Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-535 - Dental-related services › GENERAL › Section 182-535-1094 - Dental-related services-Covered-Oral and maxillofacial surgery services

Current through Register Vol. 24-14, July 15, 2024
Clients described in WAC
					 182-535-1060
					 are eligible to receive the oral and maxillofacial surgery services listed in
					 this section, subject to the coverage limitations, restrictions, and clientage
					 requirements identified for a specific service.
(1)
Oral and maxillofacial surgery
				  services.
The medicaid agency:
(a)
				  Requires enrolled providers who do not meet the conditions in WAC
				  182-535-1070(3)
				  to bill claims for services that are listed in this subsection using only the
				  current dental terminology (CDT) codes.
(b) Requires enrolled providers (oral and
				  maxillofacial surgeons) who meet the conditions in WAC
				  182-535-1070(3)
				  to bill claims using current procedural terminology (CPT) codes unless the
				  procedure is specifically listed in the agency's current published billing
				  guide as a CDT covered code (e.g., extractions).
(c) Covers nonemergency oral surgery
				  performed in a hospital or ambulatory surgery center only for:
(i) Clients age eight and younger;
(ii) Clients age nine through twenty. Prior
				  authorization is required for the site of service; and
(iii) Clients any age of the developmental
				  disabilities administration of the department of social and health services
				  (DSHS).
(d) For
				  site-of-service and oral surgery CPT codes that require prior authorization,
				  the agency requires the dental provider to submit current records (within the
				  past twelve months), including:
(i)
				  Documentation used to determine medical appropriateness;
(ii) Cephalometric films;
(iii) Radiographs (X-rays);
(iv) Photographs; and
(v) Written narrative/letter of medical
				  necessity, including proposed billing codes.
(e) Requires the client's dental record to
				  include supporting documentation for each type of extraction or any other
				  surgical procedure billed to the agency. The documentation must include:
(i) Appropriate consent form signed by the
				  client or the client's legal representative;
(ii) Appropriate radiographs;
(iii) Medical justification with
				  diagnosis;
(iv) Client's blood
				  pressure, when appropriate;
(v) A
				  surgical narrative and complete description of each service performed beyond
				  surgical extraction or beyond code definition;
(vi) A copy of the post-operative
				  instructions; and
(vii) A copy of
				  all pre- and post-operative prescriptions.
(f) Covers simple and surgical
				  extractions.
(g) Covers unusual,
				  complicated surgical extractions with prior authorization.
(h) Covers tooth reimplantation/stabilization
				  of accidentally evulsed or displaced teeth.
(i) Covers surgical extraction of unerupted
				  teeth.
(j) Covers debridement of a
				  granuloma or cyst that is five millimeters or greater in diameter. The agency
				  includes debridement of a granuloma or cyst that is less than five millimeters
				  as part of the global fee for the extraction.
(k) Covers biopsy of soft oral tissue, brush
				  biopsy, and surgical excision of soft tissue lesions. Providers must keep all
				  biopsy reports or findings in the client's dental record.
(l) Covers only the following excisions of
				  bone tissue in conjunction with placement of complete or partial dentures:
(i) Removal of lateral exostosis;
(ii) Removal of torus palatinus or torus
				  mandibularis;
(iii) Surgical
				  reduction of osseous tuberosity.