Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street Boston, MA 02111 www.mass.gov/dma

MASSHEALTH
TRANSMITTAL LETTER DEN-60
March 2002
TO:      Dental Providers Participating in MassHealth
FROM:      Wendy E. Warring, Commissioner
RE:      Dental Manual (Revisions to Subchapter 6 Service Codes and Descriptions)

This letter transmits changes to the service codes and descriptions in Subchapter 6 of the Dental Manual. While the billing codes for dental services have not changed, the age groups to which they apply have been modified in accordance with 130 CMR 420.000.
These regulations are effective March 15, 2002.
NEW MATERIAL
(The pages listed here contain new or revised language.)
Dental Manual
Pages vi and 6-1 through 6-10
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Dental Manual
Page vi — transmitted by Transmittal Letter DEN-58
Pages 6-1 through 6-10 — transmitted by Transmittal Letter DEN-55

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DENTAL MANUAL	SUBCHAPTER NUMBER AND TITLE
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6. SERVICE CODES AND DESCRIPTIONS
Explanation of Abbreviations 		6-1
Service Codes and Descriptions: Diagnostic Services 		6-1
Service Codes and Descriptions: X Rays 		6-2
Service Codes and Descriptions: Preventive Services 		6-2
Service Codes and Descriptions: Restorative Services 		6-3
Service Codes and Descriptions: Endodontic Services. . 		6-4
Service Codes and Descriptions: Periodontic Services 		6-5
Service Codes and Descriptions: Prosthodontic (Removable) Services 		6-5
Service Codes and Descriptions: Prosthodontic (Fixed) Services 		6-6
Service Codes and Descriptions: Exodontic Services 		6-7
Service Codes and Descriptions: Orthodontic Services 		6-8
Service Codes and Descriptions: General Anesthesia and IV Sedation Services 		6-9
Service Codes and Descriptions: Other Services — All Members 		6-9
Appendix A. DIRECTORY 		A-1
Appendix B. ENROLLMENT CENTERS 		B-1
Appendix C. THIRD-PARTY-LIABILITY CODES 		C-1
Appendix D. PAR INDEX 		D-1
Appendix E. ORAL SURGERY SERVICE CODES AND DESCRIPTIONS 		E-1
Appendix F. (Reserved)
Appendix G. UTILIZATION MANAGEMENT PROGRAM 		G-1
Appendix H. ADMISSION GUIDELINES 		H-1
Appendix I. NONLEGEND DRUGS 		I-1
Appendix W. EPSDT SERVICES: MEDICAL PROTOCOL AND
PERIODICITY SCHEDULE 		W-1
Appendix X. FAMILY ASSISTANCE COPAYMENTS AND DEDUCTIBLES 		X-1
Appendix Y. REVS/CODES MESSAGES 		Y-1
Appendix Z. EPSDT SERVICES LABORATORY CODES 		Z-1

Commonwealth of Massachusetts
Division of Medical Assistance
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The dental service codes and descriptions that are listed in this Subchapter 6 must be used when providing dental services to members. For each dental service code, the description indicates what age range or if the Special Circumstances designation applies. The age ranges are “under 21,” “21 and older with special circumstances designation,” and “21 and older — other.” The dental service code applies to “all members” where no age range or Special Circumstances designation is indicated.
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)).
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 Evaluations
D0120     Periodic oral examination (once per 12-month period and no sooner than 12 months from the
date of the last evaluation) (under 21 and S.C. only) D0150     Comprehensive oral evaluation (once per member per dentist) (under 21 and S.C. only)

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603   Service Codes and Descriptions: X Rays
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 12 periapical films and two posterior bitewings) (S.C.: minimum of 12 periapical films and two posterior bitewings) (21 & older — other: minimum of 12 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 and S.C., twice per calendar year)
(21 & older — other, limited as noted above) D0274     Bitewings—four films (under 21 and S.C. only, twice per calendar year) D0330     Panoramic film (nonsurgical condition) (under 21 only) (P.A.) X0331     Panoramic film (surgical condition only) (all members) D0340     Cephalometric film (under 21 only) (P.A.)
Test and Laboratory Examinations
D0470     Diagnostic casts (only when requested by the Division) (P.A.) D0471     Diagnostic photographs (only when requested by the Division) (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 (once per six-month period and no sooner than six months from the date of the last prophylaxis)
D1110     Prophylaxis—adult (ages 14 through 20 and S.C. only) D1120     Prophylaxis—child (to age 14)

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604   Service Codes and Descriptions: Preventive Services (cont.)
Topical Fluoride Treatment (Office Procedure)
D1203     Topical application of fluoride (prophylaxis not included)—child (once per six-month period and no sooner than six months from the date of the last topical fluoride treatment) (under 21 only) (S.C. and 21 & older — other require P.A.)
Other Preventive Services
D1351     Sealant—per tooth (permanent first and second molars only) (once per three years per tooth)
(ages 5 through 20 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)
D2110	Amalgam—one surface, primary (under 21 only)
D2120	Amalgam—two surfaces, primary (under 21 only)
D2130	Amalgam—three surfaces, primary (under 21 only)
D2131	Amalgam—four or more surfaces, primary (under 21 only)
D2140	Amalgam—one surface, permanent (under 21 and S.C. only)
D2150	Amalgam—two surfaces, permanent (under 21 and S.C. only)
D2160	Amalgam—three surfaces, permanent (under 21 and S.C. only)
D2161	Amalgam—four or more surfaces, permanent (under 21 and S.C. only)
Resin Restorations (Composite Restorations)
D2330	Resin—one surface, anterior (under 21 and S.C. only)
D2331	Resin—two surfaces, anterior (under 21 and S.C. only)
D2332	Resin—three surfaces, anterior (under 21 only)
D2335	Resin—four or more surfaces or involving incisal angle (anterior) (for fractured incisal
angle) (includes pins) (S.C. only)
D2336	Composite resin crown—anterior—primary (under 21 only)
D2380	Resin—one surface, posterior—primary (under 21 only)
D2381	Resin—two surfaces, posterior—primary (under 21 only)
D2382	Resin—three or more surfaces, posterior—primary (under 21 only)
D2385	Resin—one surface, posterior—permanent (under 21 and S.C. only)
D2386	Resin—two surfaces, posterior—permanent (under 21 and S.C. only)
D2387	Resin—three or more surfaces, posterior—permanent (under 21 and S.C. only)

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605   Service Codes and Descriptions: Restorative Services (cont.)
Crowns—Single Restoration Only
D2710     Crown—resin (laboratory) (under 21 only) (P.A.)
D2751     Crown—porcelain fused to predominantly base metal (under 21 and S.C. only) (P.A.)
Other Restorative Services
D2910	Recement inlay (under 21 and S.C. only)
D2920	Recement crown (under 21 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 and S.C. only)
D2954	Prefabricated post and core in addition to crown (under 21 and S.C. only) (P.A.)
D2980	Crown repair, by report (under 21 and S.C. only) (I.C.)
X2981	Crown repair, extensive, by report (under 21 and S.C. only) (P.A.) (I.C.)
D2999	Unspecified restorative procedure, by report (under 21 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) (under 21 only)
Root Canal Therapy (Including Treatment Plan, Clinical Procedures and Follow-up Care)
D3310     Anterior (excluding final restoration) (one canal) (bicuspid—one canal) (under 21 and S.C.
only) (P.A.) D3320     Bicuspid (excluding final restoration) (two canals) (under 21 only) (P.A.) D3330     Molar (excluding final restoration) (three canals) (under 21 only) (P.A.)
Periapical Services
D3410     Apicoectomy/periradicular surgery—anterior (per tooth) (includes retrograde filling) (under
21 and S.C. only) (P.A.) D3421     Apicoectomy/periradicular surgery—bicuspid (first root) (under 21 and S.C. only) (P.A.) D3426     Apicoectomy/periradicular surgery (each additional root) (under 21 and S.C. only) (P.A.) X2104     Apicoectomy with root-canal filling (same visit) (under 21 and S.C. only) (P.A.) (I.C.)

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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—per quadrant (once per quadrant per three-year period)
(under 21 and S.C. only) (P.A.) D4341     Periodontal scaling and root planing—per quadrant (includes curettage) (once per quadrant per
three-year period) (under 21 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 (P.A.)
D5120	Complete denture—mandibular (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 Upper partial—resin base (including any conventional clasps, rests, and teeth) (P.A.) D5212 Lower partial—resin base (including any conventional clasps, rests, and teeth) (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 (cast metal base
with resin saddles) (including any conventional clasps, rests, and teeth) (under 21 only)
(P.A.)
Repairs to Complete Dentures
D5510     Repair broken complete denture base
D5520     Replace missing or broken teeth—complete denture (each tooth)

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608   Service Codes and Descriptions: Prosthodontic (Removable) Services (cont.)
Repairs to Partial Dentures
D5610	Repair resin denture base
D5620	Repair cast framework
D5630	Repair or replace broken clasp
D5640	Replace broken teeth—per tooth
D5650	Add tooth to existing partial denture
D5660	Add clasp to existing partial denture
Denture Rebase Procedures
D5710	Rebase complete maxillary denture (laboratory) (P.A.)
D5711	Rebase complete mandibular denture (laboratory) (P.A.)
D5750	Reline complete maxillary denture (light-cured) (P.A.)
D5751	Reline complete mandibular denture (light-cured) (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
Bridges
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 Prosthetic Services
D6930	Recement bridge (ages 16 through 20 only)
D6980	Bridge repair, by report (ages 16 through 20 only) (I.C.)
X6981	Bridge repair, by report (ages 16 through 20 only) (P.A.) (I.C.)
D6999	Unspecified, fixed prosthodontic procedure, by report (P.A.) (I.C.)

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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, Suturing, if Needed, and Routine Postoperative Care) (Place of Service Excludes Emergency Room and Hospital Inpatient)
D7110     Extraction—single tooth
D7120     Extraction—each additional tooth
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 (P.A.) D7230     Removal of impacted tooth—partially bony (P.A.) D7240     Removal of impacted tooth—completely bony (P.A.) D7281     Surgical exposure of impacted or unerupted tooth to aid eruption (for orthodontic purposes
only) (under 21 only) (P.A.)
Surgical Procedures (Place of Service Excludes Emergency Room and Hospital Inpatient)
D7310	Alveoplasty in conjunction with extractions—per quadrant (seven or more extractions per arch)
D7320	Alveoplasty not in conjunction with extractions—per quadrant
D7340	Vestibuloplasty—ridge extension (second epithelialization) (P.A.)
D9930	Treatment of complications (postsurgical)—unusual circumstances, by report (I.C.)
D7960	Frenulectomy (frenectomy or frenotomy)—separate procedure (S.P.)
D7970	Excision of hyperplastic tissue—per arch (P.A.)
D7999	Unspecified oral surgery procedure, by report (P.A.) (I.C.)
X8000	Unspecified oral surgery procedure, emergency, by report (I.C.)

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611   Service Codes and Descriptions: Orthodontic Services
See 130 CMR 420.428 for limitations.
Service
Code       Service Description
Consultations
X2208     Orthodontic consultation (accredited orthodontists only) (once per six months) (under 21 only)
Orthodontic Diagnosis
Y9700     Orthodontic diagnosis and records, models, photos, and X rays (under 21 only) (P.A.) Y9701     Initial fabrication and insertion of orthodontic appliance (includes all orthodontic records,
models, photos, and X rays (treatment must commence before age 18½ years) ) (under 21
only) (P.A.)
Full Orthodontic Treatment
Y9703     Active, first year ortho (including a retainer) (per quarter) (under 21 only) (P.A.) Y9704     Active, second year ortho (including a retainer) (per quarter) (under 21 only) (P.A.) X2006     Active, first half of third year if necessary, including a retainer (per quarter) (under 21 only)
(P.A.) X2005     Active, second half of third year if necessary, including a retainer (for cases that began before
April 1, 1998 only) (per quarter) (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)
D1525	Space maintainer—removable-bilateral (under 21 only)
X2004	Replace space maintainer (under 21 only) (P.A.) (I.C.)
D1550	Recementing of space maintainer (under 21 only) (I.C.)
Other Orthodontic Services
D8750     Post-treatment stabilization (maximum of five visits) (under 21 only)
X8751     Replacement retainer (under 21 only) (P.A.)
D8999     Unspecified orthodontic procedure, by report (under 21 only) (P.A.) (I.C.)

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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	
X2008	Onset to 15 minutes	
X2009	16 to 30 minutes	
X2010	31 to 45 minutes	
X2011	46 to 60 minutes	
X2012	61 to 75 minutes	
X2013	76 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
Oral Screenings
X2098     Oral screening in an inpatient hospital setting for members scheduled for radiation treatment, chemotherapy, bone marrow transplant, or organ transplant (all members) (P.A.) (I.C.)
X2099     Oral screening in an outpatient hospital setting for members scheduled for radiation treatment, chemotherapy, bone marrow transplant, or organ transplant (all members) (P.A.) (I.C.)
Treatment of Physically or Developmentally Disabled Recipients
X2105     Dental treatment of physically or developmentally disabled member in the hospital (inpatient or outpatient setting) or a freestanding ambulatory surgery center, by report (P.A.) (I.C.) X2108     Dental treatment of physically or developmentally disabled member in the office (P.A.)
Unclassified Treatment
D9110     Palliative (emergency) treatment of dental pain—minor procedure D9941     Fabrication of athletic mouthguard (under 21 only) (P.A.) D9999     Unspecified adjunctive procedure, by report (P.A.) (I.C.)
This publication contains codes that are copyrighted by the American Medical Association.

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