reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 2 - PROVISIONS FOR SERVICES › Section 10:56-2.10 - Restorative services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Restorative treatment shall be limited to those services necessary to adequately restore and maintain the integrity and contours of the natural tooth, as follows:
1. Filling restorations shall be reimbursed as follows:
i. Reimbursement for restorations in primary teeth shall be limited to primary cuspids and molars of children up to and including age nine, or in primary incisors up to and including age five, but not where exfoliation is imminent, except when prior authorization by a Division dental consultant has been obtained by the provider.
ii. Amalgam and composite restorations may be provided on anterior and posterior teeth (numbers 1 through 16 and 17 through 32). The provider should select the restorative material most appropriate for the beneficiary's dental needs.
iii. Reimbursement for a restoration will include treatment of pulp exposure, lining or base, restoration, polishing of restoration, and local anesthesia.
iv. Plastic, acrylic, or unfilled resin restorative material shall be reimbursable.
v. A procedure code shall be selected on the basis of the number of surfaces restored per individual tooth (not on the basis of individual restorations); therefore, the fee for any surface shall include one or more restorations on that surface.
vi. Only one code is reimbursable per tooth except when amalgam and composite resin restorations are placed on the same tooth.
vii. Reimbursement for an occlusal restoration includes any extensions onto the occlusal one-third of the buccal or lingual surface(s) of the tooth.
viii. Extension of interproximal restorations into self cleansing areas will not be considered as additional surfaces. An additional surface will be reimbursable only when the buccal (facial) or lingual margin extends beyond the proximal one-third of the buccal (facial) and/or lingual surface(s).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 2 - PROVISIONS FOR SERVICES › Section 10:56-2.11 - Endodontic services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Reimbursement for root canal therapy for all teeth shall include pulpal extirpation, endodontic treatment to include complete filling of the root canal(s) with permanent material, all necessary radiographs during treatment, a radiograph demonstrating proper completion, and follow-up care.
1. Silver points shall not be reimbursed when used as the "permanent material" for filling the root canal.
2. Complete filling of the root canal is defined as filling of the canal to within 0.5 millimeters of the apex.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 2 - PROVISIONS FOR SERVICES › Section 10:56-2.12 - Periodontal services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Reimbursement shall be provided for periodontal scaling and root planing for four quadrants annually without prior authorization. Prior authorization shall be obtained for additional quadrants of periodontal scaling and root planing, and all other periodontal services. Such requests for prior authorization shall be submitted using the Dental Prior Authorization Form (MC-10A) and the Dental Claim Form (MC-10).
(b) Additional periodontal services may be prior authorized by the Division on a very selective basis. Such prior authorization shall be based on the requirements of this section and on the professional judgment of the Division dental consultant. A detailed description of the condition, including periodontal charting, radiographs, and photographs where appropriate, shall be submitted to the Division dental consultant. Photographs are an excellent means of presenting the condition of the oral tissues to the consultant and shall be reimbursable.
(c) When requesting periodontal surgery, consideration should be given to the age and health of the beneficiary, the amount of bone loss, the condition of the remaining dentition, the desire, ability, and motivation of the beneficiary to follow through with necessary home and follow-up care, and the prognosis for the remaining teeth.
(d) When requesting prior authorization for periodontal services, the provider should submit, in addition to radiographs and photographs, a narrative, to include periodontal charting, indicating pocket depth for each tooth in the quadrant requested.
(e) Reimbursement will be based upon quadrants, a site in a quadrant or the equivalent thereof, as determined by the Division dental consultant in accordance with 10:56-3.1(d)6  vi.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 2 - PROVISIONS FOR SERVICES › Section 10:56-2.14 - Oral and maxillofacial surgical services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Dental extraction services shall be provided as follows:
1. Extraction of teeth other than those classified as non-restorable shall require prior authorization.
i. If a provider is considering any extraction which will necessitate the insertion of a dental prosthesis, the provider shall request prior authorization. Reimbursement for such an extraction rendered without prior authorization will be denied, or if already paid, reimbursement will be recovered. Due to the rule limiting the authorization of dentures, 10:56-2.13, it may be impossible to replace a denture following such extraction(s). Therefore, careful consideration should be given to the condition of teeth prior to a request for dentures initially; and prior to any extraction which would jeopardize an existing denture.
ii. When any extraction is to be performed in conjunction with or during orthodontic treatment, the dentist shall determine:
(1) That such orthodontic treatment has met the Salzmann Handicapping Malocclusion Guidelines established by the New Jersey Medicaid/NJ FamilyCare Program or has been prior authorized by a Division dental consultant.
(2) That such extraction has the express consent of the practitioner to whom orthodontic treatment has been authorized. Reimbursement will be denied (or if already paid, reimbursement will be recovered) for any extraction performed:
(A) In conjunction with orthodontic care, if such orthodontic treatment has not met the New Jersey Medicaid/NJ FamilyCare guidelines or has not been prior authorized by the Division dental consultant; or
(B) On a prior authorized orthodontic case without the consent of the practitioner to whom orthodontic treatment has been authorized, or without the approval of the Division dental consultant.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 2 - PROVISIONS FOR SERVICES › Section 10:56-2.15 - Orthodontic services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The procedures in this section shall be followed for orthodontic referral, evaluation, and treatment.
(b) Comprehensive orthodontic treatment shall be limited to handicapping malocclusions. Cases with 24 or more points on the New Jersey Handicapping Malocclusion Assessment System shall be considered as having a handicapping malocclusion. Prior authorization shall be obtained in accordance with (e) below before any orthodontic treatment is initiated.
1. Orthodontic treatment shall not be reimbursed for the following:
i. For cosmetic purposes only;
ii. For individuals age 21 or older; and
iii. Except as specified at (d) below, for individuals with less than 24 points on the New Jersey Handicapping Malocclusion Assessment System (see (c) below).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 2 - PROVISIONS FOR SERVICES › Section 10:56-2.16 - Pediatric dental services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In recognition of the unique needs of providing dental care for children, and in conformance with the Federally mandated Early and Periodic Screening, Diagnosis and Treatment program for providing services for children, a special HCPCS code has been defined, "D0150 EP," to be used by dental providers when billing for comprehensive clinical oral evaluations of children.
(b) A dental provider shall bill using the HCPCS code for a comprehensive clinical oral evaluation provided to a child.
1. This evaluation may be either an initial or a periodic evaluation.
2. For determining when this HCPCS code may be used, a child is defined as a person under the age of 21 years.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 2 - PROVISIONS FOR SERVICES › Section 10:56-2.18 - Adjunctive general services: prescriptions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This section is intended to describe the practitioner's responsibility in the writing of prescriptions in order to maintain the traditional beneficiary-prescriber-provider relationship, and to insure the beneficiary free choice of provider. Practitioners are urged to familiarize themselves with all aspects of this section in order to effect economies consistent with good medical/dental practices and to facilitate prompt payment to the provider.
1. The New Jersey Medicaid/NJ FamilyCare program will reimburse pharmaceutical providers for prescriptions prescribed by a dentist within the scope of their practice as defined by the State of New Jersey or the state in which they are practicing.
2. The New Jersey Medicaid/NJ FamilyCare program has an approved generic formulary (see N.J.A.C. 8:71). The prescriber shall give preference to generic drugs of equal therapeutic effectiveness if available at a lower cost than proprietary or brand named drugs. When prescribing a brand named multi-source drug product for which a maximum allowance cost (MAC) limitation has been established by the Secretary of the Department of Health and Human Services, the prescriber shall write "brand medically necessary" on each written prescription. When prescribing a non-MAC brand named drug, the prescriber may initial either "substitution allowed" or "dispense as written (DAW)" on each written prescription.
i. For claims with service dates on or after July 1, 1999, the pharmacist shall dispense the least expensive, therapeutically effective nutritional supplement or specialized infant formula, at the time of dispensing, unless the prescriber indicates in his or her own handwriting on each written prescription, or follow-up written prescription to a telephone rendered prescription, the phrase "Brand Medically Necessary."
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 2 - PROVISIONS FOR SERVICES › Section 10:56-2.19 - Adjunctive general services: medical supplies

Current through Register Vol. 56, No. 14, July 15, 2024
Following receipt of a prescription from the dentist, prior authorization from the Medical Assistance Customer Center shall be obtained by the medical supplier for certain medical supplies; therefore, the practitioner shall be prepared to certify and document dental necessity to the Division dental consultant.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 2 - PROVISIONS FOR SERVICES › Section 10:56-2.20 - Consultations

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Consultations shall be subject to the following conditions:
1. A written report which includes diagnosis and recommendations for future management shall be provided to the referring practitioner. A copy shall be retained with the beneficiary's records and must be available, upon request, to the New Jersey Medicaid/NJ FamilyCare fee-for-service programs or any of their authorized representatives.
i. When the practitioner rendering the consultation services assumes the continuing care of the beneficiary, any subsequent services rendered by him or her will no longer be considered as consultation.
ii. When consultation services are requested, the referring practitioner shall include on the clinical records the name of the consulting practitioner to whom the beneficiary is being referred. The consulting practitioner shall note the diagnosis under Remarks (Item 20) and the name and the Medicaid/NJ FamilyCare Provider Services number of the referring practitioner on the clinical records and on the Dental Claim Form (MC-10) under Referring Practitioner (Item 14).
iii. A consultation shall be disallowed if either or both diagnosis or referring practitioner is missing. However, an examination may be billed alone or in conjunction with other treatment if the beneficiary makes an appointment on his or her own.
iv. A consultation shall be disallowed if performed on the same beneficiary by the same practitioner, members of the same group, members of a shared health care facility, or practitioners sharing a common record within a 12 month span of a prior claim for the same or related disease, illness or condition.
v. A consultation shall be declined in any setting, if the consultation occurs between members of the same group, shared health care facility, or practitioners sharing common records.
vi. If a consultation is billed in an inpatient setting and the beneficiary is then transferred to the service of the consultant, the consultant shall not bill for a Hospital Call.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 2 - PROVISIONS FOR SERVICES › Section 10:56-2.21 - Pharmaceutical: program restrictions affecting payment for prescribed drugs

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The choice of prescribed drugs shall be at the discretion of the prescriber within the limits of applicable laws. However, the prescriber's discretion is limited for certain drugs. Reimbursement shall be denied (except for dentist's prescriptions) if the requirements of the following rules are not met:
1. Covered and non-covered pharmaceutical services as listed in the Pharmaceutical Services chapter at 10:51-1.11 and 1.12, respectively, incorporated herein by reference;
2. Pharmaceutical services requiring prior authorization (see 10:51-1.13, incorporated herein by reference);
3. Quantity of medication (see 10:51-1.14, incorporated herein by reference);
4. Dosage and directions (see 10:51-1.15, incorporated herein by reference);
5. Telephone-rendered original prescriptions (see 10:51-1.16, incorporated herein by reference);
6. Changes or additions to the original prescription (see 10:51-1.17, incorporated herein by reference);
7. Prescription refill (see 10:51-1.18, incorporated herein by reference);
8. Prescription Drug Price and Quality Stabilization Act (24:6E-1 et seq.) (see N.J.A.C. 10:51-1.20, incorporated herein by reference);
i. Products listed in the New Jersey Drug Utilization Review Council (DURC) Formulary, N.J.A.C. 8:71, (hereafter referred to as, "the Formulary"); and
ii. Non-proprietary or generic dispensing (see 10:51-1.9, incorporated herein by reference).
9. Federal regulations ( 42 CFR 447.301, 447.331 - 447.333 ) that set the aggregate upper limits on payment for certain multi-source drugs if Federal Financial Participation (FFP) is to be made available. The limit applies to all "maximum allowable cost" drugs (see 10:51-1.5, Basis of payment, incorporated herein by reference);
10. Drug Efficacy Study Implementation (DESI): "less than effective drugs" subject to a Notice of Opportunity for Hearing (NOOH) by the Federal Food and Drug Administration (see 10:51-1.20 and listing of DESI drugs in Appendix A of N.J.A.C. 10:51, incorporated herein by reference);
11. Drug Manufacturers' Rebate Agreement with the Centers for Medicare & Medicaid Services of the United States Department of Health and Human Services (see 10:51-1.21, incorporated herein by reference);
12. Medical exception process (see 10:56-2.22 ); and
13. Diabetic testing materials, including blood glucose reagent strips, urine monitoring strips, tapes, tablets, and lancets. Electronic blood glucose monitoring devices or other devices used in the monitoring of blood glucose levels are considered medical supplies and are covered services by Medicaid/NJ FamilyCare. These services require prior authorization from the Medical Assistance Customer Center (MACC). (See Medical Supplier Services chapter, N.J.A.C. 10:59.)
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 2 - PROVISIONS FOR SERVICES › Section 10:56-2.22 - Medical exception process (MEP)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For pharmacy claims with service dates on or after September 1, 1999, which exceed PDUR standards recommended by the New Jersey DUR Board and approved by the Commissioners of DHS and DHSS, the Division of Medical Assistance and Health Services has established a Medical Exception Process (MEP).
(b) The medical exception process (MEP) shall be administered by a contractor, referred to as the MEP contractor, under contract with the Department of Human Services.
(c) The medical exception process shall apply to all pharmacy claims, regardless of claim media, unless there is a recommended exemption by the New Jersey DUR Board which has been approved by the Commissioners of DHS and DHSS, in accordance with the rules of those Departments.
(d) The medical exception process (MEP) is as follows:
1. The MEP contractor shall contact prescribers of conflicting drug therapies, or drug therapies which exceed established PDUR standards, to request written justification to determine medical necessity for continued drug utilization.
i. The MEP contractor shall send a Prescriber Notification Letter which includes, but may not be limited to, the beneficiary name, HSP identification number, dispense date, drug quantity, drug description. The prescriber shall be requested to provide the reason for medical exception, diagnosis, expected duration of therapy, and expiration date for medical exception.
ii. The prescriber shall provide information requested on the Prescriber Notification to the MEP contractor.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:56-3.1 - Introduction

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The New Jersey Medicaid/NJ FamilyCare program utilizes the American Dental Association's Code on Dental Procedures and Nomenclature as published in the Current Dental Terminology (CDT) and incorporated herein by reference, as amended and supplemented, and designated by the Centers for Medicare & Medicaid Services (CMS) as the national standard for reporting dental services under the Health Insurance Portability and Accountability Act of 1996, P.L. 104-191. The CDT is published by, and may be obtained from, the American Dental Association, 211 East Chicago Ave., Chicago, Illinois 60611,
http://www.ada.org/
and/or PMIC, 4727 Wilshire Blvd., Suite 300, Los Angeles, CA 90010,
http://www.medicalcodingbooks.com
. Revisions to the CDT (code additions, code deletions and replacement codes) will be reflected in this chapter through publication of a notice of administrative change in the New Jersey Register. Revisions to existing reimbursement amounts specified by the Department and specification of new reimbursement amounts for new codes will be made by rulemaking in accordance with the Administrative Procedure Act, N.J.S.A. 52:14B-1 et seq.
(b) The HCPCS codes listed in this subchapter are divided into 11 sections.
Section 3.2-Diagnostic
Section 3.3-Preventive
Section 3.4-Restorative
Section 3.5-Endodontics
Section 3.6-Periodontics
Section 3.7-Prosthodontics, Removable
Section 3.8-Maxillofacial Prosthetics
Section 3.9-Prosthodontics, Fixed
Section 3.10-Oral Surgery
Section 3.11-Orthodontics
Section 3.12-Adjunctive General Services
(c) The basic categories and their assigned code series are as follows:
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(d) Specific elements of the HCPCS which require the attention of the dental provider are as follows:
1. The lists of HCPCS in the 11 separate sections of this subchapter are arranged in tabular form with specific information for a code given under columns with titles such as: "IND," "HCPCS CODES," "MOD," "DESCRIPTION," and "MAXIMUM FEE ALLOWANCE." The information given under each column is summarized below in (d)2 through 6.
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New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:56-3.3 - D1000-D1999 PREVENTIVE

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Dental prophylaxis:
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NOTE: Patients 16 years of age or older, maxillary and mandibular arches; includes additional scaling.
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NOTE 1: Patients 16 years of age or older, maxillary or mandibular arch, includes additional scaling.
NOTE 2: Code to be used if patient is edentulous in one arch.
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NOTE: Patients up to and including 15 years of age, maxillary and mandibular arches; includes additional scaling, includes additional scaling.
1. The following codes should be used when a beneficiary is developmentally disabled or neurologically impaired. (See N.J.A.C. 10:56-2.9(a)1  ii.)
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NOTE: Patients 16 years of age or older, maxillary and mandibular arches.
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NOTE: Patients up to and including 15 years of age, maxillary and mandibular arches.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:56-3.4 - D2000-D2999 RESTORATIVE

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Amalgam restorations (including polishing):
Maximum Fee
HCPCS
Allowance
IND
Code
Mod
Procedure Description
S
$
NS
D2110
Amalgam--One Surface, Primary
32.00
30.00
D2120
Amalgam--Two Surfaces, Primary
38.00
35.50
D2130
Amalgam--Three Surfaces, Primary
44.00
41.00
D2131
Amalgam--Four or More Surfaces,
51.00
46.50
Primary
D2140
Amalgam--One Surface, Permanent
32.00
30.00
D2150
Amalgam--Two Surfaces, Permanent
38.00
35.50
D2160
Amalgam--Three Surfaces, Permanent
44.00
41.00
D2161
Amalgam--Four or More Surfaces,
51.00
46.50
Permanent
(b) Filled or Unfilled Resin Restorations:
1. Proximal restorations in anterior teeth are normally considered to be single surface restorations. When access to a proximal cavity is gained by involvement of a second surface, reimbursement will be permitted for only one surface. A two or three surface proximal restoration will be reimbursed only when the facial and/or lingual margin(s) of the restoration extends beyond the proximal one-third of the facial and/or lingual surface(s).
2. Reimbursement will include acid etch where appropriate.
D2330
Resin-based composite--One
35.50
33.00
Surface, anterior
D2331
Resin-based composite--Two
42.50
39.00
Surfaces, anterior
D2332
Resin-based composite--Three
49.50
45.00
Surfaces, anterior
D2335
Resin-based composite--Four or
59.50
54.00
more Surfaces or involving incisal
angle (anterior)
D2336
Resin-based composite crown,
40.00
35.00
anterior--primary
D2337
Resin-based composite crown,
40.00
35.00
anterior--permanent
D2380
Resin-based composite--One
32.00
30.00
surface, posterior--primary
D2381
Resin-based--Two surfaces,
38.00
35.00
posterior--primary
D2382
Resin-based composite--three or
44.00
41.00
more surfaces, posterior--primary
For permanent teeth only:
D2385
Resin-based composite--One
32.00
30.00
surface, posterior--permanent
D2386
Resin-based composite--two
38.00
35.50
surfaces, posterior--permanent
D2387
Resin-based composite--three
44.00
41.00
surfaces, posterior--permanent
D2388
Resin-based composite--four or
44.00
41.00
more surfaces, posterior--permanent
NOTE: Code to be used for three or more surfaces.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:56-3.5 - D3000-D3999 ENDODONTICS

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Therapeutic Pulpotomy:
Maximum Fee
HCPCS
Allowance
IND
Code
Mod
Procedure Description
S
$
NS
D3220
Therapeutic Pulpotomy (Excluding
28.00
26.00
Final Restoration)--removal of
pulp coronal to the
Dentinocemental junction and
application of medicament
D3221
Gross pulpal debridement, Primary
28.00
26.00
and Permanent teeth
D3230
Pulpal therapy (resorbable
74.00
67.50
filling)--Anterior, Primary Tooth
(excluding final restoration)
D3240
Pulpal therapy (resorbable
95.00
86.50
filling)--Posterior, Primary Tooth
(excluding final restoration)
(b) Root Canal Therapy (including treatment plan, clinical procedures, and follow-up care):
1. For emergency endodontic procedures, use code D3220.
D3310
Anterior (excluding final
148.00
135.00
restoration)
NOTE: Code to be used for incisors and cuspids (permanent).
D3320
Bicuspid (excluding final
190.00
173.00
restoration)
NOTE: Code to be used for premolars and all primary teeth without permanent successors.
D3330
Molar (excluding final restoration)
247.00
225.00
NOTE: Code to be used for molars (permanent).
D3346
Retreatment of previous root canal
148.00
135.00
therapy--anterior
D3347
Retreatment of previous root canal
190.00
173.00
therapy--bicuspid
D3348
Retreatment of previous root canal
247.00
225.00
therapy--molar
D3351
Apexification/ recalcification--In
31.00
27.00
itial visit (apical
closure/calcific repair of
perforations, root resorption,
etc.)
NOTE 1: Treatment may extend over a period of six to 18 months.
NOTE 2: Maximum--two visits.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:56-3.6 - D4000 D4999 PERIODONTICS

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Surgical services (including usual post-operative services):
Maximum Fee
HCPCS
Allowance
IND
Code
Mod
Procedure Description
S
$
NS
#
D4210
Gingivectomy or Gingivoplasty--Per
43.60
37.50
Quadrant
*
D4211
Gingivectomy or Gingivoplasty--Per
6.00
5.50
Tooth
NOTE 1: Maximum number of teeth reimbursable--Three.
NOTE 2: D4210 PA required only when exceeding four quadrants, twice annually.
#
D4220
Gingival Curettage, Surgical--Per
22.50
19.50
Quadrant
#
D4260
Osseous Surgery (including Flap
75.00
64.50
Entry and Closure)--Per Quadrant
*
D4261
Osseous, Single Site
56.25
48.40
*
D4263
Bone Replacement Graft First Site
261.00
261.00
in Quadrant
*
D4264
Bone Replacement Graft--Each
130.50
130.50
Additional Site in Quadrant (Use
if Performed on Same Date of
Service)
#
D4270
Pedicle Soft Tissue Graft Procedure
32.00
28.00
NOTE 1: Per site.
NOTE 2: D4220, D4260, D4261, D4270 PA required only for services exceeding four quadrants, twice annually.
#
D4271
Free Soft Tissue Graft Procedure
49.00
42.00
(Including Donor Site)
NOTE: Per site.
*
D4245
Apically Positioned Flap
36.00
31.50
NOTE: Per quadrant.
*
D4249
Clinical Crown Lengthening--Hard
75.00
64.50
Tissue
NOTE: Per quadrant.
*
D4274
Distal or Proximal Wedge Procedure
169.00
153.00
(When Not Performed in Conjunction
with Surgical Procedures in the
same Anatomical Area)
(b) Adjunctive periodontal services:
D4320
Provisional Splinting--Intracoronal
18.00
16.00
NOTE: Per tooth.
D4321
Provisional Splinting--Extracoronal
11.00
10.00
NOTE 1: Per tooth.
NOTE 2: This code may also be used for stabilization of traumatized teeth.
#
D4341
Periodontal Scaling and Root
37.50
34.50
Planing--Per Quadrant
D4355
Full Mouth Debridement to Enable
11.00
10.00
Comprehensive Periodontal
Evaluation and Diagnosis
D4355
76
Full Mouth Debridement to Enable
11.00
10.00
Comprehensive Periodontal
Evaluation and Diagnosis
NOTE 1: Code to replace Y2105-76--additional scaling.
NOTE 2: Code to be used when the beneficiary is developmentally disabled * [on]* *or* neurologically impaired (see 10:56-2.9(a)1  ii).
NOTE 3: D4341 PA required for services exceeding four quadrants, twice annually.
d*
D4999
Unspecified Periodontal Procedure,
BR
BR
By Report
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:56-3.7 - D5000-D5899 PROSTHODONTICS (REMOVABLE)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Complete dentures (including six months post delivery care):
Maximum Fee
HCPCS
Allowance
IND
Code
Mod
Procedure Description
S
$
NS
*
D5110
Complete Denture--Maxillary
334.00
302.00
NOTE: Including denture I.D.
*
D5120
Complete Denture--Mandibular
342.00
311.00
NOTE: Including denture I.D.
(b) Immediate complete dentures (six months post delivery care and placement of ID is included in fee):
1. Reimbursement also includes necessary rebases and/or relines for the six months following insertion.
2. In order to qualify for immediate denture reimbursement, the denture must involve the immediate replacement of anterior teeth which may include first premolars (teeth numbers 5 through 12 and 21 through 28 only). Second premolars and molars must not be included among the qualifying teeth. The date of insertion of a denture and the extractions must carry an identical date of service. List tooth code(s) of teeth involved.
*
D5130
Immediate Denture--Maxillary
365.00
332.00
NOTE 1: Replacing 1 through 4 teeth
*
D5130
22
Immediate Denture--Maxillary
392.00
353.00
NOTE 1: Replacing 5 through 8 teeth
*
D5140
Immediate Denture--Mandibular
372.00
338.00
NOTE 1: Replacing 1 through 4 teeth
*
D5140
22
Immediate Denture--Mandibular
400.00
363.00
NOTE 1: Replacing 5 through 8 teeth
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:56-3.8 - D5900-D5999 MAXILLOFACIAL PROSTHETICS

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Treatment prosthesis:
Maximum Fee
HCPCS
Allowance
IND
Code
Mod
Procedure Description
S
$
NS
D5931
Obturator prosthesis, surgical
250.00
250.00
D5936
Obturator prosthesis, interim
200.00
200.00
D5937
Trismus appliance (not for TMD
125.00
125.00
treatment)
D5951
Feeding aid
500.00
500.00
D5952
Speech aid prosthesis, pediatric
450.00
450.00
D5953
Speech aid prosthesis, adult
450.00
450.00
D5982
Surgical Stent
50.00
43.00
D5986
Fluoride gel carrier
30.00
30.00
D5988
Surgical splint
250.00
250.00
*
D5999
Unspecified Maxillofacial
BR
BR
Prosthesis, by report
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:56-3.9 - D6000-D6999 PROSTHODONTICS, FIXED

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each abutment and each pontic constitutes a unit in a bridge.
1. The Noble Metal Classification System has been adopted as a more precise method of reporting various alloys used in dentistry. The alloys are defined on the basis of the percentage of noble metal content.
High
Predominantly
Noble
Noble
Base
Classification
Alloy
Alloy
Alloy
Weight %
Au., Pd. and/or
Au., Pd. and/or
Au., Pd. and/or
Pt. > 60% (with
Pt. > 25%
Pt. < 25%
at least 40% Au)
2. There is only one fee for each type of pontic or crown. Use the type of alloy most appropriate for the patient's needs.
Implant services:
Maximum Fee
HCPCS
Allowance
IND
Code
Mod
Procedure Description
S
$
NS
*
D6010
Surgical placement of implant
500.00
500.00
body: endosteal implant
*
D6056
Prefabricated abutment
76.00
70.00
*
D6059
Abutment supported porcelain fused
279.00
253.00
to metal crown (high noble metal)
*
D6060
Abutment supported porcelain fused
279.00
253.00
to metal crown (predominantly base
metal)
*
D6061
Abutment supported porcelain fused
279.00
253.00
to metal crown (noble metal)
*
D6062
Abutment supported cast metal
161.00
140.00
crown (high noble metal)
*
D6063
Abutment supported cast metal
161.00
140.00
crown (predominantly base metal)
*
D6064
Abutment supported cast metal
161.00
140.00
crown (noble metal)
*
D6066
Implant supported porcelain fused
279.00
253.00
to metal crown (titanium, titanium
alloy, high noble metal)
*
D6067
Implant supported metal crown
161.00
140.00
(titanium, titanium alloy, high
noble metal)
*
D6069
Abutment supported retainer for
279.00
253.00
porcelain fused to metal FPD (high
noble metal)
*
D6070
Abutment supported retainer for
279.00
256.00
porcelain fused to metal FPD
(predominantly base metal)
*
D6071
Abutment supported retainer for
279.00
256.00
porcelain fused to metal FPD
(noble metal)
*
D6072
Abutment supported retainer for
161.00
140.00
cast metal FPD (high noble metal)
*
D6073
Abutment supported retainer for
161.00
140.00
cast metal FPD (predominantly base
metal)
*
D6074
Abutment supported retainer for
161.00
140.00
cast metal FPD (noble metal)
*
D6199
Unspecified implant procedure, by
BR
BR
report
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:56-3.10 - D7000-D7999 ORAL SURGERY

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Extractions--includes local anesthesia and routine post-operative care:
Maximum Fee
HCPCS
Allowance
IND
Code
Mod
Procedure Description
S
$
NS
D7110
Single Tooth
32.00
30.00
D7120
Extraction--each additional tooth
32.00
30.00
D7130
Root Removal--Exposed Roots
19.50
18.00
NOTE 1: Per tooth.
(b) Surgical extractions--includes local anesthesia and routine post-operative care:
1. Prior authorization for the removal of impacted teeth is necessary for those beneficiaries up to and including 17 years of age as denoted by those codes with the "#" (cross-hatch) indicator.
#
D7210
Surgical Removal of Erupted Tooth
33.00
31.00
Requiring Elevation of
Mucoperiosteal Flap and Removal of
Bone and/or Section of Tooth
#
D7220
Removal of Impacted Tooth--Soft
43.00
40.00
Tissue
#
D7230
Removal of Impacted
114.00
106.00
Tooth--Partially Bony
#
D7240
Removal of Impacted
114.00
106.00
Tooth--Completely Bony
#
D7250
Surgical Removal of Residual Tooth
43.00
39.00
Roots (Cutting Procedure)
NOTE: Includes cutting of soft tissue and bone, removal of tooth structure and closure.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:56-3.11 - D8000-D8999 ORTHODONTICS

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Minor treatment for tooth guidance:
1. Includes all necessary adjustments.
2. Code may also be used for Orthodontic Retention Appliances following comprehensive treatment by a previous dentist.
Maximum Fee
HCPCS
Allowance
IND
Code
Mod
Procedure Description
S
$
NS
D8010
Limited orthodontic treatment of
595.00
590.00
the primary dentition
D8020
Limited orthodontic treatment of
595.00
590.00
the transitional dentition
D8030
Limited orthodontic treatment of
595.00
590.00
the adolescent dentition
D8040
Limited orthodontic treatment of
595.00
590.00
the adult dentition
D8050
Interceptive orthodontic treatment
595.00
590.00
of the primary dentition
D8060
Interceptive orthodontic treatment
595.00
590.00
of the transitional dentition
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:56-3.12 - D9000-D9999 ADJUNCTIVE GENERAL SERVICES

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Unclassified treatment:
Maximum Fee
HCPCS
Allowance
IND
Code
Mod
Procedure Description
S
$
NS
d
D9110
Palliative (Emergency) Treatment
10.00
9.00
of Dental Pain--Minor Procedures
NOTE: Emergency treatment of dental pain or infection, palliative (flat fee for all services performed, when not covered by separately listed procedure). Diagnosis and description of treatment is required. Per tooth or per site.
(b) Anesthesia:
D9210
Local Anesthesia Not in
13.00
11.00
Conjunction with Operative or
Surgical Procedures
NOTE 1: Infiltration and/or nerve block for diagnostic purposes or purposes other than anesthesia.
NOTE 2: Complete report must be available in patient records.
D9211
Regional block anesthesia
13.00
11.00
D9212
Trigeminal division block
18.00
16.00
anesthesia
D9220
22
General Anesthesia
125.00
125.00
NOTE: This code applies when the dentist performing the services (attending dentist) also administers the general anesthesia or in conjunction with oral surgery services only.
(c) Special general anesthesia:
1. (Basic units--See American Society of Anesthesiologists Relative Value Guide--2000).
D9220
General anesthesia--first 30
22.00
22.00
minutes
D9221
General anesthesia--each
11.00
11.00
additional 15 minutes
NOTE 1: Time units are for each additional 15 minute period or major portion thereof limited to "table" or "chair" time only. Maximum reimbursable is two hours.
NOTE 2: The general anesthesia codes above are limited to use in restorative dentistry alone or restorative dentistry in conjunction with other dental services requiring anesthetic management. These codes are reimbursable only to the dentist whose sole function is to administer general anesthesia.
NOTE 3: An anesthesia record must be available which shows elapsed anesthesia time, and pinpoints time and amounts of drugs administered, pulse rate and character, blood pressure, respiration, and so forth.
D9230
Analgesia, anxiolysis, inhalation
15.00
14.00
of nitrous oxide
D9241
Intravenous sedation/
50.00
49.00
analgesia--first 30 minutes
NOTE: Parenteral Conscious Sedation.
D9242
Intravenous sedation/
11.00
11.00
analgesia--each additional 15
minutes
NOTE: Maximum reimbursable is eight units.
D9248
Non-intravenous conscious sedation
40.00
40.00
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Appendix A - FISCAL AGENT BILLING SUPPLEMENT

Current through Register Vol. 56, No. 14, July 15, 2024
FISCAL AGENT BILLING SUPPLEMENT
AGENCY NOTE: The Fiscal Agent Billing Supplement is filed as an incorporated Appendix of this chapter but is not reproduced in the New Jersey Administrative Code. When revisions are made to the fiscal agent billing supplement, copies will be filed with the Office of Administrative Law and revisions will be made available to providers. For a copy of the Fiscal Agent Billing Supplement, access
www.njmmis.com
or write to:
Unisys
PO Box 4801
Trenton, New Jersey 08650-4801
or contact:
Office of Administrative Law
Quakerbridge Plaza, Building 9
PO Box 049
Trenton, New Jersey 08625-0049
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 57 - PODIATRY SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:57-1.1 - Introduction

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This chapter is concerned with the provision of podiatric services by a person licensed to practice podiatry in accordance with the New Jersey Medicaid/NJ FamilyCare programs, policies, and procedures and the standards of practice as defined by the laws of the State of New Jersey (N.J.S.A. 45:5-1et seq.) and the American Podiatric Medical Association.
(b) An approved New Jersey Medicaid/NJ FamilyCare provider of podiatric services may be reimbursed for medically necessary covered services provided within the scope of her or his license, and her or his approved New Jersey Medicaid/NJ FamilyCare fee-for-service programs Provider Agreement.
(c) A podiatrist may enroll in the New Jersey Medicaid/NJ FamilyCare fee-for-service programs and provide covered, medically necessary services as an independent practitioner, or may provide such services as part of another entity, such as a hospital or clinic, physician group practice, a mixed practitioner practice, or under the managed care program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 57 - PODIATRY SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:57-1.2 - Scope of services

Current through Register Vol. 56, No. 14, July 15, 2024
Podiatry care under the Medicaid/NJ FamilyCare programs is allowable to covered persons if such services are essential. Essential podiatric care includes those services that require the professional knowledge and skill of a licensed podiatrist. For beneficiaries in the Medically Needy Program, podiatric care is only available to pregnant women, and the aged, the blind, or disabled. (For information on how to identify a covered person, please refer to N.J.A.C. 10:49-2.)
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 57 - PODIATRY SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:57-1.3 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this chapter, shall have the following meanings unless the context clearly indicates otherwise.
"CPT" means that edition of the Current Procedural Terminology most current at the time of reference, as published annually by the American Medical Association, Chicago, Illinois, unless otherwise specified in rule.
"Flat-foot conditions" means the local condition of flattened arches regardless of the underlying etiology. Treatment of flat-foot conditions encompasses all phases of services in connection with flat feet.
"Podiatrist" means a doctor of podiatric medicine licensed to practice podiatry by the New Jersey State Board of Medical Examiners, or similarly licensed by a comparable agency in the state in which he or she practices.
"Podiatry services" means those services performed by a licensed podiatrist within the scope of practice as defined by the laws of the State of New Jersey (N.J.S.A. 45:5-7) and that are within the scope of the services covered by the New Jersey Medicaid/NJ FamilyCare program.
"Routine foot care" means the cutting or removal of corns or calluses, the trimming of nails, and other hygienic and preventive maintenance care in the realm of self-care, such as cleaning and soaking the feet, the use of skin creams to maintain skin tone for both ambulatory and bedfast patients, and any services performed in the absence of localized illnesses, injury or symptoms involving the foot.
"Specialist" for purposes of the New Jersey Medicaid/NJ FamilyCare program, means a fully licensed podiatrist who:
1. Is a diplomate of the appropriate specialty board as recognized by the American Podiatric Medical Association; or
2. Has been notified of board eligibility by the appropriate specialty board as recognized by the American Podiatric Medical Association.
"Subluxation" means the structural misalignment of the joints of the feet which do not require surgical methods of treatment and/or correction, with the exception of fractures and complete dislocations.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 57 - PODIATRY SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:57-1.4 - Provisions for provider participation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In order to participate in the Medicaid/NJ FamilyCare programs, a podiatrist shall apply to, and be approved by, the New Jersey Medicaid/NJ FamilyCare program. Application for approval by the New Jersey Medicaid/NJ FamilyCare program requires completion and submission of the "Medicaid Provider Application" (FD-20) and the "Medicaid Provider Agreement" (FD-62).
1. The documents referenced in (a) above are located as Forms #8 and #9 in the Appendix at the end of the Administration Chapter (N.J.A.C. 10:49), and may be obtained from, and submitted to:
DXC Technology
Provider Enrollment
PO Box 4804
Trenton, New Jersey 08650-4804
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 57 - PODIATRY SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:57-1.5 - Prior authorization

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Authorization by the Podiatry Services Unit ("Unit"), Division of Medical Assistance and Health Services, PO Box 712, Trenton, New Jersey 08625-0712, shall be obtained prior to the provision of the following services:
1. All orthopedic footwear;
2. Custom molded foot or ankle orthoses;
3. Routine debridement of toenails, more than once every two months.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 57 - PODIATRY SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:57-1.6 - Basis of reimbursement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Reimbursement for podiatry services covered under the New Jersey Medicaid/NJ FamilyCare fee-for-service program shall be on the basis of the customary charge, not to exceed a fixed fee schedule determined reasonable by the Commissioner, Department of Human Services (see N.J.A.C. 10:57-3for fee schedule), and further limited by Federal policy relative to payment of practitioners and other individual providers. In no event shall the payment exceed the charge by the provider for identical services to other governmental agencies, or other groups or individuals in the community.
(b) Any podiatric physician who meets the above cited qualifications listed in N.J.A.C. 10:57-1.3as a specialist and the requirements specified in N.J.A.C. 10:57-1.4shall be eligible for specialist reimbursement.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 57 - PODIATRY SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:57-1.7 - Personal contribution to care requirements for NJ FamilyCare-Plan C and copayments for NJ FamilyCare-Plan D

Current through Register Vol. 56, No. 14, July 15, 2024
(a) General policies regarding the collection of personal contribution to care for NJ FamilyCare-Plan C and copayments for NJ FamilyCare-Plan D are set forth at N.J.A.C. 10:49-9.
(b) Personal contribution to care for NJ FamilyCare-Plan C services is $5.00 per visit for podiatric services.
1. A podiatric visit is defined as a face-to-face contact with a medical professional, including services provided under the supervision of the podiatrist, which meets the documentation requirements of this chapter and allows the podiatrist to request reimbursement for services.
2. Podiatric visits include podiatric services provided in the office, patient's home, or any other site, except any site of the hospital, where the child may have been examined by the podiatrist or the podiatric staff.
3. The podiatrist shall collect one personal contribution to care per podiatric visit, regardless of the number of podiatric services provided in the session.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 57 - PODIATRY SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:57-1.8 - Record keeping

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Podiatrists shall keep such individual records as are necessary to fully disclose the kind and extent of the services provided and shall make such information available as the Division or its agents may request. For the initial examination, the following documentation shall be on the record, regardless of the setting where the examination was performed:
1. Date of service;
2. Chief complaint(s);
3. Pertinent historical and physical data;
4. Reports of diagnostic procedures ordered or performed;
5. Diagnosis;
6. Prescription (including medication) and treatment.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 57 - PODIATRY SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:57-2.1 - Covered and non-covered services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following foot care services shall not be covered:
1. Flat-foot conditions:
i. Exceptions:
(1) Treatment which is an integral part of post-fracture or postoperative treatment plan;
(2) Supportive devices (for example, arch supports, specific additions to shoes and the like) which are prescribed to palliate pain and other symptoms associated with the condition.