Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.14-014 - Revision to Dental 5-13; Nurse Practitioner 4-13; Physician 7-13 and SPA #2014-004

Current through Register Vol. 49, No. 6, June, 2024
Section II
Nurse Practitioner
215.000
Fluoride Varnish Treatment
Arkansas Medicaid covers fluoride varnish application, ADA code
				D1206, performed by physicians who have completed the online training program
				approved by the Arkansas Department of Health, Office of Oral Health. Eligible
				physicians may delegate the application to a nurse or other licensed health
				care professional under his or her supervision that has also completed the
				online training. The online training course can be accessed at
http://ar.train.org
. Each provider
				must maintain documentation to establish his or her successful completion of
				the training and submit a copy of the certificate of completion to HP Provider
				Enrollment.
252.453
Fluoride Varnish Treatment
The American Dental Association (ADA) procedure code D1206 is
				covered by the Arkansas Medicaid Program. This code is payable for
				beneficiaries under the age of 21. Topical fluoride varnish application benefit
				is two (2) per SFY for beneficiaries under age 21.
A new specialty code, FC-Fluoride Certification will be tied to
				provider types 01, 03, 58 and 69. These providers must send proof of their
				fluoride varnish certification to HP Provider Enrollment before the specialty
				code will be added to their file in the MMIS. After the specialty code,
				FC-Fluoride Certification, is added to the provider's file, the provider will
				be able to bill for procedure code D1206, Topical Application of Fluoride
				Varnish.
Providers must check the Supplemental Eligibility Screen to
				verify that topical fluoride varnish benefit of two (2) per State Fiscal Year
				(SFY) has not been exhausted. If further treatment is needed due to severe
				periodontal disease, then the beneficiary must be referred to a Medicaid dental
				provider.
NOTE: This service is billed on form CMS-1500 with ADA
				procedure code D1206 (Topical application of fluoride varnish (prophylaxis not
				included) - child (ages 0-20).
View a form CMS-1500 sample
				form.
217.100
Dental Prophylaxis and Fluoride
			 Treatment
Dental prophylaxis and a fluoride treatment are preventive
				treatments covered by Medicaid. Prophylaxis, in addition to application of
				topical fluoride and/or fluoride varnish, is covered every six (6) months plus
				one (1) day for beneficiaries under age 21. Arkansas Medicaid covers fluoride
				varnish application, ADA code D1206, performed by physicians who have completed
				the online training program approved by the Arkansas Department of Health,
				Office of Oral Health. Eligible physicians may delegate the application to a
				nurse or other licensed health care professional under his or her supervision
				that has also completed the online training. Physicians and nurse practitioners
				must complete training on dental caries risk and have an approved fluoride
				varnish certification from the Arkansas Department of Health, Office of Oral
				Health. Each provider must maintain documentation to establish his or her
				successful completion of the training and submit a copy of the certificate to
				HP Provider Enrollment. The course that meets the requirements outlined by the
				ACT can be accessed at
http://ar.train.org
. If further treatment is
				needed due to severe periodontal problems, the provider must request prior
				authorization with a brief narrative.
Prophylaxis and fluoride treatments are each covered once per
				state fiscal year (July 1 through June 30) for beneficiaries age 21 and over.
				Topical fluoride treatment or fluoride varnish is covered every six (6) months
				plus one (1) day for beneficiaries under age 21.
A new specialty code, FC-Fluoride Certification will be tied to
				provider types 01, 03, 58 and 69. These providers must send proof of their
				fluoride varnish certification to HP Provider Enrollment before the specialty
				code will be added to their file in the MMIS. After the specialty code,
				FC-Fluoride Certification, is added to the provider's file, the provider will
				be able to bill for procedure code D1206, Topical Application of Fluoride
				Varnish.
Medicaid does not reimburse for nitrous oxide for examinations,
				fluorides, oral prophylaxis and sealants unless other procedures are performed
				at the same time.
A provider may generally perform the following procedures
				without prior authorization:
A.
			 Periodic EPSDT screening exam (for beneficiaries under age 21).
B. Prophylaxis, topical fluoride and/or
			 fluoride varnish.
C. Periapical
			 X-rays, amalgam-composite restorations (except four or more
			 surfaces).
D. Pulpotomies for
			 deciduous teeth. (Pulpotomies are not a covered service for beneficiaries age
			 21 and over.)
E. Chrome crowns on
			 deciduous teeth.
See Sections
				262.100 and
				262.200 for applicable
				codes.
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.
NOTE: Only physicians who have completed the training on
				dental caries and have an approved fluoride varnish certification on file with
				HP provider enrollment can bill for the fluoride varnish treatment. Eligible
				physicians may delegate the application to a nurse or other licensed health
				care professional under his or her supervision that has also completed the
				online training. Providers must check the Supplemental Eligibility Screen to
				verify that topical fluoride treatment or fluoride varnish was not applied by
				another Medicaid dental provider.
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
A(...) 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 He
alth Services (EPSDT) Dental Screening
(See Se
ction 215.000)
D0120
A(CHS/EPSDT Dental Screening Exam)
No
No
D0140
A(CHS/EPSDT Interperiodic Dental Screening Exam)
No, but limited to two (2) per SFY
No
Radiogr
aphs
(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 an
d Laboratory
D0350
Oral/facial photographic images
Yes
No
D0470
Diagnostic casts
Yes
No
Preventive
Dental Prophylaxis
(See Section
						  217.100 )
D1120 Prophylaxis - child A(ages 0-9)
No
No
D1110 Prophylaxis - adult A(ages 10-20)
No
No
Topical Fluoride Treatment (Office Procedure)
(See Section
						  217.100 )
D1206 Topical application of fluoride varnish
(prophylaxis not included) - child
A
(ages
						  0-20)
No
No
D1208 Topical application of fluoride (prophylaxis not
						  included) - child A(ages 0-20)
No
No
Dental Sealants
(See Section
						  217.200 )
D1351 Sealant per tooth A(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 A(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
241.000
Fluoride Varnish Treatment
Arkansas Medicaid will expand coverage for fluoride varnish
				application, ADA code D1206, to physicians and nurse practitioners who have
				completed the online training program approved by the Arkansas Department of
				Health, Office of Oral Health. The online training course can be accessed at
http://ar.train.org
. The provider will
				need to maintain a copy of the certificate of completion in their files and
				submit a copy to the Arkansas Medicaid provider enrollment unit.
292.470
Fluoride Varnish
			 Treatment
The American Dental Association (ADA) procedure code D1206 is
				covered by the Arkansas Medicaid Program. This code is payable for
				beneficiaries under the age of 21. Topical fluoride varnish is covered every
				six (6) months for beneficiaries under age 21.
A new specialty code, FC-Fluoride Certification will be tied to
				provider types 01, 03, 58 and 69. These providers must send proof of their
				fluoride varnish certification to Provider Enrollment before the specialty code
				will be added to their file in the MMIS. After the specialty code, FC-Fluoride
				Certification, is added to the provider's file, the provider will be able to
				bill for procedure code D1206, Topical Application of Fluoride Varnish.
Providers must check the Supplemental Eligibility Screen to
				verify that topical fluoride varnish benefit of two (2) per State Fiscal Year
				(SFY) has not been exhausted. If further treatment is needed due to severe
				periodontal disease, then the beneficiary must be referred to a Medicaid dental
				provider.
NOTE: This service is billed on form CMS-1500 with ADA
				procedure code D1206 (Topical application of fluoride varnish (prophylaxis not
				included) - child (ages 0-20).
View a form CMS-150 sample
				form.
4.
b. Early and Periodic Screening and Diagnosis
			 of Individuals Under 21 Years of Age, and Treatment of Conditions Found.
(16)
Dental Services
(1) Services are limited to eligible Medicaid
			 recipients in the Child Health Services (EPSDT) Program.
(2) Procedures which may be provided to
			 recipients in the Child Health Services (EPSDT) Program without prior
			 authorization are:
a. Initial radiographs
			 taken in conjunction with preparation of a treatment plan.
b. Periodic oral exam, prophylaxis, topical
			 fluoride
and/or fluoride varnish
for children in the Child Health
			 Services (EPSDT) Program.
c.
			 Emergency treatment. One visit without prior authorization is payable for any
			 emergency. Procedures payable without prior authorization when provided as
			 emergency care include:
1. All necessary
			 radiographs.
2. Extraction of up to
			 three teeth for relief of pain or acute infections.
3. Control of bleeding.
4. Treatment for relief of pain resulting
			 from injuries to the oral cavity or related services.
5. Emergency services provided to patients in
			 hospitals or long term care facilities.
All other procedures require prior authorization from the
				Medical Assistance Section. A full mouth radiograph is limited to once every
				five years. Periodic oral exam, prophylaxis, fluoride treatment,
fluoride
				varnish
and bite-wing X-rays are limited to once per 6 (six) months plus
				1 (one) day. Scaling is limited to one per state fiscal year (July 1 through
				June 30). Periapical X-rays are limited to four (4) per recall visit. Any
				limits will be exceeded based on medical necessity.
4.
b. Early
			 and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and
			 Treatment of Conditions Found.
(16)
Dental Services
(1)
			 Services are limited to eligible Medicaid recipients in the Child Health
			 Services (EPSDT) Program.
(2)
			 Procedures which may be provided to recipients in the Child Health Services
			 (EPSDT) Program without prior authorization are:
a. Initial radiographs taken in conjunction
			 with preparation of a treatment plan.
c. Periodic oral exam, prophylaxis, topical
			 fluoride
and/or fluoride varnish
for children in the Child Health
			 Services (EPSDT) Program.
c.
			 Emergency treatment. One visit without prior authorization is payable for any
			 emergency. Procedures payable without prior authorization when provided as
			 emergency care include:
6. All necessary
			 radiographs.
7. Extraction of up to
			 three teeth for relief of pain or acute infections.
8. Control of bleeding.
9. Treatment for relief of pain resulting
			 from injuries to the oral cavity or related services.
10. Emergency services provided to patients
			 in hospitals or long term care facilities.
All other procedures require prior authorization from the
				Medical Assistance Section. A full mouth radiograph is limited to once every
				five years. Periodic oral exam, prophylaxis, fluoride treatment,
fluoride
				varnish
and bite-wing X-rays are limited to once per 6 (six) months plus
				1 (one) day. Scaling is limited to one per state fiscal year (July 1 through
				June 30). Periapical X-rays are limited to four (4) per recall visit. Any
				limits will be exceeded based on medical necessity.