Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.13-008 - Provider Manual Update Transmittal DENTAL-2-13

Current through Register Vol. 49, No. 6, June, 2024
Section II
Dental
215.000
Child Health Services (EPSDT)
			 Dental Screening
The Child Health Services (EPSDT) periodic and interperiodic
				dental screening exams consist of an inspection of the oral cavity by a
				licensed dentist
.
The purpose of the dental screening exams is
				to check for obvious dental abnormalities and to assure access to needed dental
				care. Regular screening exams should be performed in accordance with the
				recommendations of the Child Health Service (EPSDT) periodicity
				schedule.
The Child Health Services (EPSDT) periodic dental screening
				exam is limited to two screening exams every six (6) months plus one (1) day
				for individuals under age 21. These benefits may be extended if documentation
				is provided that verifies medical necessity. See Section
				262.100 to view the procedure
				code for periodic dental screening exams.
Individuals under age 21 enrolled in the EPSDT Program may
				receive an interperiodic dental screening exam twice per SFY. Extension of
				benefits is available in cases of medical necessity.
.View or
				print form ADA-J400
.
See Section
				262.100 for the interperiodic
				dental screening examprocedure code.
NOTE: ARKids First-B beneficiaries may also receive an
				interperiodic dental
screening exam twice per SFY. There is no extension of
				benefits for ARKids First-B beneficiaries.
Extension of benefits requests, in addition to a narrative and
				any supporting documentation, should be submitted to the Division of Medical
				Services Dental Care Unit - ATTN Dental
Extension of Benefits
.
.View or print the
				Division of Medical Services Dental Care Unit
_______
contact information.
Infant oral health care examinations must be based on the
				recommendations of the American Academy of Pediatric Dentistry. Essential
				elements of an infant oral health care visit are a thorough medical and dental
				history, oral examination, parental counseling, preventive health education and
				determination of appropriate periodic re-evaluation. See Section
				201.500 for information regarding
				the dentist's role in the EPSDT Program.
216.200
Bitewing Radiographs
Bitewing radiographs are covered for beneficiaries of all ages.
				There are different limitations of coverage for beneficiaries under age 21 and
				for those beneficiaries age 21 and older.
The EPSDT periodic screening exam may include only two
				bitewings and is allowed every six (6) months plus one (1) day for
				beneficiaries under age 21. See Section
				262.100 for the appropriate
				procedure code.
Two bitewing films are allowed once per state fiscal year (July
				1 through June 30) for beneficiaries age 21 and over. See Section
				262.200 for appropriate procedure
				codes.
221.100
Endodontia
A. Guidelines
Root canal treatment should attempt to achieve the
				following:
1. Achieve and maintain
			 access to apical anatomy during chemo-mechanical debridement.
2. Obturate the canal with densely compacted
			 material within 2 mm of the apical terminus.
3. Prevent re-infection with a coronal
			 restoration. If unable to conform in the above guidelines, the dentist must
			 provide a narrative as to why it does not conform and the plan for monitoring
			 the patient. Radiographic evidence (pre-operative and postoperative) must
			 demonstrate completion of treatment and be maintained in the patient file. The
			 following procedures may not be billed when performed on the same tooth and
			 same day as root canal therapy: pulpotomy, pulpectomy, temporary restorations,
			 palliative treatment or sedative fillings.
4. Root canal therapy is not allowed on the
			 2nd and 3rd molars with
			 the exception of when the 1st molar is absent. Also,
			 root canal therapy is not allowed on maxillary 1st
				molar if the 2nd molar is
			 unerupted.
B.
			 Reimbursement
Pulpotomy for deciduous teeth may be performed without prior
				authorization for beneficiaries under age 21.
Pulpotomies are not covered
				for beneficiaries age 21 and over.
Current indications require carious exposure of the pulp.
				Payment for pulp caps is included in the fee for restorations and is not
				payable separately.
Endodontic therapy is not covered for beneficiaries age
				21 and over.
The fee for endodontic therapy does not include restoration to
				close a root canal access, but does include films for measurement control and
				post-op.
Medicaid does not cover endodontic retreatment,
				apexification, retrograde fillings or root amputation.
See Section
				262.100 for applicable procedure
				codes.
225.500
Deep Sedation and General Anesthesia
Providers administering general anesthesia services must
				possess the appropriate permit as required by Arkansas law. Services performed
				in the dental office must be documented in the patient's record to include
				specific information on intubation, pharmacologic agents and amounts used,
				monitoring of vital signs and total anesthesia time. Prior authorization is
				required for deep sedation and general anesthesia procedures. General
				anesthesia and intravenous sedation will not be reimbursed for periods of time
				in excess of two (2) hours. D9220 and D9248 are not allowed on the same day.
				These codes are subject to post payment review; therefore, providers should be
				prepared to justify utilization of these procedures and the amount of time
				patients were kept under deep sedation and general anesthesia.
228.000
Hospital
			 Services
All inpatient and outpatient hospitalization for dental
				treatment requires prior authorization. The dental consultant may request a
				second opinion when reviewing requests for dental prior authorization.
To request prior authorization, the dental treatment plan must
				be submitted on the ADA claim form with the appropriate X-rays. A copy of the
				Additional Information form (DMS-32-A) should be attached indicating the
				reason(s) hospitalization is necessary and the name of the hospital.
.View or print form DMS-32-A
.
_________________________________________________________
In unusual cases, for beneficiaries under age 21, when it is
				impossible to determine the treatment plan before the patient is anesthetized,
				indicate the information on the DMS-32-A. Beneficiaries age 21 and over are not
				covered for general anesthesia, nitrous oxide and non-intravenous conscious
				sedation.
The provider must complete the first portion of the ADA claim
				form (the ID of the patient and doctor) and submit both forms together. After
				the treatment is performed, any procedure(s) requiring prior authorization must
				be submitted to the dental consultant for authorization.
228.100
Inpatient Hospital Services
Hospitalization for dental treatment may be approved when the
				patient's age, medical or mental problems and/or the extensiveness of treatment
				necessitates hospitalization. Consideration is given in cases of traumatic
				accidents and extenuating circumstances.
Because of the cost of a hospital stay, providers are
				encouraged to use outpatient hospital care whenever feasible. The length of
				hospitalization should be kept to a minimum.
Request for hospitalization should be made only when other
				methods such as premedication, delay of treatment, limited in office treatment,
				sedation, etc., have been evaluated.
228.200
Outpatient Hospital Services
When a primary procedure to be performed in outpatient surgery
				is medical in nature, Arkansas Medicaid will not cover a dental procedure that
				is incidental to the primary procedure (e.g., the removal of a wisdom tooth
				when a tonsillectomy is being performed). When the primary procedure is
				medical, and it is cancelled, the provider may request a prior authorization
				for the dental procedure to be performed as outpatient surgery.
Information that should be included in the request for prior
				authorization for outpatient surgery includes the following.
A. An explanation for the reason the dental
			 procedure cannot be performed in the provider's office.
B. An explanation for the reason a dental
			 procedure cannot be postponed. (e.g., a procedure that cannot be postponed
			 until a child matures and becomes receptive to a dental office environment and
			 treatment.)
C. The provider should
			 also state whether sedation or general anesthesia will be used during the
			 procedure for beneficiaries under age 21.
Note: General anesthesia,
			 nitrous oxide and non-intravenous conscious sedation are not covered for
			 beneficiaries age 21 and over.
D. A copy of the dental treatment plan must
			 be included with the prior authorization request. For
outpatient
			 hospitalization
,
all procedures
involved
			 must be indicated on the treatment plan.
262.100
ADA Procedure Codes Payable to
			 Beneficiaries Under Age 21
The following ADA procedure codes are covered by the Arkansas
				Medicaid Program. These codes are payable for beneficiaries under the age of
				21.
Beside each code is a reference chart that indicates whether
				X-rays are required and when prior authorization (PA) is required for the
				covered procedure code. If a concise report is required, this information is
				included in the PA column.
* Revenue code
***
(...) This symbol, along with text in
				parentheses, indicates the Arkansas Medicaid description of the covered
				service.
** Prior authorization is required for panoramic X-rays
				performed on children under six years of age (See Section
				216.100 ).
ADA Code
Description
PA Yes/No
Submit X-Ray with Treatment Plan Yes/No
Child Health Services (EPSDT) Dental Screening
(See Section
						  215.000 )
D0120
***(CHS/EPSDT Dental Screening Exam)
No
No
D0140
***(CHS/EPSDT Interperiodic Dental Screening
						  Exam)
No, but limited to two (2) per SFY
No
Radiographs
(See Sections
						  216.000 - 216.300)
D0210
Intraoral - complete series (including
						  bitewings)
No
No
D0220
Intraoral - periapical - first film
No, but limited to five (5) per SFY
No
D0230
Intraoral - periapical - each additional film
No, but limited to five (5) per SFY
No
D0240
Intraoral - occlusal film
No, but limited to five (5) per SFY
No
D0250
Extraoral - first film
No
No
D0260
Extraoral - each additional film
No, but limited to five (5) per SFY
No
D0272
Bitewings - two films
No
No
D0330
Panoramic film
No**
No
D0340
Cephalometric film
Yes
No
Tests and Laboratory
D0350
Oral/facial photographic images
Yes
No
D0470
Diagnostic casts
Yes
No
Preventive
Dental Prophylaxis
(See Section
						  217.100 )
D1120
Prophylaxis - child ***(ages 0-9)
No
No
D1110
Prophylaxis - adult ***(ages 10-20)
No
No
Topical Fluoride Treatment (Office Procedure)
(See Section
						  217.100 )
D1203
Topical application of fluoride (prophylaxis not
						  included) - child ***(ages 0-20)
No
No
Dental Sealants
(See Section
						  217.200 )
D1351
Sealant per tooth ***(1st and 2nd permanent molars
						  only)
No
No
Space Maintainers
(See Section
						  218.000 )
D1510
Space maintainer - fixed - unilateral
Yes
Yes
D1515
Space maintainer - fixed - bilateral
Yes
Yes
D1525
Space maintainer - removable-bilateral
Yes
Yes
Restorations
(See Sections
						  219.000 - 219.200)
Amalgam Restorations (including polishing)
(See Section
						  219.100 )
D2140
Amalgam - one surface
No
No
D2150
Amalgam - two surfaces
No
No
D2160
Amalgam - three surfaces
No
No
D2161
Amalgam - four or more surfaces
No
No
Composite Resin Restorations
(See Section
						  219.200 )
D2330
Resin - one surface, anterior, permanent
No
No
D2331
Resin - two surfaces, anterior, permanent
No
No
D2332
Resin - three surfaces, anterior, permanent
No
No
D2335
Resin - four or more surfaces or involving incisal
						  angle, permanent
Yes
Yes
Crowns - Single Restoration Only
(See
						  Section 220.000 )
D2710
Crown - resin (laboratory)
Yes
Yes
D2752
Crown - porcelain -ceramic substrate
Yes
Yes
D2920
Re-cement crown
No
Yes
D2930
Prefabricated stainless steel crown - primary
No
No
D2931
Prefabricated stainless steel crown - permanent
Yes, but no PA required when billed for tooth numbers
						  3, 14, 19 and 30.
Yes
Endodontia
(See Section
						  221.000 )
Pulpotomy
D3220
Therapeutic pulpotomy (excluding final
						  restoration)
No
No
D3221
Gross pulpal debridement, primary and permanent
						  teeth
Yes
No
Endodontic (Root Canal) therapy (including
						  treatment plan, clinical procedures and follow-up care)
D3310
Anterior tooth (excluding final restoration)
No
No
D3320
Bicuspid tooth (excluding final restoration)
No
No
D3330
Molar (excluding final restoration)
No
No
Periapical Services
D3410
Apicoectomy (per tooth) - first root
Yes
Yes
Periodontal Procedures
(See Section
						  222.000 )
Surgical Services (including usual postoperative
						  services)
D4341
Periodontal scaling and root planing
Yes
Yes
D4910
Periodontal maintenance procedures (following active
						  therapy)
Yes
Yes
Complete dentures (Removable Prosthetics
						  Services)
(See Section
						  223.000 )
D5110
Complete denture - maxillary
Yes
Yes
D5120
Complete denture - mandibular
Yes
Yes
Partial Dentures (Removable Prosthetic Services)
(See Section
						  223.000 )
D5211
Upper partial - acrylic base (including any
						  conventional clasps and rests)
Yes
Yes
D5212
Lower partial - acrylic base (including any
						  conventional clasps and rests)
Yes
Yes
Repairs to Partial Denture
(See Section
						  223.000 )
D5610
Repair acrylic saddle or base
Yes
No
D5620
Repair cast framework
Yes
No
D5640
Replace broken teeth - per tooth
Yes
No
D5650
Add tooth to existing partial denture
Yes
No
Fixed Prosthodontic Services
(See Section
						  224.000 )
D6930
Re-cement bridge
Yes
No
Oral Surgery
(See Section
						  225.000 )
Simple Extractions (includes local anesthesia and
						  routine postoperative care)
(See Section
						  225.100 )
D7111
Extraction, coronal remnants-deciduous tooth
No
No
D7140
Extraction, erupted tooth or exposed root (elevation
						  and/or forceps removal)
No
No
Surgical Extractions (includes local anesthesia
						  and routine postoperative care)
(See Section
						  225.200 )
D7210
Surgical removal of erupted tooth requiring elevation
						  of mucoperiosteal flap and removal of bone and/or section of tooth
Yes
Yes
D7220
Removal of impacted tooth - soft tissue
Yes
Yes
D7230
Removal of impacted tooth - partially bony
Yes
Yes
D7240
Removal of impacted tooth - completely bony
Yes
Yes
D7241
Removal of impacted tooth - completely bony, with
						  unusual surgical complications
Yes
Yes
D7250
Surgical removal of residual tooth roots (cutting
						  procedure)
Yes
Yes
Other Surgical Procedures
D7270
Tooth reimplantation and/or stabilization of
						  accidentally evulsed or displaced tooth and/or alveolus
Yes
Yes
D7280
Surgical exposure of impacted or un-erupted tooth for
						  orthodontic reasons (including orthodontic attachments)
Yes
Yes
D7285
Biopsy of oral tissue - hard
Yes
Yes
D7286
Biopsy of oral tissue - soft
Yes
Yes
Osteoplasty for Prognathism, Micrognathism or
						  Apertognathism
D7510
Incision and drainage of abscess, intraoral soft
						  tissue
Yes
No
Frenulectomy
D7960
Frenulectomy (Frenectomy or Frenotomy) Separate
						  procedure
Yes
Yes
Orthodontics
(See Section
						  226.000 )
Minor Treatment of Control Harmful Habits
D8210
Removable appliance therapy
Yes
Yes
D8220
Fixed appliance therapy
Yes
Yes
Comprehensive Orthodontic Treatment - Permanent
						  Dentition
D8070
Class I Malocclusion
Yes
Yes
D8080
Class II Malocclusion
Yes
Yes
D8090
Class III Malocclusion
Yes
Yes
Other Orthodontic Devices
D8999
Unspecified orthodontic procedure, by report
Yes
Yes
Anesthesia
D9220
General Anesthesia - first 30 minutes
Yes
Yes
D9221
General Anesthesia - each 15 minutes
Yes
No
D9230
Analgesia N20
No, but requires report for request for more than 1
						  unit per day
No
D9248
Non-I.V. Conscious Sedation
Yes and requires report
No
Consultations
(See Section
						  214.000 )
D9310
*(Second opinion examination) Consultation, diagnostic
						  service provided by dentist or physician other than practitioner providing
						  treatment
Yes
No
Smoking Cessation
D1320
Tobacco counseling for the control and prevention of
						  oral disease - Counseling and referral by a provider to a tobacco cessation
						  program
No
No
D9920
Behavior Management by Report - Tobacco counseling
						  received from the provider for the control and prevention of oral
						  disease
No
No
Unclassified Treatment
D9110
Palliative treatment with dental pain
Yes
No
262.200
ADA Procedure Codes Payable to
			 Medically Eligible Beneficiaries
Age 21 and Older
The following list shows the procedure code, procedure code
				description, whether or not prior authorization is required, whether an X-ray
				should be submitted with a treatment plan and if there is a benefit limit on a
				procedure.
The column titled
Benefit Limit
indicates the
				benefit limit, if any, and how the limit is to be applied. When the column
				indicates
"Yes, $500.00",
then that item, when used in combination
				with other items listed, cannot exceed the $500.00 Medicaid maximum allowable
				reimbursement limit for the state fiscal year (July 1 through June 30).
Other limitations
are also shown in the column (i.e.:
1 per
				lifetime
). If
"No"
is shown, the item is not benefit
				limited.
NOTE: The use of the symbol, #*, along with text in
				parentheses, indicates the Arkansas Medicaid description of the product.
ADA Code
Description
PA Yes/No
Submit
X-Ray
with
Treatment
Plan
Yes/No
Benefit Limit Yes/No
Dental Screening
(See Section
						  215.000 )
D0120
Periodic oral evaluation
No
No
Yes-$500 Yes-1 per year
D0140
Limited oral evaluation-problem focused
No
No
Yes-$500 Yes-12 per year
Radiographs
(See Sections
						  216.000 - 216.300)
D0210
Intraoral - complete series (including
						  bitewings)
No
No
Yes-$500 Yes-1 per 5 years
D0220
Intraoral - periapical - first film
No
No
Yes-$500 Yes-5 per year
D0230
Intraoral - periapical - each additional film
No
No
Yes-$500 Yes-5 per year
D0272
Bitewings - two films
No
No
Yes-$500 Yes-1 per year
D0330
Panoramic film
No
No
Yes-$500 Yes-1 per 5 years
Tests and Laboratory
D0470
Diagnostic Casts (full denture) Diagnostic Casts
						  (partial denture)
No Yes
No Yes
Yes-$500 Yes-4 per lifetime
Dental Prophylaxis
(See Section
						  217.100 )
D1110
Prophylaxis - adult
No
No
Yes-$500 Yes-1 per year
Topical Fluoride Treatment (Office Procedure)
(See Section
						  217.100 )
D1204
Topical application of fluoride (prophylaxis not
						  included) - adult
No
No
Yes-$500 Yes-1 per year
Restorations
(See Sections
						  219.000 - 219.200)
Amalgam Restorations (including polishing)
(See Section
						  219.100 )
D2140
Amalgam - one surface, primary or permanent
No
No
Yes-$500
D2150
Amalgam - two surfaces, primary or permanent
No
No
Yes-$500
D2160
Amalgam - three surfaces, primary or permanent
No
No
Yes-$500
D2161
Amalgam - four or more surfaces, primary or
						  permanent
No
No
Yes-$500
Composite Resin Restorations
(See Section
						  219.200 )
D2330
Resin - one surface, anterior, permanent
No
No
Yes-$500
D2331
Resin - two surfaces, anterior, permanent
No
No
Yes-$500
D2332
Resin - three surfaces, anterior, permanent
No
No
Yes-$500
D2335
Resin - four or more surfaces or involving incisal
						  angle, permanent
Yes
Yes
Yes-$500
Crowns - Single Restoration Only
(See
						  Section 220.000 )
D2920 D2931
Re-cement crown
Prefabricated stainless steel crown - permanent
No
Yes, but no PA required when billed for tooth numbers
						  3, 14, 19 and 30.
Yes Yes
Yes-$500 Yes-$500
Surgical Services (including usual postoperative
						  services)
D4341
Periodontal scaling and root planing-four or more
						  contiguous
Yes
Yes
Yes-$500
D4355
Full mouth debridement to enable comprehensive
						  evaluation and diagnosis
Yes
Yes
Yes-$500
D4910
Periodontal maintenance procedures (following active
						  therapy)
Yes
Yes
Yes-$500
Repairs to Complete and Partial Dentures
(See Section
						  223.000 )
D5410
Adjust complete denture-maxillary
No
No
Yes-$500 Yes-3 per lifetime
D5411
Adjust complete denture-mandibular
No
No
Yes-$500 Yes-3 per lifetime
D5610 D5640 D5650 D5730
Repair acrylic saddle or base
Replace broken teeth - per tooth
Add tooth to existing partial denture
Reline complete maxillary denture (chairside)
Yes Yes Yes No
No No No No
Yes-$500 Yes-$500 Yes-$500 Yes-$500 Yes-1 every 3
						  years
D5731
Reline lower complete mandibular denture
						  (chairside)
No
No
Yes-$500
Yes-1 every 3 years
Fixed Prosthodontic Services
(See Section
						  224.000 )
D6930
Re-cement bridge
Yes
No
Yes-$500
Oral Surgery
(See Section
						  225.000 )
Simple Extractions (includes local anesthesia and
						  routine postoperative care)
(See Section
						  225.100 )
D7140
Single tooth
No
No
No
Surgical Extractions (includes local anesthesia
						  and routine postoperative care)
(See Section
						  225.200 )
D7210
Surgical removal of erupted tooth requiring elevation
						  of mucoperiosteal flap and removal of bone and/or section of tooth
Yes
Yes
No
D7220
Removal of impacted tooth - soft tissue
Yes
Yes
No
D7230
Removal of impacted tooth - partially bony
Yes
Yes
No
D7240
Removal of impacted tooth - completely bony
Yes
Yes
No
D7241
Removal of impacted tooth - completely bony, with
						  unusual surgical complications
Yes
Yes
No
D7250
Surgical removal of residual tooth roots (cutting
						  procedure)
Yes
Yes
Yes-$500
Other Surgical Procedures
D7285
Biopsy of oral tissue - hard
Yes
Yes
Yes-$500
D7286
Biopsy of oral tissue - soft
Yes
Yes
Yes-$500
D7310
Alveoplasty in conjunction with extractions-four or
						  more teeth
Yes
No
Yes-$500
D7472
Removal of torus palatinus
Yes
No
Yes-$500 1 per lifetime
D7473
Removal of torus mandibularis
Yes
No
Yes-$500 1 per lifetime
Osteoplasty for Prognathism, Micrognathism or
						  Apertognathism
D7510
Incision and drainage of abscess, intraoral soft
						  tissue
Yes
No
Yes-$500
Unclassified Treatment
D9110
Palliative treatment with dental pain
Yes
No
Yes-$500
Smoking Cessation
D1320
Tobacco counseling for the control and prevention of
						  oral disease - Counseling and referral by a provider to a tobacco cessation
						  program
No
No
Yes-$500
2 counseling sessions per SFY
D9920
Behavior Management by Report - Tobacco counseling
						  received from the provider for the control and prevention of oral
						  disease
No
No
Yes-$500
2 counseling sessions per SFY