New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:56-3.2 - D0100-D0999 DIAGNOSTIC

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Clinical Oral Examination:
Maximum Fee
HCPCS
Allowance
IND
Code
Mod
Procedure Description
S
$
NS
D0150
Comprehensive oral evaluation
15.00
14.00
NOTE 1: This code is to be used for comprehensive clinical oral evaluation of a Medicaid/NJ FamilyCare fee-for-service beneficiary.
NOTE 2: This code requires a thorough observation of all conditions present in the oral cavity and contiguous structures to include:
a. An oral cancer screening;
b. Charting of all abnormalities;
c. Development of a complete treatment plan to be recorded in its entirety, including provisions for further treatment and follow-up, by referral if necessary;
NOTE 3: For reimbursement of the comprehensive oral evaluation with code D0150:
a. The examination is limited to once every six months for patients under 21 years of age and every 12 months for patients over 21 years of age, except as authorized by a dental consultant of the New Jersey Medicaid/NJ FamilyCare program;
b. All items on the Dental Services Claim form (MC-10) should be completed;
c. If no other treatment is necessary, this fact must be noted on the Dental Services Claim form (MC-10) in the diagnosis box (20). The abbreviation "NOTN" may be used to indicate no other treatment needed.
D0150
76
Comprehensive oral evaluation
14.00
13.00
NOTE 1: This code is to be used only if a beneficiary is developmentally disabled or neurologically impaired (see 10:56-2.9(a)1  ii), in which case an examination may be provided as often as every three months and may be submitted directly to the fiscal agent for payment without prior authorization. The nature of the beneficiary's disability must be recorded under "Remarks" on the Dental Services Claim form (MC-10).
D0150
EP
Comprehensive oral evaluation
25.00
21.00
NOTE 1:
a.This code is to be used for comprehensive oral evaluation of a Medicaid/NJ FamilyCare fee-for-service beneficiary through and including the age of 20.
b. This code is to be used for comprehensive oral evaluation referred from EPSDT screenings.
NOTE 2: This code requires a thorough observation of all conditions present in the oral cavity and contiguous structures to include:
a. An oral cancer screening;
b. Assessment of dental development;
c. Charting of all abnormalities;
d. Development of a complete treatment plan to be recorded in its entirety, including provisions for further treatment and follow-up, by referral if necessary;
e. Anticipatory guidance concerning dental health to the patient or parent/guardian;
f. Assessment of the caries index and nutritional needs relating to oral health and oral hygiene practices;
g. Assessment of systemic or topical fluoride needs.
NOTE 3: For reimbursement of the comprehensive oral evaluation with code D0150 EP:
a. The examination is limited to once every six months for patients under 21 years of age, except as authorized by a dental consultant of the New Jersey Medicaid/NJ FamilyCare program;
b. All items on the Dental Services Claim form (MC-10) should be completed;
c. If no other treatment is necessary, this fact must be noted on the Dental Services Claim form (MC-10) in the diagnosis box (20). The abbreviation "NOTN" may be used to indicate no other treatment needed.
D0120
Periodic Oral Evaluation
15.00
14.00
NOTE: An evaluation performed on a patient of record to determine any changes in the patient's oral health status since a previous initial or periodic examination.
D0120
EP
Periodic Oral Evaluation
15.00
14.00
NOTE: This code is to be used with an EPSDT referral on a patient of record to determine any changes in the patient's oral health status since a previous initial or periodic examination.
d
D0140
Limited oral evaluation
4.00
3.00
NOTE: Make note of diagnosis and/or observation(s) on the Dental Services Claim form (MC-10).
D0160
Detailed and extensive oral
14.00
13.00
evaluation problem focused by
report.
D0170
Re-evaluation--limited, problem
14.00
13.00
focused (Established patient; not
post-operative visit)