)
(BR)
(BR)
(BR)
(BR)
(BR)
(BR)
(BR)

D5935

Mandibular resection prosthesis without guide flange(BR)

Obturator prosthesis, interim (REPORT NEEDED)
Trismus appliance (not for TMD treatment) (REPORT NEEDED)
Feeding aid (REPORT NEEDED)
Speech aid prosthesis, pediatric (REPORT NEEDED)
Speech aid prosthesis, adult (REPORT NEEDED)
Palatal augmentation prosthesis (REPORT NEEDED)
Palatal lift prosthesis, definitive (REPORT NEEDED)
Palatal lift prosthesis, interim (REPORT NEEDED)
Palatal lift prosthesis, modification (REPORT NEEDED)
Speech aid prosthesis, modification (REPORT NEEDED)
Surgical stent (REPORT NEEDED)
Radiation carrier (REPORT NEEDED)
Radiation shield (REPORT NEEDED)
Radiation cone locator (REPORT NEEDED)
Fluoride gel carrier (per arch) (ARCH)
Commissure splint (REPORT NEEDED)
Surgical splint (REPORT NEEDED)
Unspecified maxillofacial prosthesis, by report(BR)$145.00$435.00
(BR)
(BR)
(BR)
(BR)
(BR)
(BR)
(BR)
(BR)
(BR)
(BR)
(BR)
$10.00
(BR)
(BR)
(BR)

D5936
D5937
D5951
D5952
D5953
D5954
D5955
D5958
D5959
D5960
D5982
D5983
D5984
D5985
D5986
D5987
D5988
D5999

(REPORT NEEDED)(REPORT NEEDED)(REPORT NEEDED)

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VIII. IMPLANT SERVICES D6000 - D6199
Dental implants and implant related services will be covered by Medicaid when
medically necessary. Prior approval requests for implants must have supporting
documentation from the patient’s physician and dentist. A letter from the patient’s
physician must explain how implants will alleviate the patient’s medical condition. A
letter from the patient’s dentist must explain why other covered functional alternatives
for prosthetic replacement will not correct the patient’s dental condition and why thepatient requires implants.
General Guidelines: A complete treatment plan addressing all phases of care is required and should
include the following:• Accurate pretreatment charting;• Complete treatment plan addressing all areas of pathology;• Inter-arch distances;• Number, type and location of implants to be placed;• Design and type of planned restoration(s);• Sufficient number of current, diagnostic radiographs and/or CT scansallowing for the evaluation of the entire dentition.
 If bone graft augmentation is needed there must be a 4 to 6-month healing period
before a dental implant can be placed Dental implant code D6010 will be re-evaluated via intraoral radiographs or CT
scans prior to the authorization of abutments, crowns, or dentures four to six
months after dental implant placement.
 Treatment on an existing implant / implant prosthetic will be evaluated on a caseby-case basis.
 Implant and implant related codes not listed will be considered on a case-by-casebasis.
 Physician’s documentation must include a list of all medications currently being
taken and all conditions currently being treated.
 All cases will be considered based upon supporting documentation and current
standard of care.
For procedure codes D6010 and D6013 the following must be submitted:
 Full mouth radiographs or a diagnostic panorex including periapicals ofsite requesting dental implant(s).
D6010 Surgical placement of implant body (TOOTH) (PAREQUIRED) (POST OPERATIVE CARE: 90 DAYS)$1000.00

Full mouth radiographs or diagnostic panorex including periapicals ofsite requesting dental implant(s) must be provided.
D6013 Surgical placement of mini implant (TOOTH) (PA REQUIRED)(POST OPERATIVE CARE: 90 DAYS)

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Full mouth radiographs or diagnostic panorex including periapicals of site
requesting dental implant(s) must be provided.

For procedure codes D6055– D6057 the following must be submitted:
 Periapical radiograph of the integrated implant(s); and,
 Panorex or sufficient number of radiographs showing thecomplete arch and the placed implant(s)D6055 Connecting bar – implant supported or abutment supported$400.00

D6056 Prefabricated abutment – includes modification and placement$400.00

D6057 Custom fabricated abutment – includes placement$400.00(ARCH) (PA REQUIRED)(TOOTH) (PA REQUIRED)(TOOTH) (PA REQUIRED)For procedure codes D6058 – D6067, D6094 the following must be submitted:
 Periapical radiograph of integrated implant with abutment
 Intra-oral photograph of healed abutment showing healthy gingiva
D6058 Abutment supported porcelain/ceramic crown$800.00

D6059 Abutment supported porcelain fused to metal crown (high noble
metal) (TOOTH) (PA REQUIRED)
D6060 Abutment supported porcelain fused to metal crown(predominantly base metal) (TOOTH) (PA REQUIRED)
D6061 Abutment supported porcelain fused to metal crown (noble metal)$800.00

D6062 Abutment supported cast metal crown (high noble metal) (TOOTH)$800.00

D6063 Abutment supported cast metal crown (predominately base metal)$800.00

D6064 Abutment supported cast metal crown (noble metal) (TOOTH) (PA$800.00

D6065 Implant supported porcelain/ceramic crown (TOOTH) (PA REQUIRED)
D6066 Implant supported crown - porcelain fused to high noble alloys$800.00$800.00

D6067 Implant supported crown - high noble alloys (TOOTH) (PA REQUIRED)
D6081 Scaling and debridement in the presence of inflammation or
mucositis of a single implant, including cleaning on the implantsurfaces, without flap entry and closure (TOOTH) (REPORT NEEDED) Cannot bill for same date of service as D1110 or D4910.
 Cannot bill for same date of service and same quadrantas D4341, D4342.

$800.00(BR)(TOOTH) (PA REQUIRED)(TOOTH) (PA REQUIRED)(PA REQUIRED)(TOOTH) (PA REQUIRED)REQUIRED)(TOOTH) (PA REQUIRED)

D6090
D6091

Repair implant supported prosthesis (ARCH) (REPORT NEEDED)
Replacement of replaceable part of semi-precision or precisionattachment of implant/abutment supported prosthesis, perattachment (QUAD) (REPORT NEEDED)

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DESCRIPTION

D6092

Re-cement or re-bond implant/abutment supported crown (TOOTH)

(BR)

D6093

(BR)

D6094

Re-cement or re-bond implant/abutment supported fixed partial
denture (QUAD) (REPORT NEEDED)
Abutment supported crown – titanium and titanium alloys (TOOTH)

D6095
D6096
D6100

Repair implant abutment (TOOTH) (REPORT NEEDED)
Remove broken implant retaining screw (TOOTH) (REPORT NEEDED)
Surgical removal of implant body ( TOOTH) (REPORT NEEDED) (POST

(BR)
(BR)
(BR)

(REPORT NEEDED)(PA REQUIRED)OPERATIVE CARE: 10 DAYS)

For procedure codes D6101 – D6103 the following must be submitted:
 Pre-operative radiographic image of defect Detailed narrative Intra-oral photograph of defect area
D6101 Debridement of a peri-implant defect or defects surrounding asingle implant, and surface cleaning of the exposed implantsurfaces, including flap entry and closure (TOOTH) (PA REQUIRED)
D6102

D6103
D6104

(POST OPERATIVE CARE: 30 DAYS)$800.00$250.00

Debridement and osseous contouring of a peri-implant defect ordefects surrounding a single implant and includes surface cleaningof the exposed implant surfaces, including flap entry and closure$400.00

Bone graft for repair of peri-implant defect – does not include flap
entry and closure (TOOTH) (PA REQUIRED) (POST OPERATIVE CARE: 30$200.00

Bone graft at time of implant placement (TOOTH) (PA REQUIRED) (POST$250.00(TOOTH) (PA REQUIRED) (POST OPERATIVE CARE: 30 DAYS)DAYS)OPERATIVE CARE: 90 DAYS)

For procedure codes D6110 – D6113 the following must be submitted:
 Periapical radiograph of integrated implant(s) with abutment
placed IO photo of healed abutment showing healthy gingiva
D6110
D6111
D6112
D6113
D6190
D6191

Implant/abutment supported removable denture for edentulous
arch – maxillary (PA REQUIRED)
Implant/abutment supported removable denture for edentulous
arch – mandibular (PA REQUIRED)
Implant/abutment supported removable denture for partiallyedentulous arch – maxillary (PA REQUIRED)
Implant/abutment supported removable denture for partiallyedentulous arch – mandibular (PA REQUIRED)Radiographic/surgical implant index, by report (ARCH) (REPORT$1000.00

Semi-precision abutment - placement (TOOTH) (PA REQUIRED) This
procedure is the initial placement, or replacement, or a semi-precisionabutment on the implant body.

$200.00

NEEDED)

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D6192
D6199

DESCRIPTION
Semi-precision attachment - placement (TOOTH) (PA REQUIRED)This procedure involves the luting of the initial, or replacement, semiprecision attachment to the removable prosthesis.
Unspecified implant procedure, by report (REPORT NEEDED)

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DESCRIPTION

The following procedure codes are a covered benefit only when associated with an
implant or an implant-related service: D4245, D4266, D4267, D4273, D4275, D4277,
D4278, D4283, D4285.
D4245

Apically positioned flap (TOOTH) (PA REQUIRED) (POSTOPERATIVE CARE: 14 DAYS)$125.00

Procedure is used to preserve keratinized gingiva in conjunction with osseous
resection and second stage implant procedure. Procedure may also be used
to preserve keratinized/attached gingiva during surgical exposure of labially
impacted teeth and may be used during treatment of peri-implantitis.
D4266 Guided tissue regeneration – resorbable barrier, per$125.00
site (TOOTH) (PA REQUIRED) (POST OPERATIVE CARE: 14
DAYS)

This procedure does not include flap entry and closure, or, when indicated,wound debridement, osseous contouring, bone replacement grafts, andplacement of biologic materials to aid in osseous regeneration. This procedurecan be used for periodontal and peri-implant defects.
D4267 Guided tissue regeneration – non-resorbable barrier, per site$150.00(includes membrane removal) (TOOTH) (PA REQUIRED)(POST OPERATIVE CARE: 14 DAYS)This procedure does not include flap entry and closure, or, when indicated,wound debridement, osseous contouring, bone replacement grafts, andplacement of biologic materials to aid in osseous regeneration. This procedurecan be used for periodontal and peri-implant defects.
D4273 Autogenous connective tissue graft procedure$300.00(including donor and recipient surgical sites) first
tooth, implant or edentulous tooth position in graft(TOOTH) (PA REQUIRED) (POST OPERATIVE CARE: 14 DAYS)

There are two surgical sites. The recipient site utilizes a split thickness incision,
retaining the overlapping flap of gingiva and/or mucosa. The connective tissue
is dissected from a separate donor site leaving anepithelialized flap for closure.
D4275 Non-autogenous connective tissue graft (including$400.00
recipient site and donor material) – first tooth, implant, oredentulous tooth position in graft (TOOTH) (PA REQUIRED)(POST OPERATIVE CARE: 14 DAYS)

D4277 Free soft tissue graft procedure (including recipient anddonor surgical sites) first tooth, implant, or edentulous
tooth position in graft (TOOTH) (PA REQUIRED) (POST$400.00

OPERATIVE CARE: 14 DAYS)

There is only a recipient surgical site utilizing split thickness incision,
retaining the overlaying flap of gingiva and/or mucosa. A donor surgicalsite is not present.
D4278

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edentulous tooth position in same graft site (TOOTH) (PAREQUIRED) (POST OPERATIVE CARE: 14 DAYS)

Used in conjunction with D4277.
D4283 Autogenous connective tissue graft procedure (including
donor and recipient surgical sites) – each additional
contiguous tooth, implant or edentulous tooth position insame graft site (TOOTH) (PA REQUIRED) (POST OPERATIVE CARE: 14$200.00

DAYS)

Used in conjunction with D4273.
D4285 Non-autogenous connective tissue graft procedure (including
recipient surgical site and donor material) – each additional
contiguous tooth, implant or edentulous tooth position insame graft site. (TOOTH) (PA REQUIRED) (POST OPERATIVE CARE: 14$300.00

DAYS)

Used in conjunction with D4275.
The following procedure codes are a covered benefit only when associated with an implant or
an implant-related service: D7951, D7952, D7953.
D7951

Sinus augmentation with bone or bone substitutes via a lateral $800.00
open approach (QUAD) (PA REQUIRED) (POST OPERATIVE CARE: 14
DAYS)

The augmentation of the sinus cavity to increase alveolar height forreconstruction of edentulous portions of the maxilla. This procedure is
performed via a lateral open approach. This includes obtaining thebone or bone substitutes. Placement of a barrier membrane if usedshould be reported separately.
D7952 Sinus augmentation with bone or bone substitutes via a
vertical approach (QUAD) (PA REQUIRED) (POST OPERATIVE CARE: 14$800.00DAYS)

The augmentation of the sinus to increase alveolar height by verticalaccess through the ridge crest by raising the floor of the sinus andgrafting as necessary. This includes obtaining the bone or bone
substitutes.
$250.00
D7953 Bone replacement graft for ridge preservation – per site
(TOOTH) (PA REQUIRED) (POST OPERATIVE CARE: 10 DAYS)

Graft is placed in an extraction or implant removal site at the time ofthe extraction or removal to preserve ridge integrity (e.g., clinicallyindicated in preparation for implant reconstruction or where alveolar
contour is critical to planned prosthetic reconstruction). Does notinclude obtaining graft material. Membrane, if used should be reported
separately.

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IX. PROSTHODONTICS, FIXED D6200 - D6999
Fixed bridgework that is supported by natural teeth or dental implants isgenerally considered beyond the scope of the NYS Medicaid program. The
placement of a fixed prosthetic appliance will only be considered for theanterior segment of the mouth in those exceptional cases where there is adocumented physical or neurological disorder that would preclude placement ofa removable prosthesis, or in those cases requiring cleft palate stabilization.
In cases other than for cleft palate stabilization, treatment would generally belimited to replacement of a single maxillary anterior tooth or replacement of two
adjacent mandibular teeth. The fabrication of a fixed bridge is generally
considered for members with no recent caries activity (no initial restorations
placed during the past year), no unrestored carious lesions, no significant
periodontal bone loss in the same arch and no posterior tooth loss withreplaceable space in the same arch.
The replacement of a missing tooth or teeth with a fixed partial denture will
not be approved under the Medicaid program when either no replacement or
replacement with a removable partial denture could be consideredappropriate based on Medicaid prosthetic guidelines.
For a member under the age of 21 or one whose pulpal anatomy precludes
crown preparation of abutments without pulp exposure, acid etched castbonded bridges (“Maryland Bridges”) may be approved only for the
replacement of a single missing maxillary anterior tooth, two adjacent missing
maxillary anterior teeth, or two adjacent missing mandibular incisors. The sameguidelines as previously listed apply. Abutments for resin bonded fixed partial
dentures (i.e. “Maryland Bridges”) should be billed using code D6545 andpontics using code D6251.
The materials used in the fabrication of a crown (e.g. all-metal, porcelain,ceramic, resin) is at the discretion of the provider. The crown fabricated mustcorrectly match the procedure code approved on the Prior Approval.
FIXED PARTIAL DENTURE PONTICS
D6210
D6211
D6212
D6214
D6240

Pontic - cast high noble metal (TOOTH) (PA REQUIRED)
Pontic - cast predominately base metal (TOOTH) (PA REQUIRED)
Pontic - cast noble metal (TOOTH) (PA REQUIRED)
Pontic - titanium and titanium alloys (TOOTH) (PA REQUIRED)
Pontic - porcelain fused to high noble metal (TOOTH) (PA$400.00$400.00$400.00$400.00$400.00

D6241

Pontic - porcelain fused to predominately base metal (TOOTH)$400.00

Pontic - porcelain fused to noble metal (TOOTH) (PA REQUIRED)
Pontic - porcelain fused to titanium and titanium alloys$400.00$400.00

Pontic - porcelain/ceramic (TOOTH) (PA REQUIRED)$400.00

D6242
D6243
D6245

REQUIRED)(PA REQUIRED)(TOOTH) (PA REQUIRED)

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D6250
D6251

Pontic - resin with high noble metal (TOOTH) (PA REQUIRED)
Pontic - resin with predominately base metal (TOOTH) (PA$400.00$400.00

REQUIRED)

Limited to the pontics for resin bonded fixed partial dentures(i.e. “Maryland Bridges”).
D6252 Pontic - resin with noble metal (TOOTH) (PA REQUIRED)$400.00

FIXED PARTIAL DENTURE RETAINERS-INLAYS/ONLAYS
D6545

Retainer - cast metal for resin bonded fixed prosthesis$145.00(TOOTH)(PA REQUIRED)

Limited to abutment for resin bonded fixed partial dentures(i.e. “Maryland Bridges”).
FIXED PARTIAL DENTURE RETAINERS - CROWNS
D6720

Retainer crown - resin with high noble metal (TOOTH) (PA$500.00

D6721

Retainer crown - resin with predominately base metal (TOOTH)$500.00

Retainer crown - resin with noble metal (TOOTH) (PA REQUIRED)
Retainer crown - porcelain/ceramic (TOOTH) (PA REQUIRED)
Retainer crown - porcelain fused to high noble metal (TOOTH)$500.00$500.00$500.00

Retainer crown - porcelain fused to predominantly base metal$500.00

Retainer crown - porcelain fused to noble metal (TOOTH)$500.00$500.00

D6780

Retainer crown – porcelain fused to titanium and titanium
alloys (TOOTH) (PA REQUIRED)
Retainer crown - ¾ cast high noble metal (TOOTH) (PAD6781

Retainer crown - ¾ cast predominately base metal (TOOTH)$400.00

Retainer crown - ¾ cast noble metal (TOOTH) (PA REQUIRED)
Retainer crown - ¾ porcelain/ceramic (TOOTH) (PA REQUIRED)
Retainer crown - ¾ titanium and titanium alloys (TOOTH) (PA$400.00$400.00$400.00

Retainer crown – full cast high noble metal (TOOTH) (PA$500.00

Retainer crown - full cast predominantly base metal (TOOTH)$500.00

Retainer crown – full cast noble metal (TOOTH) (PA REQUIRED)
Retainer crown – titanium and titanium alloys (TOOTH) (PA$500.00$500.00

D6722
D6740
D6750
D6751
D6752
D6753

D6782
D6783
D6784
D6790
D6791
D6792
D6794

REQUIRED)(PA REQUIRED)(PA REQUIRED)(TOOTH) (PA REQUIRED)(PA REQUIRED)$400.00

REQUIRED)(PA REQUIRED)REQUIRED)REQUIRED)(PA REQUIRED)REQUIRED)OTHER FIXED PARTIAL DENTURE SERVICES

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DESCRIPTION

Re-cement or re-bond fixed partial denture (QUAD)
Fixed partial denture repair necessitated by restorative
material failure (QUAD) (REPORT NEEDED)For sectioning of a fixed partial denture, use procedure code D9120.
D6999 Unspecified, fixed prosthodontic procedure, by report
D6930
D6980

(REPORT NEEDED)

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X. ORAL AND MAXILLOFACIAL SURGERY
D7000 - D7999
For details regarding the “ORAL AND MAXILLOFACIAL SURGERY” codesthat are associated with the implant and implant-related services benefit
ONLY (D7951, D7953), see section VIII. IMPLANTS.
All surgical procedures include the surgery and the follow-up care forthe period indicated after the procedure description (e.g. (POSTOPERATIVE CARE: 7 DAYS)). Necessary follow-up care beyond the listed
period should be billed using codes D7999, D9110 or D9430.
When multiple surgical procedures are performed on the same quadrant orarch, the claim may be pended for professional review. When extensive
multiple surgical procedures are performed at the same operative session,
the total reimbursement requested will be evaluated on a case by case basis,
with possible reduction or denial of one or more of the billed procedures.
Removal of bilateral tori or bilateral impactions and multiple extractions
performed at the same operative session are examples of exceptions due tothe independence of the individual procedures.
When a provider performs surgical excision and removal of tumors, cysts
and neoplasms, the extent of the procedure claimed must be supported byinformation in the member's record. This includes radiographic images,
clinical findings, and operative and histopathologic reports. To expedite
review and reimbursement, this material (except radiographs) should besubmitted on paper claims for procedures that have no established fee and are
priced "By Report."
If a change is needed or there exists a disagreement with a prior approval
review and you would like to challenge a determination rendered by the DOH on
an existing finalized prior approval, a request may be submitted withsupporting documentation and a detailed report using a “Prior Approval
Change Request Form”. This form may be submitted pre-operatively or postoperatively. If the requested change is submitted post-operatively a copy of
the treatment notes should be included with the request.
The Prior Approval Change Request Form can be obtained by clicking
on the link below or by calling eMedNY at 1-800-343-9000.
eMedNY: Information: Paper Forms

EXTRACTIONS (INCLUDES LOCAL ANESTHESIA, SUTURING, IF
NEEDED, AND ROUTINE POSTOPERATIVE CARE)
D7111
D7140

Extraction, coronal remnants – primary tooth
Extraction, erupted tooth or exposed root (elevation and/or
forceps removal) (TOOTH) (POST OPERATIVE CARE: 3 DAYS)

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D7210

DESCRIPTION
Extraction, erupted tooth requiring removal of bone and/or
sectioning of tooth, and including elevation of
mucoperiosteal flap if indicated (TOOTH) (POST OPERATIVE CARE:$85.0010 DAYS)

Includes related cutting of gingiva and bone, removal of tooth
structure, minor smoothing of socket bone and closure. Prior approvalis required if performed more than four (4) times within twelve (12)months from the date of the first surgical extraction(D7210).
D7220 Removal of impacted tooth - soft tissue (TOOTH) (PA REQUIRED)$100.00
D7230
D7240
D7241
D7250

(POST OPERATIVE CARE: 10 DAYS)

Removal of impacted tooth - partially bony (TOOTH) (PA$180.00

Removal of impacted tooth - completely bony (TOOTH)$300.00

Removal of impacted tooth - completely bony, with unusual
surgical complications (TOOTH) (REPORT NEEDED)(BR)

Removal of residual tooth roots (cutting procedure) (TOOTH)$58.00REQUIRED) (POST OPERATIVE CARE: 10 DAYS)(PA REQUIRED) (POST OPERATIVE CARE: 10 DAYS)(POST OPERATIVE CARE: 30 DAYS)(POST OPERATIVE CARE: 10 DAYS)

Includes cutting of soft tissue and bone, removal of tooth structure, and closure
OTHER SURGICAL PROCEDURES
D7260

Oroantral fistula closure (QUAD 10 or 20)$200.00

D7261

Primary closure of sinus perforation (QUAD 10 or 20)$200.00

Tooth re-implantation and/or stabilization of accidentally
evulsed or displaced tooth (TOOTH) (POST OPERATIVE CARE: 30$114.00

D7270(POST OPERATIVE CARE: 14 DAYS)(POST OPERATIVE CARE: 14 DAYS)

DAYS)

D7272
D7280

Includes splitting and/or stabilization.
Tooth transplantation (includes re-implantation from one site
to another and splinting and/or stabilization) (TOOTH)(POST OPERATIVE CARE: 30 DAYS)

Exposure of an unerupted tooth (TOOTH)$290.00(POST OPERATIVE CARE: 14 DAYS)

An incision is made and the tissue is reflected and bone removed asnecessary to expose the crown of an impacted tooth not intended to
be extracted.
D7283 Placement of device to facilitate eruption of impacted tooth(TOOTH) (POST OPERATIVE CARE: 14 DAYS)

D7285

Report the surgical exposure separately using D7280.
Incisional Biopsy of oral tissue - hard (bone, tooth) (REPORTNEEDED) This procedure does not entail an excision.
(POST OPERATIVE CARE: 30 DAYS)

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DESCRIPTION
Claims must be submitted on paper with a copy of the operative
report, including the description and location of the lesion andpathology report.

D7286

Incisional Biopsy of oral tissue – soft (REPORT NEEDED)$84.00(POST OPERATIVE CARE: 30 DAYS) This procedure does not entail anexcision.

Claims must be submitted on paper with a copy of the operative
report, including the description and location of the lesion andpathology report.
D7290

Surgical repositioning of teeth (TOOTH) (PA REQUIRED)$145.00(POST OPERATIVE CARE: 60 DAYS)ALVEOPLASTY - PREPARATION OF RIDGE
D7310

Alveoloplasty in conjunction with extractions – four or moreteeth or tooth spaces, per quadrant (QUAD)$70.00(POST OPERATIVE CARE: 14 DAYS)This procedure will be reimbursed when additional surgicalprocedures above and beyond the removal of the teeth are required
to prepare the ridge for dentures. Not reimbursable in addition tosurgical extractions in the same quadrant. Claims should besubmitted on the same invoice as extractions to expedite review.
D7311 Alveoloplasty in conjunction with extractions – one to three$50.00teeth or tooth spaces, per quadrant (QUAD)(POST OPERATIVE CARE: 14 DAYS)This procedure will be reimbursed when additional surgicalprocedures above and beyond the removal of the teeth are required
to prepare the ridge for dentures. Not reimbursable in addition tosurgical extractions in the same quadrant. Claims should besubmitted on the same invoice as extractions to expedite review.
D7320 Alveoloplasty not in conjunction with extractions – four or$115.00
more teeth or tooth spaces, per quadrant (QUAD)(POST OPERATIVE CARE: 14 DAYS)

The fee for each quadrant includes the recontouring of both osseousand soft tissues in that quadrant. Will not be reimbursed inconjunction with procedure code D7310 in the same quadrant.
D7321 Alveoloplasty not in conjunction with extractions – one to$75.00three or tooth spaces, per quadrant (QUAD) (POST OPERATIVE
CARE: 14 DAYS)

The fee for each quadrant includes the recontouring of both osseousand soft tissues in that quadrant. Will not be reimbursed inconjunction with procedure code D7311 in the same quadrant.
VESTIBULOPLASTY

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CODE

DESCRIPTION

Vestibuloplasty may be approved when a denture could not otherwise be
worn.
D7340
D7350

Vestibuloplasty - ridge extension (secondary
epithelialization) (ARCH) (PA REQUIRED) (POST OPERATIVE CARE:$300.00

Vestibuloplasty - ridge extension (including soft tissue
grafts, muscle reattachment, revision of soft tissue
attachment and management of hypertrophied andhyperplastic tissue) (ARCH)$400.00

60 DAYS)(PA REQUIRED) (POST OPERATIVE CARE: 60 DAYS)EXCISION OF SOFT TISSUE LESIONS (INCLUDES NONODONTOGENIC CYSTS)All claims for D7410, D7411, and D7412, should be submitted with a copyof the operative report and all claims for D7413, D7414, and D7415 should
be submitted with a copy of the pathology and operative report(s). All
operative reports must include a description of the lesion and its location.
D7410

Excision of benign lesion up to 1.25 cm (REPORT NEEDED)$101.00

D7411

Excision of benign lesion greater than 1.25cm (REPORT

(BR)

D7412
D7413
D7414
D7415

(POST OPERATIVE CARE: 30 DAYS)

NEEDED) (POST OPERATIVE CARE: 60 DAYS)
Excision of benign lesion complicated (REPORT NEEDED)(POST OPERATIVE CARE: 60 DAYS)
Excision of malignant lesion up to 1.25cm (REPORT NEEDED)(POST OPERATIVE CARE: 30 DAYS)
Excision of malignant lesion greater than 1.25cm (REPORTNEEDED) (POST OPERATIVE CARE: 60 DAYS)

(BR)
(BR)
(BR)

Excision of malignant lesion complicated (REPORT NEEDED)(BR)(POST OPERATIVE CARE: 60 DAYS)EXCISION OF INTRA-OSSEOUS LESIONS
Claims must be submitted with a copy of the pathology and operative
report(s) and must include a description of the lesion and its location.
Reimbursement for routine or surgical extractions includes removal of tooth, soft
tissue associated with the root and curettage of the socket. Periapicalgranulomas at the apex of decayed teeth will not be separately reimbursedin addition to the tooth extraction.
D7440

Excision of malignant tumor - lesion diameter up to 1.25 cm

(BR)

D7441

Excision of malignant tumor -lesion greater than 1.25 cm(BR)

Removal of benign odontogenic cyst or tumor-lesion
diameter up to 1.25 cm (QUAD) (REPORT NEEDED) (POST$84.72

D7450(QUAD) (REPORT NEEDED) (POST OPERATIVE CARE: 30 DAYS)(QUAD) (REPORT NEEDED) (POST OPERATIVE CARE: 60 DAYS)OPERATIVE CARE: 30 DAYS)

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D7451
D7460
D7461
D7465

DESCRIPTION
Removal of benign odontogenic cyst or tumor-lesion greaterthan 1.25 cm (QUAD) (REPORT NEEDED) (POST OPERATIVE CARE: 60(BR)

Removal of benign nonodontogenic cyst or tumor - lesion
diameter up to 1.25 cm (QUAD) (REPORT NEEDED)$101.00

Removal of benign nonodontogenic cyst or tumor - greaterthan 1.25 cm (QUAD) (REPORT NEEDED) (POST OPERATIVE CARE: 30(BR)

Destruction of lesion(s) by physical or chemical methods, byreport (REPORT NEEDED) (POST OPERATIVE CARE: 60 DAYS)

(BR)

DAYS)

(POST OPERATIVE CARE: 30 DAYS)DAYS)EXCISION OF BONE TISSUE
D7471 Removal of lateral exostosis (maxilla or mandible) (QUAD)

(BR)

D7472

(BR)

D7473
D7485
D7490

(REPORT NEEDED) (POST OPERATIVE CARE: 21 DAYS)
Removal of torus palatinus (REPORT NEEDED) (POST OPERATIVE
CARE: 21 DAYS)
Removal of torus mandibularis (QUAD 30 or 40) (REPORT NEEDED)(POST OPERATIVE CARE: 21 DAYS)
Reduction of osseous tuberosity (QUAD 10 or 20)(REPORT NEEDED) (POST OPERATIVE CARE: 21 DAYS)
Radical resection of maxilla or mandible (ARCH) (REPORTNEEDED) (POST OPERATIVE CARE: 180 DAYS)SURGICAL INCISION
Reimbursement for incision and drainage procedures includes both theinsertion and the removal of all drains.
D7510 Incision and drainage of abscess – intraoral soft tissue
D7511
D7520
D7521
D7530
D7540

(QUAD) (POST OPERATIVE CARE: 10 DAYS) (REPORT NEEDED)

(BR)
(BR)
(BR)

$70.00

Incision and drainage of abscess – intraoral soft tissue –complicated (includes drainage of multiple fascial spaces)(BR)

Incision and drainage of abscess – extraoral soft tissue$140.00

Incision and drainage of abscess – extraoral soft tissue –complicated (includes drainage of multiple fascial spaces)(BR)

Removal of foreign body from mucosa, skin, or
subcutaneous alveolar tissue (QUAD) (REPORT NEEDED)(BR)

Removal of reaction-producing foreign bodies –musculoskeletal system (QUAD) (REPORT NEEDED) (POST(BR)(QUAD) (REPORT NEEDED)(QUAD) (POST OPERATIVE CARE: 21 DAYS)(QUAD) (REPORT NEEDED)(POST OPERATIVE CARE: 21 DAYS)OPERATIVE CARE: 90 DAYS)

The report must include a description of the foreign body and its
location.
D7550 Partial ostectomy / sequestrectomy for removal of non-vitalbone (QUAD) (REPORT NEEDED) (POST OPERATIVE CARE: 90 DAYS)
The report must include a description of the surgical site.

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DESCRIPTION

D7560

Maxillary sinusotomy for removal of tooth fragment or
foreign body (QUAD) (REPORT NEEDED) (POST OPERATIVE CARE:$435.00

60 DAYS)

Includes closure of oroantral communication when performed concurrently.

TREATMENT OF CLOSED FRACTURES
D7610

Maxilla - open reduction (teeth immobilized if present)$1,160.00

D7620

Maxilla - closed reduction (teeth immobilized if present)$435.00

Mandible - open reduction (teeth immobilized if present)$1,305.00

Mandible - closed reduction (teeth immobilized if present)$435.00

D7630
D7640
D7650
D7660
D7670
D7671
D7680

(REPORT NEEDED) (POST OPERATIVE CARE: 90 DAYS)(REPORT NEEDED) (POST OPERATIVE CARE: 90 DAYS)(REPORT NEEDED) (POST OPERATIVE CARE: 90 DAYS)(REPORT NEEDED) (POST OPERATIVE CARE: 90 DAYS)
Malar and/or zygomatic arch - open reduction (REPORTNEEDED) (POST OPERATIVE CARE: 90 DAYS)
Malar and/or zygomatic arch - closed reduction (REPORTNEEDED) (POST OPERATIVE CARE: 90 DAYS)$725.00(BR)

Alveolus - closed reduction, may include stabilization ofteeth (REPORT NEEDED) (POST OPERATIVE CARE: 60 DAYS)
Alveolus - open reduction, may include stabilization of teeth$203.00

Facial bones – complicated reduction with fixation andmultiple surgical approaches (REPORT NEEDED)(BR)(REPORT NEEDED) (POST OPERATIVE CARE: 90 DAYS)(BR)(POST OPERATIVE CARE: 90 DAYS)TREATMENT OF OPEN FRACTURES
Reimbursement for codes D7710-D7740 includes splint fabrication whennecessary.
D7710
D7720
D7730
D7740
D7750
D7760
D7770
D7771

Maxilla – open reduction (REPORT NEEDED)(POST OPERATIVE CARE: 90 DAYS)
Maxilla - closed reduction (REPORT NEEDED)(POST OPERATIVE CARE: 90 DAYS)
Mandible - open reduction (REPORT NEEDED)(POST OPERATIVE CARE: 90 DAYS)
Mandible - closed reduction (REPORT NEEDED)(POST OPERATIVE CARE: 90 DAYS)(BR)$580.00(BR)$580.00

Malar and/or zygomatic arch - open reduction (REPORT(BR)

Malar and/or zygomatic arch - closed reduction (REPORT(BR)

Alveolus – open reduction stabilization of teeth (REPORT(BR)

Alveolus - closed reduction stabilization of teeth (REPORT(BR)

NEEDED) (POST OPERATIVE CARE: 90 DAYS)
NEEDED) (POST OPERATIVE CARE: 90 DAYS)

NEEDED) (POST OPERATIVE CARE: 90 DAYS)

NEEDED) (POST OPERATIVE CARE: 90 DAYS)

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CODE

DESCRIPTION

D7780

Facial bones – complicated reduction with fixation andmultiple approaches (REPORT NEEDED) (POST OPERATIVE CARE:(BR)

90 DAYS)REDUCTION OF DISLOCATION AND MANAGEMENT OF OTHERTEMPOROMANDIBULAR JOINT DYSFUNCTIONS
Routine services for treatment of temporomandibular joint, myofacial pain
and related disorders are generally considered beyond the scope of the
program. Reimbursement for temporomandibular joint dysfunctions will bepermitted only in the specific conditions wherein a definitive diagnosis
corroborates necessary treatment. Appropriate documentation (e.g.,
operative report, procedure description) should accompany all claims as
attachments.
D7810

Open reduction of dislocation (REPORT NEEDED)$1450.00

D7820

Closed reduction of dislocation (REPORT NEEDED)$140.00

Manipulation under anesthesia (REPORT NEEDED)$174.00

D7830
D7840
D7850
D7852
D7854
D7856
D7858
D7860
D7865
D7870
D7872
D7873
D7874
D7875
D7876

(POST OPERATIVE CARE: 90 DAYS)(POST OPERATIVE CARE: 7 DAYS)(POST OPERATIVE CARE: 7 DAYS)
Condylectomy (REPORT NEEDED) (POST OPERATIVE CARE: 90
DAYS)

Surgical discectomy; with/without implant$1740.00(POST OPERATIVE CARE: 90 DAYS)
Disc repair (REPORT NEEDED) (POST OPERATIVE CARE: 90 DAYS)
Synovectomy (REPORT NEEDED) (POST OPERATIVE CARE: 90
DAYS)
Myotomy (REPORT NEEDED) (POST OPERATIVE CARE: 90 DAYS)
Joint reconstruction (REPORT NEEDED)(POST OPERATIVE CARE: 120 DAYS)
Arthrotomy (REPORT NEEDED) (POST OPERATIVE CARE: 90 DAYS)
Arthroplasty (REPORT NEEDED) (POST OPERATIVE CARE: 90 DAYS)
Arthrocentesis (REPORT NEEDED) (POST OPERATIVE CARE: 7
DAYS)
Arthroscopy - diagnosis, with/without biopsy (REPORTNEEDED) (POST OPERATIVE CARE: 14 DAYS)$870.00$1,044.00$812.00(BR)$2,900.00$870.00$2,030.00$116.00$725.00

Arthroscopy: lavage and lysis of adhesions$725.00

Arthroscopy: disc repositioning and stabilization (REPORT$1,044.00(REPORT NEEDED) (POST OPERATIVE CARE: 30 DAYS)
NEEDED) (POST OPERATIVE CARE: 60 DAYS)
Arthroscopy: synovectomy (REPORT NEEDED)(POST OPERATIVE CARE: 60 DAYS)
Arthroscopy: discectomy (REPORT NEEDED)(POST OPERATIVE CARE: 60 DAYS)

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DESCRIPTION

D7877 Arthroscopy: debridement (REPORT NEEDED)$1,044.00

D7880 Occlusal orthotic appliance, by report (REPORT NEEDED)(BR)

Reimbursable only when performed in conjunction with a covered
surgical procedure. Not used for “night guards”, “occlusal guards”,
bruxism appliances, or other TMJ appliances.
D7899 Unspecified TMD therapy, by report (REPORT NEEDED)(BR)(POST OPERATIVE CARE: 60 DAYS)(POST OPERATIVE CARE: 10 DAYS)REPAIR OF TRAUMATIC WOUNDS
Excludes closure of surgical incisions.
D7910 Suture of recent small wounds up to 5 cm (REPORT NEEDED)$100.00(POST OPERATIVE CARE: 14 DAYS)COMPLICATED SUTURING (RECONSTRUCTION REQUIRING
DELICATE HANDLING OF TISSUES AND WIDE UNDERMINING FOR
METICULOUS CLOSURE)
Excludes closure of surgical incisions.
Utilized in situations requiring unusual and time-consuming techniques ofrepair to obtain the maximum functional and cosmetic result. The extent of
the procedure claimed must be supported by information in the operative
report.
D7911 Complicated suture - up to 5 cm (REPORT NEEDED)$125.00

D7912 Complicated suture - greater than 5 cm, (REPORT NEEDED)(BR)(POST OPERATIVE CARE: 30 DAYS)(POST OPERATIVE CARE: 60 DAYS)OTHER REPAIR PROCEDURES
D7920 Skin graft (identify defect covered, location and type of graft)(REPORT NEEDED) (POST OPERATIVE CARE: 90 DAYS)
D7940 Osteoplasty - for orthognathic deformities (REPORT NEEDED)(POST OPERATIVE CARE: 90 DAYS)

Use to report genioplasty.
D7941 Osteotomy - mandibular rami (REPORT NEEDED)(POST OPERATIVE CARE: 90 DAYS)

(BR)
(BR)
$1,450.00

D7943 Osteotomy - mandibular rami with bone graft; includes
obtaining the graft (REPORT NEEDED) (POST OPERATIVE CARE: 90$2,175.00

D7944 Osteotomy - segmented or subapical (REPORT NEEDED)$1160.00

D7945$1102.00

DAYS)

D7946

(POST OPERATIVE CARE: 90 DAYS)
Osteotomy - body of mandible (REPORT NEEDED)(POST OPERATIVE CARE: 90 DAYS)
LeFort I (maxilla-total) (REPORT NEEDED)(POST OPERATIVE CARE: 90 DAYS)

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DESCRIPTION

D7947 LeFort I (maxilla-segmented) (REPORT NEEDED)$2,900.00(POST OPERATIVE CARE: 90 DAYS)

When reporting a surgically assisted palatal expansion without
downfracture, this code would entail a reduced service and should be“by report” using procedure code D7999.
D7948 LeFort II or LeFort III (osteoplasty of facial bones for midface $2,900.00
hyperplasia or retrusion) - without bone graft (REPORT
D7949
D7950
D7961

NEEDED) (POST OPERATIVE CARE: 90 DAYS)
LeFort II or LeFort III with bone graft (REPORT NEEDED)(POST OPERATIVE CARE: 90 DAYS)$3,480.00(REPORT NEEDED) (POST OPERATIVE CARE: 90 DAYS)
Buccal / labial frenectomy (frenulectomy) (ARCH) (REPORTNEEDED) (POST OPERATIVE CARE: 14 DAYS)$190.00(BR)

Osseous, osteoperiosteal, or cartilage graft of the mandibleor maxilla - autogenous or nonautogenous, by report

Removal or release of mucosal and muscle elements of abuccal/labial frenum that is associated with a pathological condition
or interferes with proper oral development or treatment.
D7962 Lingual frenectomy (frenulectomy) (ARCH) (REPORT NEEDED)$190.00(POST OPERATIVE CARE: 14 DAYS)

Removal or release of mucosal and muscle elements of a lingual
frenum that is associated with a pathological condition or interfereswith proper oral development or treatment.
D7970 Excision of hyperplastic tissue- per arch (ARCH) (REPORT$150.00
D7971
D7972
D7980
D7981
D7982
D7983
D7990
D7991
D7997

NEEDED) (POST OPERATIVE CARE: 14 DAYS)
Excision of pericoronal gingiva (TOOTH) (REPORT NEEDED)(POST OPERATIVE CARE: 10 DAYS)$60.00All claims will be pended for professional review.
Surgical reduction of fibrous tuberosity (QUAD) (REPORT(BR)

NEEDED) (POST OPERATIVE CARE: 14 DAYS)
Surgical sialolithotomy (POST OPERATIVE CARE: 14 DAYS)
Excision of salivary gland, by report (REPORT NEEDED)(POST OPERATIVE CARE: 30 DAYS)
Sialodochoplasty (REPORT NEEDED) (POST OPERATIVE CARE: 30
DAYS)
Closure of salivary fistula (REPORT NEEDED)(POST OPERATIVE CARE: 30 DAYS)$290.00(BR)$826.00(BR)

Emergency tracheotomyCoronoidectomy (REPORT NEEDED) (POST OPERATIVE CARE: 60$725.00$551.00

Appliance removal (not by dentist who placed appliance),
includes removal of archbar (REPORT NEEDED)

(BR)

DAYS)

(POST OPERATIVE CARE: 14 DAYS)

Not for removal of orthodontic appliances. Includes both arches, if
necessary.
D7998 Intraoral placement of a fixation device not in conjunction
with a fracture (REPORT NEEDED)
Includes both arches, if necessary.
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CODE
D7999

DESCRIPTION
Unspecified oral surgical procedure, by report (REPORTNEEDED)

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CODE

DESCRIPTIONXI. ORTHODONTICS D8000 - D8999
ELIGIBILITY
Eligibility is limited to members who:
1. are under 21 years of age;
2. meet financial standards for Medicaid eligibility; and,3. exhibit a SEVERE PHYSICALLY HANDICAPPING MALOCCLUSION.
Orthodontic care for severe physically handicapping malocclusions is a once in a
lifetime benefit that will be reimbursed for an eligible member for a maximum of three
years of active orthodontic care, plus one year of retention care. Retreatment for
relapsed cases is not a covered service. Treatment must be approved and active
therapy begun (appliances placed and activated) prior to the member’s 21st birthday.
Treatment of cleft palate or approved orthognathic surgical cases may be approved
after the age of 21 or for additional treatment time.
With the exception of D8210, D8220 and D8999, orthodontic care is reimbursable only
when provided by an orthodontist or an Article 28 facility which have met thequalifications of the DOH and are enrolled with the appropriate specialty
code.

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CODE

DESCRIPTIONPRIOR APPROVAL
The following orthodontic procedures codes require prior approval:
D8010,
D8020, D8030, D8040, D8070, D8080, D8090, D8670, and D8680
The following documentation must be submitted along with the prior approval request:
 Pages 1 and 2 of the completed and signed “Handicapping Labio-Lingual(HLD) Index Report”. The HLD Index Report is available on the internet at:https://www.emedny.org/ProviderManuals/Dental/PDFS/HLD_Index_NY.pdf
 A panoramic and/or mounted full mouth series of intra-oral radiographic
images; A cephalometric radiographic image with teeth in centric occlusion andcephalometric analysis / tracing; Photographs of frontal and profile views;
 Intra-oral photographs depicting right and left occlusal relationships as wellas an anterior view;
 Maxillary and mandibular occlusal photographs;
 Photos of articulated models can be submitted optionally (Do NOT send stone
casts).
Subjective statements submitted by the provider or others must be substantiated by
objective documentation such as photographs, radiographic images, credible medical
documentation, etc. verifying the nature and extent of the severe physical handicapping
malocclusion. Requests where there is significant disparity between thesubjective documentation (e.g. HLD index report and narrative) and objective
documentation (e.g. photographs and/or radiographic images) will be returnedfor clarification without review.
Requests for continuation of orthodontic treatment which was begun without priorapproval from the DOH or a NYS Medicaid Managed Care Plan will be evaluated using
the same criteria and guidelines to determine if a severe physically handicapping
malocclusion currently exists. A completed HLD index report based on the current
dentition, and all of the required documentation (listed above) must be submitted alongwith the prior approval request. If continuation of treatment is denied, debanding andretention might be approvable using procedure code D8695.
Orthognathic Surgical Cases with Comprehensive Orthodontic Treatment
 Members must be at least 15 years of age for case consideration; The surgical consult, complete treatment plan and approval for surgicaltreatment (if necessary) must be included with the request for orthodontic
treatment;
 Prior approval and documentation requirements are the same as those forcomprehensive treatment;

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CODE

DESCRIPTION A statement signed by the parent/guardian and member that they understandand accept the proposed treatment, both surgical and orthodontic, andunderstand that approval for orthodontic treatment is contingent uponcompletion of the surgical treatment.

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DESCRIPTIONLIMITED EXTENDED COVERAGE
Regardless of whether the dental benefit is administered through Managed Careor through fee-for-service, when eligibility is lost after active orthodontic treatment
has been initiated, fee-for-service Medicaid will provide for up to:• Two (2) quarterly payments; or,• One (1) quarterly payment and retention; or,• Retention alone.
The treating orthodontist may decide to complete active treatment (including retentioncare), initiate retention care to preserve current status, or remove the appliances incases of minimal progress during active therapy. At least thirty (30) days of treatment
must have been provided following the loss of eligibility. When billing for the limited
extended coverage, submit a paper claim to eMedNY using procedure code D8999,
the last date of eligibility as the date of service and identify the stage of treatment when
eligibility was lost (e.g. 2nd quarter of second year; 1st quarter of third year, etc.). The
maximum benefit for limited extended coverage is only payable one (1) time during thecourse of orthodontic treatment.
If approval for orthodontic treatment was issued through Medicaid Managed Care
(MMC) a copy of the authorization for treatment and remittance statement(s) must also
be included. Only those cases previously approved for comprehensive orthodontic
treatment (D8070, D8080, or D8090) in which appliances have been placed andactivated are eligible for the “Limited Extended Coverage” benefit. Claims for the“Limited Extended Coverage” benefit MUST be submitted within 9 months of the lossof eligibility. Claims submitted for payment beyond that time range will be subject todenial.
CONTINUATION OF ACTIVE ORTHODONTIC
MEMBER’S MEDICAID COVERAGE CHANGESTREATMENT

WHEN

THE

When a member undergoing active orthodontic treatment that was authorized by MMC Plan(or their vendor) has coverage changed to fee-for-service Medicaid, a prior approval forcontinued treatment is required from the fee-for-service program. In such cases,
providers must adhere to the original treatment time authorized by MMC Plans. A priorapproval request for continuation of orthodontic care (D8670) should be submitted toeMedNY with the following documentation:••••

A copy of the original Medicaid Managed Care Plan authorization or approval forcomprehensive orthodontic treatment;
A copy of the remittance statement from the Medicaid Managed Care Plan;
All pre-treatment records and recent progress photographs depicting the current
dentition; and,A brief narrative describing the services already rendered (e.g. Initial placementof orthodontic appliances and two quarters of D8670 have been paid byHealthplex).

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CODE

DESCRIPTION

Again, orthodontic coverage for procedure codes D8670 and D8680 is subject to themember’s eligibility. If a member’s coverage is changed back to managed care arequest for these orthodontic services will need to be submitted to the member’sManaged Care Plan.
The total fee-for-service reimbursement amount for active treatment will not exceed the
maximum fees listed in the Dental Fee Schedule.
MEDICAID MEMBERS CANNOT BE BILLED
 By enrolling in the Medicaid program, a provider agrees to accept payment under the
Medicaid program as payment in full for services rendered.
 There is no separate billing for the replacement of broken appliances such as
bands, brackets or arch wires.
 Medicaid payment for orthodontic services represents payment in full for theentire treatment protocol, regardless of the type of appliances used. Separately
billing the member for any portion of orthodontic treatment is prohibited.
 Orthodontists must offer Medicaid members the same treatment options offeredto the majority of patients in the provider’s practice with similar treatment needs(e.g., orthodontists may not restrict Medicaid members to metal brackets if nonMedicaid patients are routinely provided other types of devices (e.g. bonded“clear” brackets, “Damon®” brackets, clear appliance therapy, bite plates orremovable appliances) and may not charge Medicaid members for the use of
these other techniques and/or devices.
 Reimbursement for orthodontic services includes the placement and removal of all
appliances and brackets. Should it become necessary to remove the bands due
to non-compliance or elective discontinuation of treatment by the provider,parent, guardian or member the appliance(s) must be removed at no additionalcharge to either the member, family or Medicaid.
DISCONTINUATION OF TREATMENT
In cases where treatment is discontinued, a “Release from Treatment” form must be
provided by the dental office which documents the date and the reason for discontinuingcare. The release form must be reviewed and signed by the parent/guardian andmember. The “Release from Treatment” form must indicate that all those involved
understand future orthodontic treatment will not be covered by Medicaid. A copy must
be sent to NYSDOH OHIP Bureau of Dental Review.
New York State Department of Health
Office of Health Insurance Programs
Bureau of Dental Review
431B Broadway
Menands, NY 12204-2836

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DESCRIPTION

Behavior Not Conducive to Favorable Treatment Outcomes
It is the expectation that the case selection process for orthodontic treatment take into
consideration the member’s ability over the course of treatment to: Tolerate orthodontic treatment; Comply with necessary instructions for home care (e.g. wear elastics, headgear,
removable appliance, etc.)
 Keep multiple appointments over several years;
 Maintain an oral hygiene regimen; Be cooperative and complete all needed preventive and treatment visits.
If it is determined that the member is exhibiting non-compliant behavior (e.g. multiple
missed orthodontic and general dental appointments, continued poor oral hygiene,
and/or failure to maintain the appliances and/or untreated dental disease) a letter must be
sent to the parent/guardian that documents the factors of concern and the corrective actions
needed and that failure to comply can result in discontinuation of treatment. A copy
must be sent to the DOH.
If orthodontic treatment is discontinued for cause, the parent/guardian and/or patientmust sign a statement indicating they understand treatment is being discontinued prior
to completion; the reason(s) for discontinuation of treatment; and, that it will jeopardize
their ability to have further orthodontic treatment provided through the NYS Medicaid
Program. The treating orthodontist must make reasonable provisions to provide
necessary treatment during the transition of care to another provider or for debanding.
In a situation when all reasonable attempts to contact the patient and/or their parent are
unsuccessful, orthodontic treatment may be discontinued without a patient/parent’s
signature. Any attempts to reach the patient should be documented in the patient’s
record. Terminating a doctor patient relationship is a medico-legal issue; therefore, thetreating orthodontist should seek an appropriate legal counsel at their own discretion.
All approved courses of comprehensive orthodontic treatment must be concluded in amanner acceptable to the DOH and the DOH must be notified. Appropriate means ofconcluding treatment include: Successful completion of treatment and the issuance of a prior approval by the
DOH for debanding and/or retention;
 Notification that treatment is being discontinued for cause and that theparent/guardian and/or member have been appropriately notified, or; Loss of eligibility and utilization of the “Limited Extended Coverage” benefit toconclude treatment.
Treatment must continue to a point satisfactory to the DOH, regardless of the length oftime treatment is required and even if all Medicaid benefits have been exhausted,
without charge to the NYS Medicaid Program, the member or family. Failure toconclude treatment in an acceptable manner can result in the recovery of theentire cost of the complete course of treatment.

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CODE

DESCRIPTION“BY REPORT” CODES THAT ARE ALSO “PA OPTIONAL”
For those procedures listed in this manual and/ or on the Dental Fee Schedule withouta published fee (D8210 and D8220) and are listed as both “(REPORT NEEDED, PA
OPTIONAL)”:

Procedures can be reviewed for appropriateness and tentatively priced before
treatment is initiated by submitting a prior approval request.
- OR -

 Procedures can be priced after treatment without prior approval as a “By Report”
based on documentation submitted with the claim substantiating a qualifying
physically handicapping malocclusion.
ORTHODONTIC RECORDS TAKEN THAT ARE NOT REQUIRED BY DOH ARE NOTREIMBURSABLE
Any records taken at the discretion of the provider cannot be charged to the NYS
Medicaid Program, the member or family.
The NYS Medicaid Program will reimburse for those services that are medicallynecessary, are an integral part of the actual treatment, or that are required by the
Department. Orthodontic records taken solely for the provider’s records, such as
photographs (D0350), diagnostic casts/study models (D0470), and radiographic images(including a FMS (D0210), panoramic (D0330) and cephalometric (D0340)) and are notrequired by the Department will be considered part of the reimbursement for thecomprehensive orthodontic treatment and are not payable separately. The provider cantake these records as part of the treatment records, but they cannot charge the
NYS Medicaid Program, the member or family. Payment may be considered on an
exceptional basis if there is documentation of medical necessity.

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CODE

DESCRIPTIONLIMITED ORTHODONTIC TREATMENT
Orthodontic treatment utilizing any therapeutic modality with a limited objective or scaleof treatment. Treatment may occur in any stage of dental development or dentition.
The objective may be limited by: not involving the entire dentition.
 not attempting to address the full scope of the existing or developing orthodontic
problem.
 mitigating an aspect of a greater malocclusion (i.e., crossbite, overjet, overbite,arch length, anterior alignment, one phase of multi-phase treatment, treatment
prior to the permanent dentition, etc.).
 a decision to defer or forego comprehensive treatment.
The submitted records must demonstrate a physically handicapping malocclusionindicating the need for limited orthodontic treatment. Procedure codes for limited
orthodontic treatment cannot be substituted for procedure codes D8070, D8080, andD8090 if a member does not qualify for comprehensive orthodontic treatment as per
NYS Medicaid criteria. Prior Approval will be determined based on the supporting
documentation submitted. There is only one flat fee for limited orthodontic treatment,that is, all adjustment visits and transitional retainer are included in one fee—there isno additional compensation beyond that.” Reimbursement will be determined based on
supporting documentation submitted.
If comprehensive treatment is required following a course of limited treatment, a periodof 12 to 18 months should be allowed prior to requesting comprehensive treatment toprovide for stabilization of the result.
D8010

Limited orthodontic treatment of the primary dentition

D8020

Limited orthodontic treatment of the transitional dentition

D8030
D8040

(PA REQUIRED)(PA REQUIRED)

Limited orthodontic treatment of the adolescent dentition(PA REQUIRED)

Limited orthodontic treatment of the adult dentition(PA REQUIRED)

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DESCRIPTIONCOMPREHENSIVE ORTHODONTIC TREATEMENT With the exception of cleft palate and other surgical cases, only members withlate mixed dentition or permanent dentition will be considered for the initiation ofcomprehensive orthodontic treatment.
 Reimbursement for codes D8070, D8080 or D8090 is limited to once in a lifetime as
initial payment for an approved course of orthodontic treatment. The member’s
dentition will determine the single code to be used and can only be billed when
all appliances have been placed and active treatment has been initiated. The
placement of the component parts (e.g. brackets, bands) does not constitutecommencement of active treatment.
 For quarterly payment, see procedure code D8670. Reimbursement forcomprehensive orthodontic treatment is ALL INCLUSIVE and covers ALL
orthodontic services, both fixed and removable that needs to be provided tocorrect the orthodontic condition.
 A prior approval request for continuation of comprehensive orthodontic treatment (2 ndyear, 3rd year and retention) must be submitted annually to the DOH along witha progress report and photographs of the current conditions to assess the
progress of treatment and determine if additional treatment time (up to a
maximum of three (3) years) is warranted. For members age 21 and over, priorapproval requests for continuation of orthodontic care (2nd year, 3rd year andretention) will be evaluated if the comprehensive orthodontic treatment wasapproved by DOH / Medicaid Managed Care Plans and fixed orthodontic
appliances were placed and activated PRIOR to the member’s 21st birthday.
 Requests to RESTART comprehensive orthodontic treatment on a member forwhich Medicaid FFS paid the original comprehensive code (D8070, D8080, orD8090), but who now has Managed Care coverage, should be submitted to theManage Care plan or their vendor.
 As of 10/01/2012, orthodontic treatment is a covered benefit under Medicaid
Managed Care Plans. All prior approvals for orthodontic treatment that werereviewed and approved on 10/1/12 and after, are subject to member’s eligibility
under the FFS (fee-for-service) Medicaid program. Providers must check themember’s eligibility at every visit, as Medicaid eligibility status may change at
any time.
 As previously indicated on page 14 of this manual:“If a member is enrolled in a managed care plan which covers the specific careor services being provided, it is inappropriate to bill such services to the Medicaid
program on a fee-for-service basis whether or not prior approval has beenobtained."

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CODE
D8070
D8080
D8090

DESCRIPTION
Comprehensive orthodontic treatment of the transitional
dentition (PA REQUIRED)
Comprehensive orthodontic treatment of the adolescentdentition (PA REQUIRED)
Comprehensive orthodontic treatment of the adult dentition(PA REQUIRED)$986.00$986.00$986.00

MINOR TREATMENT TO CONTROL HARMFUL HABITS
The following procedures (D8210 and D8220) include appliances for habits such as
thumb sucking and tongue thrusting. They do not have a published fee and are listed
as both “(REPORT NEEDED, PA OPTIONAL)”. These procedure codes can be used by all
enrolled dentists regardless of specialty.
 Procedures can be reviewed for appropriateness and tentatively priced before
treatment is initiated by submitting a prior approval request.
- OR –

 Procedures can be priced after treatment without prior approval as a “By Report”
based on documentation submitted with the claim substantiating a qualifying
physically handicapping malocclusion.
D8210
D8220

Removable appliance therapy ( REPORT NEEDED, PA OPTIONAL)
Fixed appliance therapy ( REPORT NEEDED, PA OPTIONAL)

(BR)
(BR)

OTHER ORTHODONTIC SERVICES
Pre-orthodontic treatment examination to monitor growth and$29.00development
Periodic observation of patient dentition, at intervals established by the dentist,to determine when orthodontic treatment should begin. Diagnostic proceduresare documented separately.
 Orthodontist specialty designation required.
 May not be reimbursed in conjunction with other examination codes.
 Cannot be reimbursed after active orthodontic treatment has begun.
D8670 Periodic orthodontic treatment visit (as part of contract)(PA REQUIRED)$232.00
The member must have been seen and actively treated at least once during thequarter. Cannot be used for “observation”. This code requires prior approval andcan be billed quarterly for a maximum of twelve (12) payments and can only bebilled a maximum of four (4) times in a twelve-month period beginning 90 days
after the date of service on which orthodontic appliances have been placed andactive treatment begun and at the end of each subsequent quarter. Claims billed
more frequently will result in an automatic systems denial. In the event thateligibility is lost during a quarter, at least one month of active treatment must haveelapsed to qualify for payment under the “limited extended coverage” benefit.
D8660

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CODE
D8680

D8695

DESCRIPTION
Orthodontic retention (removal of appliances, construction, andplacement of retainer(s)) (PA REQUIRED)$174.00
Includes all follow-up visits needed for observation and adjustments.
Requests must be submitted, and approval obtained PRIOR to the removal of
appliances. Any request denied or otherwise returned for insufficient results
will require the re-application of all appliances, if necessary, and continuationof care without additional compensation. Payment will not be made forretention (D8680) for a case that had been debanded without Medicaid priorauthorization.
Removal of fixed orthodontic appliances for reasons other thancompletion of treatment (REPORT NEEDED)
Services provided by an orthodontist other than the originating orthodontist.
As indicated on page 74, reimbursement for orthodontic services includes
the placement and removal of all appliances and brackets.

REPLACEMENT OF LOST OR BROKEN RETAINER
The following procedure codes (D8703 and D8704) will be reimbursed once per lifetime.
Must be within one year of D8680 having been paid by Medicaid. Appliances which do
not fit will not be replaced. The following documentation is required when submitting aclaim for a replacement retainer: Copy of a signed statement from patient / parent detailing the circumstancesof how the appliance was lost or broken Copy of patient’s treatment / progress notes indicating the date of insertion;and, Copy of dental laboratory bill, if available.
D8703 Replacement of lost or broken retainer – maxillary (REPORT$72.50
NEEDED)
D8704 Replacement of lost or broken retainer – mandibular (REPORT$72.50
NEEDED)
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DESCRIPTION

XII. ADJUNCTIVE GENERAL SERVICES D9000 D9999
UNCLASSIFIED TREATMENT
D9110 Palliative (emergency) treatment of dental pain - minor$25.00procedure (REPORT NEEDED)
Not reimbursable in addition to other therapeutic services performed at the same visit
or in conjunction with initial or periodic oral examinations when the procedure does
not add significantly to the length of time and effort of the treatment provided duringthat particular visit.
When billing, the provider must document the nature of the emergency, the dental site
and the specific treatment involved.
Not to be used for denture adjustments (Refer to procedure codes D5410 –D5422).
D9120 Fixed partial denture sectioning (QUAD) (REPORT NEEDED)(BR)
ANESTHESIA
The cost of analgesic and anesthetic agents is included in the reimbursement forthe dental service. The administration of nitrous oxide is not separately reimbursable.
Reimbursement for general anesthesia, intravenous (parenteral) sedation andanesthesia time is conditioned upon meeting the definitions listed below.
Anesthesia time begins when the doctor administering the anesthetic agent initiates theappropriate anesthesia and non-invasive monitoring protocol and remains in continuous
attendance of the member. Anesthesia services are considered completed when themember may be safely left under the observation of trained personnel and the doctor
may safely leave the room to attend to other patients or duties.
The level of anesthesia is determined by the anesthesia provider’s documentation of theanesthetic’s effect upon the central nervous system and not dependent upon the routeof administration.
Anesthesia time should be commensurate with the treatment performed.
Anesthesia time is divided into 15 minute units for billing purposes; the number of such
units should be entered in the "Times Performed" field of the claim form using theappropriate code (D9223, D9243).
D9222 Deep sedation/general anesthesia – first 15 minutes
Requires SED certificate in “General Anesthesia”
D9223 Deep sedation/general anesthesia – each subsequent 15
minute increment
Requires SED certificate in “General Anesthesia”
D9239 Intravenous moderate (conscious) sedation/analgesia – first
15 minutes
Requires SED certificate in “General Anesthesia”
D9243 Intravenous moderate (conscious) sedation/analgesia – eachsubsequent 15 minute increment
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DESCRIPTION
Requires SED certificate in “General Anesthesia”

D9310

Consultation - diagnostic service provided by dentist or$30.00physician other than requesting dentist or physician
The consulted provider must be enrolled in one of the dental specialty areas
recognized by the NYS Medicaid Program. The referring provider cannot be from thesame group as the consulting provider, although an exception can be made if thereferral is from a general dentist to a specialist for an evaluation requiring theadvanced skills and knowledge of that specialist.
If the consultant provider assumes the management of the member after the
consultation, subsequent services rendered by that provider will not be
reimbursed as consultation. Referral for diagnostic aids (including radiographic
images) does not constitute consultation but is reimbursable at the listed fees
for such services. Consultation will not be reimbursed if claimed by the sameprovider within 180 days of an examination or an office visit for observation(D9430). An exception can be made if a subsequent consultation is held for a
distinctly different condition, supported by documentation.

PROFESSIONAL VISITSHouse/extended care facility call (REPORT NEEDED)$50.00Per visit, regardless of number of members seen and represents the total extra
charge permitted, is not applicable to each member seen at such a visit. The
report must list all Medicaid covered patients seen at the facility on the date ofservice.
Fee-for-service reimbursement will not be made for those individuals who
reside in facilities where dental services are included in the facility rate. In
those cases, reimbursement must be sought directly from the facility.
D9420 Hospital or ambulatory surgical center call (REPORT NEEDED)$75.00P er visit, per member (to be added to fee for service). This service will be ognized
re only for professional visits for pre-operative or operative care. Post- erative
opvisits are not reimbursable when related to procedures with assigned low-up
fo days. Hospital calls are not reimbursable for hospital-based providers.
D9410

P ayable only when provided in a FACILITY where professional services are
not included in the rate. Please submit documentation that services were
provided in a hospital, such as a copy of the hospital notes/record.

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DESCRIPTION
Office visit for observation (during regularly scheduled$20.00hours) – no other services performed (REPORT NEEDED)
The provider must be enrolled in one of the dental specialty areas recognized by
the NYS Medicaid program. Used to monitor the status of a member following an
authorized phase of surgical treatment that are required beyond the postoperative care period for that procedure. Not be used for orthodontic retention
follow-up visits. Reimbursement includes the prescribing of medications and islimited to two instances per clinical episode.
May also be used for those individuals identified with a recipient exception codeof RE 81 (“TBI Eligible”) or RE 95 (“OPWDD/Managed Care Exemption”) wheredefinitive treatment cannot be performed due to the member’s behavior. This isa “stand-alone” procedure and cannot be billed on the same date of service withany other procedure code. Limited to four (4) instances per year per member.
Please include a report or narrative describing the circumstances involved.

D9430

D9440

Office visit - after regularly scheduled hours (REPORT NEEDED)$20.00Cannot be billed in conjunction with an examination, observation or consultation.
Please include a report or narrative describing the circumstances involved.

DRUGS
Therapeutic parenteral drug, single administration

D9610(REPORT NEEDED)(BR)

MISCELLANEOUS SERVICES
D9920.

Behavior management – No longer covered for dates ofservice after 01/01/2021. Refer to procedure code D9997.

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CODE

DESCRIPTION

For occlusal guards there must be a minimum interval of twelve (12) months between all
occlusal guards (D9944, D9945, and/or D9946) and the report must include
documentation of necessity, associated laboratory receipts and a copy of treatment
progress notes indicating the date of insertion.
D9944

Occlusal guard – hard appliance, full arch (ARCH) (REPORTNEEDED)$145.00

Removable dental appliance designed to minimize the effects of bruxism or otherocclusal factors. Not to be reported for any type of sleep apnea, snoring or TMD
appliances.
Occlusal guard – soft appliance, full arch (ARCH) (REPORT
D9945$145.00
NEEDED)

Removable dental appliance designed to minimize the effects of bruxism or otherocclusal factors. Not to be reported for any type of sleep apnea, snoring or TMD
appliances.
Occlusal guard – hard appliance, partial arch (ARCH) (REPORT
D9946$145.00
NEEDED)

Removable dental appliance designed to minimize the effects of bruxism or otherocclusal factors. Provides only partial occlusal coverage such as anterior
deprogrammer. Not to be reported for any type of sleep apnea, snoring or
TMD appliances.
D9990
Certified translation or sign-language services – per visit*$22.00(REPORT NEEDED)*D9990 is a new code; it replaces T1013 beginning on 1/17/2019. For
dates of service prior to 1/17/2019 use T1013.

For patients with limited English proficiency defined as patients whose primarylanguage is not English and who cannot speak, read, write or understand theEnglish language at a level sufficient to permit such patients to interact effectively
with health care providers and their staff.
The need for medical language interpreter services must be documented in the
medical record and must be provided during a medical visit by a third party
interpreter, who is either employed by or contracts with the Medicaid provider.
These services may be provided either face-to-face or by telephone. Theinterpreter must demonstrate competency and skills in medical interpretation
techniques, ethics and terminology. It is recommended, but not required, that suchindividuals be recognized by the National Board of Certification for Medical
Interpreters (NBCMI).
Documentation of necessity must be submitted as an attachment to a paper claim.

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DESCRIPTIONTELEHEALTH / TELEDENTISTRY
Telehealth is defined as “the use of electronic information and communication
technologies to deliver health care to patients at a distance, which shall include theassessment, diagnosis, consultation, treatment, education, care management and/or
self-management of a patient (Medicaid member)”.
Originating Site is defined as “a site at which a patient is located at the time health careservices are delivered to him or her by means of telehealth.”
Distant Site is defined as “a site at which a telehealth provider is located while delivering
health care services by means of telehealth.” Originating and Distant sites must be located within the fifty United States orUnited States’ territories and may include:o Facilities licensed under Article 28 of the Public Health Law (PHL):
hospitals, nursing homes and diagnostic and treatment centers;o Facilities licensed under Article 40 of the PHL: hospice programs;o Facilities as defined in subdivision 6 of Section 1.03 of the Mental Hygiene
Law (MHL): clinics certified under Articles 16, 31 and 32;
o Certified and non-certified day and residential programs funded or operated
by the Office of People with Developmental Disabilities (OPWDD);o Private physician or dentist offices located within the State of New York;o Adult care facilities licensed under Title 2 of Article 7 of the Social Security
Law (SSL);o Public, private and charter elementary and secondary schools locatedwithin the State of New York;o School-age child care programs located within the State of New York;o Child daycare centers located within the State of New York; and,o The member's place of residence in New York State, or other temporary
location in or out of state.
 Services provided by means of telehealth must be in compliance with the Health
Insurance Portability and Accountability Act (HIPAA) and all other relevant laws
and regulations governing confidentiality, privacy, and consent (including, but notlimited to 45 CFR Parts 160 and 164 [HIPAA Security Rules]; 42 CFR Part 2; PHL
Article 27-F; and MHL Section 33.13).
 Dentists providing services via telehealth must be licensed and currently
registered in accordance with NYS Education Law or other applicable law andenrolled in NYS Medicaid.
 Telehealth services must be delivered by dentists acting within their scope ofpractice.
 Reimbursement will be made in accordance with existing Medicaid policy related
to supervision and billing rules and requirements.

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CODE

DESCRIPTION When services are provided by an Article 28 facility, the telehealth dentist must becredentialed and privileged at both the originating and distant sites in accordancewith Section 2805-u of PHL. The law can be viewed at the following link:
http://public.leginfo.state.ny.us/lawssrch.cgi?NVLWO (Select LAWS; select PBH;
select Article 28; select 2805u)
 Telephone conversations, e-mail or text messages, and facsimile transmissions
between a dentist and a Medicaid member or between two dentists are notconsidered telehealth services and are not covered by Medicaid when provided as
standalone services.
 Remote consultations between practitioners, without a Medicaid member present,
including for the purposes of teaching or skill building, are not considered
telehealth and are not reimbursable.
 The acquisition, installation and maintenance of telecommunication devices orsystems is not reimbursable.
 Providers should bill using the claim format appropriate to their category of service.
 Place of Service (POS) code: Use 02 on professional claims to specify the location
teledentistry associated services were provided.

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CODE

DESCRIPTION

D9995

Teledentistry – synchronous; real time encounter Procedure code D9995 may be used by the provider at the
distant site; Must be reported on claim line #1;
 Report all services rendered on subsequent lines; There is no reimbursement for procedure code D9995.

D9996

Teledentistry – asynchronous; information stored and$0.00
forwarded
Store-and-Forward Technology - involves the asynchronous,
electronic transmission of a member's health information in theform of patient-specific pre-recorded videos and/or digital images
from a provider at an originating site to a telehealth provider at a
distant site.
 Store-and-forward technology aids in diagnoses when live
video or face-to-face contact is not readily available or notnecessary.
 Pre-recorded videos and/or static digital images (e.g.,
pictures), excluding radiology, must be specific to themember's condition as well as be adequate for rendering or
confirming a diagnosis or a plan of treatment.
 Procedure code D9996 may be used by the provider at the
distant site; Must be reported on claim line #1;
 Report all services rendered on subsequent lines; There is no reimbursement for procedure code D9996.
 Accompanying payable services will be reimbursed at 75% of
the requested fee, not exceeding 75% of the current
Medicaid fee.

Q3014

Telehealth originating site facility fee Procedure code Q3014 may be used by the provider at theoriginating site; Must be reported on claim line #1;
 Report all services rendered on subsequent lines.

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CODE
D9997

DESCRIPTION
Dental Case management – patients with special health careneedsSpecial treatment considerations for patients/individuals withphysical, medical, developmental, or cognitive conditions resulting
in substantial functional limitations or incapacitation, which requirethat modifications be made to delivery of treatment to provide
customized comprehensive oral health care services.
This code is replacing D9920 as of 01/01/2021.
When billing, please use the procedure code that was active on
the date the service was rendered. Code D9920 is valid if
performed prior to 01/01/2021.

$29.00 This is a per visit incentive to compensate for the greater
knowledge, skill, sophisticated equipment, extra time andpersonnel required to treat this population;
 This fee will be paid in addition to the normal fees for specificdental procedures.
 For purposes of the NYS Medicaid program, thedevelopmentally disabled population (OPWDD members)
for which procedure code D9997 may be billed is limited tothose who receive ongoing services from community
programs operated or certified by the New York State Office for
People with Developmental Disabilities (OPWDD).
These individuals are identified with a recipient exception
code of RE 81 (“TBI Eligible”) or RE 95 (“OPWDD/Managed
Care Exemption”).
 A “Medical Immobilization/Protective Stabilization (MIPS)”
form (Institutions only) also qualifies for use of thisprocedure code.
 Not billable in conjunction with D9430 or procedures
performed under deep sedation/general anesthesia.
 Not billable as a “stand-alone” procedure; another clinicalservice must be provided on the same date.
Does not require a report.
D9999

Unspecified adjunctive procedure, by report (REPORT NEEDED)

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