Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MASSHEALTH TRANSMITTAL LETTER DEN-73 January 2006 TO: Dental Providers Participating in MassHealth FROM: Beth Waldman, Medicaid Director RE: Coverage of Comprehensive Dental Benefits for Pregnant Women and for Mothers with a Child Under the Age of Three Years Effective for dates of service on or after January 15, 2006, MassHealth members aged 21 and older who are either pregnant or a mother with a child under the age of three years are eligible for the same services as those covered for members who meet the “special circumstances” criteria described in 130 CMR 420.432 through 420.439. All other conditions of payment in 130 CMR 420.000 and 450.000 still apply. Covered Services Services covered beginning January 15, 2006, for pregnant women and for mothers with a child under the age of three years, include services in the following categories, subject to the same service limitations described in 130 CMR 420.432 through 420.439 for members aged 21 and older who meet the special circumstances criteria: • emergency care visits; • diagnostic services, including oral evaluation (comprehensive and periodic); • radiographs; • preventive services, including prophylaxis, periodontal scaling and root planing, and gingivectomy or gingivoplasty; • restorative services, including amalgam restorations, composite resin restorations, reinforcing pins, and crowns for anterior teeth; • endodontic services, including root canals for anterior teeth; • prosthodontic services, including full and partial dentures; • exodontic services (extractions); and • oral surgery. Note: Members who are either pregnant or mothers with children under the age of three years, do not need to qualify as “special circumstances” in order to receive these covered services. Billing Instructions To be paid for services provided to a pregnant member or to a mother with a child under the age of three years, the provider must: • ask the member if she is either pregnant or a mother with a child under the age of three years; • document in the dental record of any such member to reflect that she is either pregnant or a mother with a child under the age of three years, as applicable; MASSHEALTH TRANSMITTAL LETTER DEN-73 January 2006 Page 2 • for paper claims, attach to the claim, a written statement on an 8 ½” by 11” piece of paper that states the member attested to either being pregnant or a mother with a child under the age of three years; • for electronic claims, enter text in the comments section of the claim that the member attested to being either pregnant or a mother with a child under the age of three years; and • submit the claim in accordance with the billing instructions in your provider manual or your companion guide, as applicable. If you have any questions about the information in this transmittal letter please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. NEW MATERIAL (The pages listed here contain new or revised language.) Dental Manual Pages iv, iv-a, 4-1, 4-2, 4-37, 4-38, and 6-1 through 6-10 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Dental Manual Page iv — transmitted by Transmittal Letter DEN-72 Page iv-a — transmitted by Transmittal Letter DEN-59 Pages 4-1 and 4-2 — transmitted by Transmittal Letter DEN-64 Pages 4-37 and 4-38 — transmitted by Transmittal Letter DEN-62 Pages 6-1 through 6-10 — transmitted by Transmittal Letter DEN-71 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series DENTAL MANUAL SUBCHAPTER NUMBER AND TITLE TABLE OF CONTENTS PAGE iv TRANSMITTAL LETTER DEN-73 DATE 01/15/06 4. PROGRAM REGULATIONS 420.401: Introduction 4-1 420.402: Definitions 4-1 420.403: Eligible Members 4-2 420.404: Provider Eligibility: Participating Providers 4-3 420.405: Provider Eligibility 4-3 (130 CMR 420.406 Reserved) 420.407: Maximum Allowable Fees 4-4 420.408: Noncovered Services 4-5 420.409: Noncovered Circumstances 4-6 420.410: Prior Authorization 4-6 420.411: Pretreatment Review 4-9 420.412: Individual Consideration 4-9 420.413: Separate Procedures 4-9 420.414: Recordkeeping Requirements 4-9 420.415: Report Requirements 4-10 420.416: Pharmacy Services: Prescription Requirements 4-11 420.417: Pharmacy Services: Covered Drugs and Medical Supplies 4-12 420.418: Pharmacy Services: Limitations on Coverage of Drugs 4-12 420.419: Pharmacy Services: Prior Authorization 4-14 420.420: Pharmacy Services: Member Copayments 4-15 420.421: Service Descriptions and Limitations: Introduction — Members Under Age 21 4-15 420.422: Service Descriptions and Limitations: Diagnostic Services — Members Under Age 21 4-15 420.423: Service Descriptions and Limitations: Radiographs — Members Under Age 21 4-16 420.424: Service Descriptions and Limitations: Preventive Services — Members Under Age 21 4-18 420.425: Service Descriptions and Limitations: Restorative Services — Members Under Age 21 4-20 420.426: Service Descriptions and Limitations: Endodontic Services — Members Under Age 21 4-22 420.427: Service Descriptions and Limitations: Prosthodontic Services — Members Under Age 21 4-23 420.428: Service Descriptions and Limitations: Orthodontic Services — Members Under Age 21 4-27 420.429: Service Descriptions and Limitations: Exodontic Services — Members Under Age 21 4-31 (130 CMR 420.430 and 420.431 Reserved) 420.432: Service Descriptions and Limitations: Introduction — Members Aged 21 and Older Who Meet the Special Circumstances Criteria 4-34 420.433: Service Descriptions and Limitations: Diagnostic Services — Members Aged 21 and Older Who Meet the Special Circumstances Criteria 4-34 420.434: Service Descriptions and Limitations: Radiographs — Members Aged 21 and Older Who Meet the Special Circumstances Criteria 4-34 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series DENTAL MANUAL SUBCHAPTER NUMBER AND TITLE TABLE OF CONTENTS PAGE iv-a TRANSMITTAL LETTER DEN-73 DATE 01/15/06 4. PROGRAM REGULATIONS (cont.) 420.435: Service Descriptions and Limitations: Preventive Services — Members Aged 21 and Older Who Meet the Special Circumstances Criteria 4-35 420.436: Service Descriptions and Limitations: Restorative Services — Members Aged 21 and Older Who Meet the Special Circumstances Criteria 4-35 420.437: Service Descriptions and Limitations: Endodontic Services — Members Aged 21 and Older Who Meet the Special Circumstances Criteria 4-36 420.438: Service Descriptions and Limitations: Prosthodontic Services — Members Aged 21 and Older Who Meet the Special Circumstances Criteria 4-36 420.439: Service Descriptions and Limitations: Exodontic Services — Members Aged 21 and Older Who Meet the Special Circumstances Criteria 4-37 420.440: Service Description and Limitations: Introduction – Members Aged 21 and Older Who Are Either Pregnant or Mothers with a Child Under the Age of Three Years 4-37 (130 CMR 420.441 Reserved) 420.442: Service Descriptions and Limitations: Introduction — Other Members Aged 21 and Older 4-37 420.443: Service Descriptions and Limitations: Diagnostic Services — Other Members Aged 21 and Older 4-37 420.444: Service Descriptions and Limitations: Radiographs — Other Members Aged 21 and Older 4-37 420.445: Service Descriptions and Limitations: Preventive Services — Other Members Aged 21 and Older 4-38 420.446: Service Descriptions and Limitations: Restorative Services — Other Members Aged 21 and Older 4-38 420.447: Service Descriptions and Limitations: Endodontic Services — Other Members Aged 21 and Older 4-38 420.448: Service Descriptions and Limitations: Prosthodontic Services — Other Members Aged 21 and Older 4-38 420.449: Service Descriptions and Limitations: Exodontic Services — Other Members Aged 21 and Older 4-39 (130 CMR 420.450 Reserved) 420.451: Service Descriptions and Limitations: Introduction — All Members 4-40 420.452: Service Descriptions and Limitations: General Anesthesia and IV Sedation — All Members 4-40 420.453: Service Descriptions and Limitations: Oral and Maxillofacial Surgery Services — All Members 4-40 420.454: Service Descriptions and Limitations: Oral and Maxillofacial Surgery Procedures — All Members 4-42 420.455: Service Descriptions and Limitations: Maxillofacial Prosthetics — All Members 4-43 420.456: Service Descriptions and Limitations: Other Services — All Members 4-43 420.457: Dental Management of Members With Certain Disabilities in the Office 4-45 (130 CMR 420.458 through 420.460 Reserved) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series DENTAL MANUAL SUBCHAPTER NUMBER AND TITLE 4 PROGRAM REGULATIONS (130 CMR 420.000) PAGE 4-1 TRANSMITTAL LETTER DEN-73 DATE 01/15/06 420.401: Introduction (A) 130 CMR 420.000 contains regulations governing dental services under MassHealth. All dental providers participating in MassHealth must comply with the regulations of the MassHealth agency governing MassHealth, including but not limited to the MassHealth agency regulations at 130 CMR 420.000 and 450.000. (B) In general, and as further described below, coverage of dental services varies for (1) members under age 21; (2) members aged 21 and older with special circumstances that meet the criteria in 130 CMR 420.410(D); (3) members aged 21 and older who are either pregnant or a mother with a child under the age of three years; and (4) all other members aged 21 and older. (C) Coverage for members under age 21 includes services essential for the prevention and control of dental diseases and the maintenance of oral health. Coverage for members aged 21 and older with special circumstances that meet the criteria in 130 CMR 420.410(D) is similar, but not identical, to coverage for members under age 21. Coverage for all other members aged 21 and older includes emergency care, exodontic services, oral surgery, and some X-ray services. (D) The service descriptions and limitations applicable to each group are set forth in the regulations that follow. Where noted, certain service descriptions are the same for all members, regardless of age or circumstances. 420.402: Definitions The following terms used in 130 CMR 420.000 have the meanings given in 130 CMR 420.402, unless the context clearly requires a different meaning. The reimbursability of services defined in 130 CMR 420.000 is not determined by these definitions, but by application of regulations elsewhere in 130 CMR 420.000 and in 130 CMR 450.000. Controlled Substance – a drug listed in Schedules II, III, IV, V, or VI of the Massachusetts Controlled Substances Act (M.G.L. c. 94C). Drug – a substance containing one or more active ingredients in a specified dosage form and strength. Each dosage form and strength is a separate drug. Interchangeable Drug Product – a product containing a drug in the same amounts of the same active ingredients in the same dosage form as another product with the same generic or chemical name that has been determined to be therapeutically equivalent (that is, “A”-rated) by the Food and Drug Administration for Drug Evaluation and Research (FDA CDER), or by the Massachusetts Drug Formulary Commission. Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series DENTAL MANUAL SUBCHAPTER NUMBER AND TITLE 4 PROGRAM REGULATIONS (130 CMR 420.000) PAGE 4-2 TRANSMITTAL LETTER DEN-73 DATE 01/15/06 Legend Drug – any drug for which a prescription is required by applicable federal or state law or regulation. MassHealth Drug List – a list of commonly prescribed drugs and therapeutic class tables published by the MassHealth agency. The MassHealth Drug List specifies the drugs that are payable under MassHealth. The list also specifies which drugs require prior authorization. Except for drugs and drug therapies described in 130 CMR 420.418(B), any drug that does not appear on the MassHealth Drug List requires prior authorization, as otherwise set forth in 130 CMR 420.000. Multiple-Source Drug – a drug marketed or sold by two or more manufacturers or labelers, or a drug marketed or sold by the same manufacturer or labeler under two or more different names. Nonlegend Drug – any drug for which no prescription is required by federal or state law. Pharmacy Online Processing System (POPS) – the online, real-time computer network that adjudicates pharmacy claims, incorporating prospective drug utilization review, prior authorization, and member eligibility verification. Unit-Dose Distribution System – a means of packaging or distributing drugs, or both, devised by the manufacturer, packager, wholesaler, or retail pharmacist. A unit dose contains an exact dosage of medication and may also indicate the total daily dosage or the times when the medication should be taken. 420.403: Eligible Members (A) (1) MassHealth Members. The MassHealth agency pays for dental services provided to MassHealth members, subject to the restrictions and limitations described in MassHealth regulations. 130 CMR 450.105 specifically states for each MassHealth coverage type, which services are covered and the members eligible to receive those services. (2) Recipients of Emergency Aid to the Elderly, Disabled and Children Program. For information on covered services for recipients of the Emergency Aid to the Elderly, Disabled and Children Program, see 130 CMR 450.106. (B) Member Eligibility and Coverage Type. For information on verifying member eligibility and coverage type, see 130 CMR 450.107. Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series DENTAL MANUAL SUBCHAPTER NUMBER AND TITLE 4 PROGRAM REGULATIONS (130 CMR 420.000) PAGE 4-37 TRANSMITTAL LETTER DEN-73 DATE 01/15/06 420.439: Service Descriptions and Limitations: Exodontic Services — Members Aged 21 and Older Who Meet the Special Circumstances Criteria Exodontic services that are reimbursable when provided to members aged 21 and older who meet the prior-authorization criteria for those with special circumstances set forth in 130 CMR 420.410(D) consist of all services, as described and limited in 130 CMR 420.429(A) through (H), except that the services described in 130 CMR 420.429(D)(8) are not reimbursable. 420.440: Service Descriptions and Limitations: Introduction — Members Aged 21 and Older Who Are Either Pregnant or a Mother with a Child Under the Age of Three Years The descriptions and limitations for services provided to pregnant women and to mothers with a child under the age of three years are the same as set forth in 130 CMR 420.432 through 420.439. Prior authorization is not required to verify that a member is either pregnant or a mother of a child under the age of three years. All other service limitations apply. (130 CMR 420.441 Reserved) 420.442: Service Descriptions and Limitations: Introduction — Other Members Aged 21 and Older Service descriptions and limitations that are specific to members aged 21 and older who do not meet the prior-authorization criteria for those with special circumstances set forth in 130 CMR 420.410(D) (other members aged 21 and older) are described in 130 CMR 420.443 through 420.449. In addition, services that apply to all members, including members aged 21 and older who do not meet the prior-authorization criteria for those with special circumstances set forth in 130 CMR 420.410(D), are set forth in 130 CMR 420.452 through 420.457. 420.443: Service Descriptions and Limitations: Diagnostic Services — Other Members Aged 21 and Older Except for emergency dental care, as described and limited in 130 CMR 420.422(C), diagnostic services are not reimbursable when provided to other members aged 21 and older; except that the only radiographs reimbursable with regard to an emergency care visit are those described in 130 CMR 420.444. 420.444: Service Descriptions and Limitations: Radiographs — Other Members Aged 21 and Older Radiographic services that are reimbursable when provided to other members aged 21 and older consist of the following. (A) Intraoral Films. The MassHealth agency pays for intraoral films as a separate procedure as related to diagnosing an emergency-care condition, extracting a tooth, or to document a condition for covered treatment related to prior-authorization requirements. (1) Full-Mouth Radiographs. Full-mouth radiographs are reimbursable as a separate procedure as related to diagnosing an emergency-care condition, extracting a tooth, or to document a condition for covered treatment related to prior-authorization requirements. All other provisions of 130 CMR 420.423(B)(1)(a) apply. Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series DENTAL MANUAL SUBCHAPTER NUMBER AND TITLE 4 PROGRAM REGULATIONS (130 CMR 420.000) PAGE 4-38 TRANSMITTAL LETTER DEN-73 DATE 01/15/06 (2) Bitewing Survey. The MassHealth agency pays for up to two bitewing films as a separate procedure as related to diagnosing an emergency-care condition, extracting a tooth, or to document a condition for covered treatment related to prior-authorization requirements. Bitewing films may not be billed separately when taken as part of a full-mouth series. (3) Periapical Films. The MassHealth agency pays for periapical films. A maximum of four periapical films may be taken as a separate procedure as related to diagnosing an emergency-care condition, extracting a tooth, or to document a treatment related to prior-authorization requirements. Prior authorization is required for additional radiographs. (B) Panoramic Films for Surgical Conditions. The service descriptions and limitations are identical to those set forth in 130 CMR 420.423(C)(1). (C) Diagnostic Photographic Prints. Diagnostic photographic prints are not reimbursable unless otherwise requested by the MassHealth agency. 420.445: Service Descriptions and Limitations: Preventive Services — Other Members Aged 21 and Older Preventive services are not reimbursable when provided to other members aged 21 and older, with the exception of the service as described and limited in 130 CMR 420.435(A). 420.446: Service Descriptions and Limitations: Restorative Services — Other Members Aged 21 and Older Restorative services are not reimbursable when provided to other members aged 21 and older, with the exception of the service as described and limited in 130 CMR 420.449(B). 420.447: Service Descriptions and Limitations: Endodontic Services — Other Members Aged 21 and Older (A) Endodontic services are not reimbursable when provided to other members aged 21 and older, with the exception of the service described and limited in 130 CMR 420.447(B). (B) If an extraction of a tooth would cause undue medical risk for a member with one or more specific medical conditions listed below, the MassHealth agency will pay for root-canal therapy (the alternative treatment) for a tooth, subject to prior authorization. The prior-authorization request must include documentation of these medical conditions, which include, but are not limited to (1) hemophilia; (2) history of radiation therapy; (3) acquired or congenital immune disorder; (4) severe physical disabilities such as quadriplegia; (5) profound mental retardation; and (6) profound mental illness. 420.448: Service Descriptions and Limitations: Prosthodontic Services — Other Members Aged 21 and Older Prosthodontic services are not reimbursable when provided to other members aged 21 and older. Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series DENTAL MANUAL SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-1 TRANSMITTAL LETTER DEN-73 DATE 1/15/06 The dental service codes and descriptions that are listed in this Subchapter 6 must be used when providing dental services to MassHealth members. For each dental service code, the description indicates any limitations, such as age, pregnancy, or special circumstances designation, subject to The Early and Periodic Screening, Diagnosis and Treatment provisions set forth at 130 CMR 450.144(A), provide for prior authorization for medically necessary unlisted or non covered services for members under age 21. Note that prior authorization may be requested for unlisted or noncovered services and codes for members under age 21, pursuant to 130 CMR 450.144(A). 601 Explanation of Abbreviations The following abbreviations are used in Subchapter 6. (A) P.A. indicates that service-specific prior authorization is required (see 130 CMR 420.410). (B) I.C. indicates that the claim will receive individual consideration to determine payment. A descriptive report must accompany the claim (see 130 CMR 420.412). (C) S.P. indicates that the procedure is commonly performed as part of a total service and does not usually warrant a separate fee. The procedure must be performed separately to receive the separate fee(see 130 CMR 420.413). (D) S.C. indicates that the procedure is covered for members aged 21 and older who meet the Special Circumstances criteria (see 130 CMR 420.410(D)). (E) P.W. indicates that the procedure is covered for members aged 21 and older who are either pregnant or mothers with a child under the age of three years. 602 Service Codes and Descriptions: Diagnostic Services See 130 CMR 420.422, 420.433, and 420.443 for limitations. Service Code Service Description Clinical Oral Evaluation D0120 Periodic oral examination (twice per 12-month period) (under 21, P.W., and S.C. only) D0150 Comprehensive oral evaluation—new or established patient (once per member per dentist) (under 21, P.W., and S.C. only) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series DENTAL MANUAL SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-2 TRANSMITTAL LETTER DEN-73 DATE 1/15/06 603 Service Codes and Descriptions: Radiographs See 130 CMR 420.423, 420.434, and 420.444 for limitations. Service Code Service Description Radiographs D0210 Intraoral—complete series (including bitewings) (once every three calendar years) (ages 6 through 12: 10 intraoral films and two posterior bitewings) (ages 13 through 20: minimum of 10 periapical films and two posterior bitewings) (P.W. and S.C.: minimum of 10 periapical films and two posterior bitewings) (21 & older—other: minimum of 10 periapical films and two posterior bitewings as separate procedure as related to diagnosing an emergency-care condition, extracting a tooth, or to document a condition for covered treatment related to P.A. requirements) D0220 Intraoral—periapical, first film D0230 Intraoral—periapical, each additional film D0270 Bitewing—single film D0272 Bitewings—two films (under 21, P.W., and S.C., twice per calendar year) (21 and older — other, limited as noted above) D0274 Bitewings—four films (under 21, P.W., and S.C. only, twice per calendar year) D0330 Panoramic film (nonsurgical condition — under 21 only) (surgical conditions — all members) D0340 Cephalometric film (under 21 only) (P.A.) D0350 Oral/facial photographic images (includes intra and extraoral images) (excludes conventional radiographs) (only when requested by MassHealth to support a P.A. request for another service) Test and Laboratory Examinations D0470 Diagnostic casts (only when requested by MassHealth) (P.A.) 604 Service Codes and Descriptions: Preventive Services See 130 CMR 420.424, 420.435, and 420.445 for limitations. Service Code Service Description Dental Prophylaxis (twice per 12-month period) D1110 Prophylaxis—adult (ages 14 through 20, P.W., and S.C. only) D1120 Prophylaxis—child (to age 14) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series DENTAL MANUAL SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-3 TRANSMITTAL LETTER DEN-73 DATE 1/15/06 604 Service Codes and Descriptions: Preventive Services (cont.) Topical Fluoride Treatment (Office Procedure) D1203 Topical application of fluoride (prophylaxis not included)—child (under 21 only) (P.W., S.C. and 21 and older—other require P.A.) Other Preventive Services D1351 Sealant—per tooth (primary or permanent first and second non-carious molars, first and second non-carious bicuspids (premolars) with deep pits and fissures, and non-carious third molars with deep pits and fissures) (once per three years per tooth) (under 21 only) 605 Service Codes and Descriptions: Restorative Services See 130 CMR 420.425, 420.436, and 420.446 for limitations. Service Code Service Description Amalgam Restorations (Including Polishing) D2140 Amalgam—one surface, primary or permanent (primary — under 21 only) (permanent — under 21, P.W., and S.C. only) D2150 Amalgam—two surfaces, primary or permanent (primary — under 21 only) (permanent — under 21, P.W., and S.C. only) D2160 Amalgam—three surfaces, primary or permanent (primary — under 21 only) (permanent — under 21, P.W., and S.C. only) D2161 Amalgam—four or more surfaces, primary or permanent (under 21, P.W., and S.C. only) Resin Restorations (Composite Restorations) D2330 Resin-based composite—one surface, anterior (under 21, P.W., and S.C. only) D2331 Resin-based composite—two surfaces, anterior (under 21, P.W., and S.C. only) D2332 Resin-based composite—three surfaces, anterior (under 21 only) D2335 Resin-based composite—four or more surfaces or involving incisal angle (anterior) (for fractured incisal angle) (includes pins) (under 21 only) D2390 Resin-based composite crown, anterior (under 21 only) D2391 Resin-based composite—one surface, posterior (primary — under 21 only) (permanent — under 21, P.W., and S.C. only) D2392 Resin-based composite—two surfaces, posterior (primary — under 21 only) (permanent — under 21, P.W., and S.C. only) D2393 Resin-based composite—three surfaces, posterior (primary — under 21 only) (permanent — under 21, P.W., and S.C. only) D2394 Resin-based composite—four or more surfaces, posterior (primary — under 21 only) (permanent — under 21, P.W., and S.C. only) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series DENTAL MANUAL SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-4 TRANSMITTAL LETTER DEN-73 DATE 1/15/06 605 Service Codes and Descriptions: Restorative Services (cont.) Crowns—Single Restoration Only D2710 Crown—resin-based composite (indirect) (under 21 only) (P.A. ) D2751 Crown—porcelain fused to predominantly base metal (under 21, P.W., and S.C. only) (P.A.) Other Restorative Services D2910 Recement inlay, onlay, or partial coverage restoration (under 21, P.W., and S.C. only) D2920 Recement crown (under 21, P.W., and S.C. only) D2930 Prefabricated stainless steel crown—primary tooth (under 21 only) D2931 Prefabricated stainless steel crown—permanent tooth (under 21 only) D2932 Prefabricated resin crown (primary anterior teeth only) (under 21 only) D2951 Pin retention—per tooth, in addition to restoration (two or more surfaces) (commercial amalgam bonding) (under 21, P.W., and S.C. only) D2954 Prefabricated post and core in addition to crown (under 21, P.W., and S.C. only) (P.A.) D2980 Crown repair, by report (under 21, P.W., and S.C. only) (P.A.) (I.C.) D2999 Unspecified restorative procedure, by report (under 21, P.W., and S.C. only) (P.A.) (I.C.) 606 Service Codes and Descriptions: Endodontic Services See 130 CMR 420.426, 420.437, and 420.447 for limitations. Service Code Service Description Pulpotomy D3220 Therapeutic pulpotomy (excluding final restoration)—removal of pulp coronal to the dentinocemental junction and application of medicament (under 21 only) Root Canal Therapy (Including Treatment Plan, Clinical Procedures, and Follow-up Care) D3310 Anterior (excluding final restoration) (under 21, P.W., and S.C. only) (P.A.) (no limitation on number performed per treatment period) D3320 Bicuspid (excluding final restoration) (under 21 only) (P.A.) (no limitation on number performed per treatment period) D3330 Molar (excluding final restoration) (under 21 only) (P.A.) (no limitation on number performed per treatment period) Apicoectomy/Periradicular Services D3410 Apicoectomy/periradicular surgery—anterior (per tooth) (includes retrograde filling) (under 21, P.W., and S.C. only) (P.A.) D3421 Apicoectomy/periradicular surgery—bicuspid (first root) (under 21, P.W., and S.C. only) (P.A.) D3426 Apicoectomy/periradicular surgery (each additional root) (under 21, P.W., and S.C. only) (P.A.) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series DENTAL MANUAL SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-5 TRANSMITTAL LETTER DEN-73 DATE 1/15/06 607 Service Codes and Descriptions: Periodontic Services See 130 CMR 420.424, 420.435, and 420.445 for limitations. Service Code Service Description Surgical Services (Including Usual Postoperative Services) D4210 Gingivectomy or gingivoplasty—four or more contiguous teeth or bounded teeth spaces per quadrant (once per quadrant per three-year period) (under 21, P.W., and S.C. only) (P.A.) D4341 Periodontal scaling and root planing—four or more teeth per quadrant (includes curettage) (once per quadrant per three-year period) (under 21, P.W., and S.C. only) (P.A.) 608 Service Codes and Descriptions: Prosthodontic (Removable) Services See 130 CMR 420.427, 420.438, and 420.448 for limitations. Service Code Service Description Complete Dentures (Including Routine Post Delivery Care) D5110 Complete denture—maxillary (under 21, P.W., and S.C. only) (P.A.) D5120 Complete denture—mandibular (under 21, P.W., and S.C. only) (P.A.) D5130 Immediate denture—maxillary (under 21 only) (P.A.) D5140 Immediate denture—mandibular (under 21 only) (P.A.) Partial Dentures (Including Routine Post Delivery Care) D5211 Maxillary partial denture—resin base (including any conventional clasps, rests, and teeth) (under 21, P.W., and S.C. only) (P.A.) D5212 Mandibular partial denture—resin base (including any conventional clasps, rests, and teeth) under 21, P.W., and S.C. only) (P.A.) D5213 Maxillary partial denture—cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) (under 21 only) (P.A.) D5214 Mandibular partial denture—cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) (under 21 only) (P.A.) Repairs to Complete Dentures D5510 Repair broken complete denture base (under 21, P.W., and S.C. only) D5520 Replace missing or broken teeth—complete denture (each tooth) (under 21, P.W., and S.C. only) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series DENTAL MANUAL SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-6 TRANSMITTAL LETTER DEN-73 DATE 1/15/06 608 Service Codes and Descriptions: Prosthodontic (Removable) Services (cont.) Repairs to Partial Dentures D5610 Repair resin denture base (under 21, P.W., and S.C. only) D5620 Repair cast framework (under 21, P.W., and S.C. only) D5630 Repair or replace broken clasp (under 21, P.W., and S.C. only) D5640 Replace broken teeth—per tooth (under 21, P.W., and S.C. only) D5650 Add tooth to existing partial denture (under 21, P.W., and S.C. only) D5660 Add clasp to existing partial denture (under 21, P.W., and S.C. only) Denture Rebase Procedures D5710 Rebase complete maxillary denture (under 21, P.W., and S.C. only) (P.A.) D5711 Rebase complete mandibular denture (under 21, P.W., and S.C. only) (P.A.) D5750 Reline complete maxillary denture (laboratory) (under 21, P.W., and S.C. only) (P.A.) D5751 Reline complete mandibular denture (laboratory) (under 21, P.W., and S.C. only) (P.A.) 609 Service Codes and Descriptions: Prosthodontic (Fixed) Services See 130 CMR 420.427, 420.438, and 420.448 for limitations. Each abutment and each pontic constitutes a unit in a bridge. Service Code Service Description Fixed Partial Denture Pontics D6241 Pontic—porcelain fused to predominantly base metal (under 21 only) (P.A.) D6751 Crown—porcelain fused to predominantly base metal (under 21 only) (P.A.) Other Fixed Partial Denture Services D6930 Recement fixed partial denture (ages 16 through 20 only) D6980 Fixed partial denture repair, by report (ages 16 through 20 only) (P.A.) (I.C.) D6999 Unspecified, fixed prosthodontic procedure, by report (under 21, P.W., and S.C. only) (P.A.) I.C.) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series DENTAL MANUAL SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-7 TRANSMITTAL LETTER DEN-73 DATE 1/15/06 610 Service Codes and Descriptions: Exodontic Services See 130 CMR 420.429, 420.439, and 420.449 for limitations. Service Code Service Description Extractions (Includes Local Anesthesia and Routine Postoperative Care) (Place of Service Excludes Emergency Room and Hospital Inpatient) D7111 Extraction, coronal remnants—deciduous tooth D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth D7220 Removal of impacted tooth—soft tissue D7230 Removal of impacted tooth—partially bony D7240 Removal of impacted tooth—completely bony (P.A.) D7280 Surgical access of an unerupted tooth (under 21 only) (P.A.) D7283 Placement of device to facilitate eruption of impacted tooth (under 21 only) (P.A.) Surgical Procedures (Place of Service Excludes Emergency Room and Hospital Inpatient) D7310 Alveoplasty in conjunction with extractions—per quadrant D7311 Alveoplasty in conjunction with extractions—one to three teeth or tooth spaces, per quadrant (I.C.) D7320 Alveoplasty not in conjunction with extractions—per quadrant D7321 Alveoplasty not in conjunction with extractions—one to three teeth or tooth spaces, per quadrant (I.C.) D7340 Vestibuloplasty—ridge extension (second epithelialization) (P.A.) D7410 Excision of benign lesion up to 1.25 cm D7411 Excision of benign lesion greater than 1.25 cm D7960 Frenulectomy (frenectomy or frenotomy)—separate procedure (S.P.) D7963 Frenuloplasty D7970 Excision of hyperplastic tissue—per arch (P.A.) D7999 Unspecified oral surgery procedure, by report (P.A.) (I.C.) D9930 Treatment of complications (post surgical)—unusual circumstances, by report (I.C.) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series DENTAL MANUAL SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-8 TRANSMITTAL LETTER DEN-73 DATE 1/15/06 611 Service Codes and Descriptions: Orthodontic Services See 130 CMR 420.428 for limitations. Service Code Service Description Orthodontic Diagnosis and Full Orthodontic Treatment D8080 Comprehensive orthodontic treatment of the adolescent dentition (under 21 only) (P.A.) D8660 Pre-orthodontic treatment visit (consultation) (accredited orthodontists only) (once per six months)(under 21 only) D8670 Periodic orthodontic treatment visit (as part of a contract) (full orthodontic treatment, active, first year and second year, and first half of third year, if necessary, including retainer—quarterly treatment visits) (under 21 only) (P.A.) D8690 Orthodontic treatment (alternative billing to a contract fee) (under 21 only) (P.A.) Space Maintenance (Passive Appliances) D1510 Space maintainer—fixed-unilateral (under 21 only) D1515 Space maintainer—fixed-bilateral (under 21 only) D1520 Space maintainer—removable unilateral (under 21 only) D1525 Space maintainer—removable-bilateral (under 21 only) D1550 Recementation of space maintainer (under 21 only) Other Orthodontic Services D8680 Orthodontic retention (removal of appliances, construction and replacement of retainer(s)) (under 21 only) D8692 Replacement of lost or broken retainer (under 21 only) (P.A.) D8999 Unspecified orthodontic procedure, by report (under 21 only) (P.A.) (I.C.) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series DENTAL MANUAL SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-9 TRANSMITTAL LETTER DEN-73 DATE 1/15/06 612 Service Codes and Descriptions: General Anesthesia and IV Sedation Services — All Members See 130 CMR 420.452 for limitations. The allowable fees include payment for cardiac monitoring and other related costs, per 15 minutes. Service Code Service Description D9220 Deep sedation/general anesthesia—first 30 minutes D9221 Deep sedation/general anesthesia—each additional 15 minutes (from 31 to 90 minutes) 613 Service Codes and Descriptions: Other Services — All Members See 130 CMR 420.456 and 420.457 for limitations. Service Code Service Description Treatment of Physically or Developmentally Disabled Members D9920 Behavior management, by report (P.A.) Unclassified Treatment D9110 Palliative (emergency) treatment of dental pain—minor procedure (Other nonemergency medically necessary treatment may be provided during the same visit—that is, nonemergency codes may be billed in conjunction with D9110.) D9941 Fabrication of athletic mouthguard (under 21 only) D9999 Unspecified adjunctive procedure, by report (P.A.) (I.C.) This publication contains codes that are copyrighted by the American Dental Association and American Medical Association. Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series DENTAL MANUAL SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-10 TRANSMITTAL LETTER DEN-73 DATE 1/15/06 This page is reserved.