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-61
July 2002
TO:      Dental Providers Participating in MassHealth FROM:      Wendy E. Warring, Commissioner 
RE:      Dental Manual (Dental HCPCS)
The federal government has revised the HCFA Common Procedure Coding System (HCPCS) for MassHealth billing.
This letter transmits changes for your provider manual that contain the new and revised codes. The revised Appendix E is effective for dates of service on or after April 30, 2002. The new codes introduced under the 2002 HCPCS code book are effective for dates of service on or after April 30, 2002. We will accept either the new or old codes for dates of service through July 28, 2002. For dates of service on or after July 29, 2002, you must use the new codes to receive payment.
If you wish to obtain a fee schedule, you may purchase Division of Health Care Finance and Policy regulations from either the Massachusetts State Bookstore or from the Division of Health Care Finance and Policy (see addresses and telephone numbers below). You must contact them first to find out the price of the publication. The Division of Health Care Finance and Policy also has the regulations available on disk. The regulation titles for dental services listed on the attached pages are 114.3 CMR 16.00: Surgery and Anesthesia Services and 114.3 CMR 18.00: Radiology.
Massachusetts State Bookstore	Division of Health Care Finance and Policy
State House, Room 116	Two Boylston Street
Boston, MA 02133	Boston, MA 02116
Telephone: 617-727-2834	Telephone: 617-988-3100
www.mass.gov/sec/spr	www.mass.gov/dhcfp

MassHealth
Transmittal Letter DEN-61 July 2002 Page 2
NEW MATERIAL
(The pages listed here contain new or revised language.)
Dental Manual
Pages E-1 through E-28
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Dental Manual
Pages E-1 through E-28 — transmitted by Transmittal Letter DEN-57

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DENTAL MANUAL	SUBCHAPTER NUMBER AND TITLE
APPENDIX E: ORAL SURGERY SERVICE CODES AND DESCRIPTIONS	PAGE
E-1	

	TRANSMITTAL LETTER
DEN-61	DATE
04/30/02	
The all-numeric service codes that are listed in this appendix may be used when providing services to members in all categories of assistance, including category 4 (EAEDC), and may only be used by oral and maxillofacial surgeons who have submitted proof of certification to the Division. The alphanumeric codes in Sections 621, 622, and 623 may not be used for services provided to category 4 members, with the exception of Service Codes D7999, X2098, and X2099.
620 Service Codes and Descriptions: Medical Services
Service
Code       Service Description
OFFICE OR OTHER OUTPATIENT SERVICES
New Patient
99202      Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components (does not include dentoalveolar diagnosis):
-	an expanded problem focused history;
-	an expanded problem focused examination; and
-	straightforward medical decision making
Established Patient
99212      Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components (does not include dentoalveolar diagnosis):
-	a problem-focused history;
-	a problem-focused examination; and
-	straightforward medical decision making
INITIAL HOSPITAL CARE New or Established Patient
99221	Initial hospital care, per day, for the evaluation and management of a patient, which requires these
three key components:
-	a detailed or comprehensive history;
-	a detailed or comprehensive examination; and
-	medical decision making that is straightforward or of low complexity
99222	Initial hospital care, per day, for the evaluation and management of a patient, which requires these
three key components:
-	a comprehensive history;
-	a comprehensive examination; and
-	medical decision making of moderate complexity
99223	Initial hospital care, per day, for the evaluation and management of a patient, which requires these
three key components:
-	a comprehensive history;
-	a comprehensive examination; and
-	medical decision making of high complexity
-	
Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DENTAL MANUAL	SUBCHAPTER NUMBER AND TITLE
APPENDIX E: ORAL SURGERY SERVICE CODES AND DESCRIPTIONS	PAGE
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DEN-61	DATE
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620 Service Codes and Descriptions: Medical Services (cont.)
Service
Code       Service Description
SUBSEQUENT HOSPITAL CARE
99231	Subsequent hospital care, per day, for the evaluation and management of a patient, which requires
at least two of these three key components:
-	a problem-focused interval history;
-	a problem-focused examination;
-	medical decision making that is straightforward or of low complexity
99232	Subsequent hospital care, per day, for the evaluation and management of a patient, which requires
at least two of these three key components:
-	an expanded problem-focused interval history;
-	an expanded problem-focused examination;
-	medical decision making of moderate complexity
99233	Subsequent hospital care, per day, for the evaluation and management of a patient, which requires
at least two of these three key components:
-	a detailed interval history;
-	a detailed examination;
-	medical decision making of high complexity
INITIAL INPATIENT CONSULTATIONS New or Established Patient
99251	Initial inpatient consultation for a new or established patient, which requires these three key
components:
-	a problem-focused history;
-	a problem-focused examination; and
-	straightforward medical decision making
99252	Initial inpatient consultation for a new or established patient, which requires these three key
components:
-	an expanded problem-focused history;
-	an expanded problem-focused examination; and
-	straightforward medical decision making
99253	Initial inpatient consultation for a new or established patient, which requires these three key
components:
-	a detailed history;
-	a detailed examination; and
-	medical decision making of low complexity
99254	Initial inpatient consultation for a new or established patient, which requires three key
components:
-	a comprehensive history;
-	a comprehensive examination; and
-	medical decision making of moderate complexity
-	
Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DENTAL MANUAL	SUBCHAPTER NUMBER AND TITLE
APPENDIX E: ORAL SURGERY SERVICE CODES AND DESCRIPTIONS	PAGE
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DEN-61	DATE
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620 Service Codes and Descriptions: Medical Services (cont.)
Service
Code       Service Description
99255      Initial inpatient consultation for a new or established patient, which requires these three key components:
-	a comprehensive history;
-	a comprehensive examination; and
-	medical decision making of high complexity
FOLLOW-UP INPATIENT CONSULTATIONS
Established Patient
99261      Follow-up inpatient consultation for an established patient, which requires at least two of these three key components:
-	a problem-focused interval history;
-	a problem-focused examination;
-	medical decision making that is straightforward or of low complexity
EMERGENCY DEPARTMENT SERVICES New or Established Patient
99281	Emergency department visit for the evaluation and management of a patient, which requires these
three key components:
-	a problem-focused history;
-	a problem-focused examination; and
-	straightforward medical decision making
99282	Emergency department visit for the evaluation and management of a patient, which requires these
three key components:
-	an expanded problem-focused history;
-	an expanded problem-focused examination; and
-	medical decision making of low complexity
99283	Emergency department visit for the evaluation and management of a patient, which requires these
three key components:
-	an expanded problem-focused history;
-	an expanded problem-focused examination; and
-	medical decision making of moderate complexity
99284	Emergency department visit for the evaluation and management of a patient, which requires these
three key components:
-	a detailed history;
-	a detailed examination; and
-	medical decision making of moderate complexity
-	
Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DENTAL MANUAL	SUBCHAPTER NUMBER AND TITLE
APPENDIX E: ORAL SURGERY SERVICE CODES AND DESCRIPTIONS	PAGE
E-4	

	TRANSMITTAL LETTER
DEN-61	DATE
04/30/02	
620	Service Codes and Descriptions: Medical Services (cont.)
Service
Code       Service Description
99285      Emergency department visit for the evaluation and management of a patient, which requires these three key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status:
-	a comprehensive history;
-	a comprehensive examination; and
-	medical decision making of high complexity
621	Service Codes and Descriptions: Endodontic Services
See 130 CMR 420.426, 420.437, and 420.447 for limitations.
Service
Code       Service Description
Periapical Services
D3410	Apicoectomy/periradicular surgery—anterior (per tooth) (includes retrograde filling) (P.A.)
D3421	Apicoectomy/periradicular surgery—bicuspid (first root) (P.A.)
D3426	Apicoectomy/periradicular surgery (each additional root) (P.A.)
X2104	Apicoectomy with root-canal filling (same visit) (P.A.) (I.C.)
622	Service Codes and Descriptions: Exodontic Services
See 130 CMR 420.429, 420.439, and 420.449 for limitations.
Service
Code       Service Description
Extractions (including local anesthesia, suture removal, and routine postoperative care)
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.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DENTAL MANUAL	SUBCHAPTER NUMBER AND TITLE
APPENDIX E: ORAL SURGERY SERVICE CODES AND DESCRIPTIONS	PAGE
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623   Service Codes and Descriptions: Oral and Maxillofacial Surgical Services
Service
Code       Service Description
Introduction
D7280     Surgical exposure of impacted or unerupted tooth for orthodontic reasons (including orthodontic
attachments) (P.A.) D7281     Surgical exposure of impacted or unerupted tooth to aid eruption (for orthodontic purposes) (P.A.)
Surgical Procedures
D7310	Alveoplasty in conjunction with extractions—per quadrant
D7320	Alveoplasty not in conjunction with extractions—per quadrant (P.A.)
D7340	Vestibuloplasty—ridge extension (second epithelialization) (P.A.)
D7350	Vestibuloplasty—ridge extension (including soft-tissue grafts, muscle reattachments, revision of
soft-tissue attachment, and management of hypertrophied and hyperplastic tissue) (P.A.)
D7430	Excision of benign tumor–lesion diameter up to 1.25 cm
D7431	lesion diameter greater than 1.25 cm
D7450	Removal of odontogenic cyst or tumor–lesion diameter up to 1.25 cm
D7451	lesion diameter greater than 1.25 cm
D7460	Removal of nonodontogenic cyst or tumor–lesion diameter up to 1.25 cm
D7461	lesion diameter greater than 1.25 cm
D7471	Removal of exostosis—per site (P.A.)
D7960	Frenulectomy (frenectomy or frenotomy)—separate procedure (P.A.)
D7970	Excision of hyperplastic tissue—per arch (P.A.)
Suture
X2001     Control of secondary oral or nasopharyngeal hemorrhage in hospital by consultant X2002     Control of secondary oral or nasopharyngeal hemorrhage in hospital by operating surgeon
Unlisted Procedures
D7999     Unspecified oral surgery procedure, by report (P.A.) (I.C.) X8000     Unspecified oral surgery procedure, emergency, by report (I.C.) 41899      Unlisted procedure, dentoalveolar structures (I.C.)
Other Procedures
D9110     Palliative (emergency) treatment of dental pain—minor procedure
D9930     Treatment of complications (postsurgical)—unusual circumstances, by report (I.C.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DENTAL MANUAL	SUBCHAPTER NUMBER AND TITLE
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623   Service Codes and Descriptions: Oral and Maxillofacial Surgical Services (cont.)

Service
Code       Service Description
Oral Screenings
Oral screenings include but are not limited to: initial examination, consultation, salivary flow measurement, oral hygiene evaluations and instructions, construction of fluoride trays, fluoride treatments, follow-up examinations, follow-up salivary evaluations, and requests from referring doctors. Oral screening services are reimbursed through a global fee, which is an inclusive fee for the services listed above. To receive the global fee, the medical diagnosis, a request from the treating hospital, and a description of the services to be provided must be submitted with the prior authorization request to facilitate an evaluation of medical necessity.
X2098     Oral screening in an inpatient hospital setting for members scheduled for radiation treatment, chemotherapy, bone marrow transplant, or organ transplant (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 (P.A.) (I.C.)
624   Service Codes and Descriptions: Surgical Services
See 130 CMR 420.451 for limitations.
Service
Code       Service Description
INTEGUMENTARY SYSTEM
SKIN, SUBCUTANEOUS AND ACCESSORY STRUCTURES
Incision and Drainage
10060
10061 10120 10121 10140 10160 10180
Incision and drainage of abscess (e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single complicated or multiple
Incision and removal of foreign body, subcutaneous tissues; simple complicated
Incision and drainage of hematoma, seroma, or fluid collection
Puncture aspiration of abscess, hematoma, bulla, or cyst
Incision and drainage, complex, postoperative wound infection
Excision—Debridement
11010 11011
Debridement including removal of foreign material associated with open fracture(s) and/or dislocation(s); skin and subcutaneous tissues skin, subcutaneous tissue, muscle fascia, and muscle

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DENTAL MANUAL	SUBCHAPTER NUMBER AND TITLE
APPENDIX E: ORAL SURGERY SERVICE CODES AND DESCRIPTIONS	PAGE
E-7	

	TRANSMITTAL LETTER
DEN-61	DATE
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624 Service Codes and Descriptions: Surgical Services (cont.)
Service
Code       Service Description
11012	skin, subcutaneous tissue, muscle fascia, muscle, and bone
11040	Debridement; skin, partial thickness
11041	skin, full thickness
11042	skin and subcutaneous tissue
11043	skin, subcutaneous tissue, and muscle
11044	skin, subcutaneous tissue, muscle, and bone
Biopsy
11100	Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless
otherwise listed (separate procedure); single lesion
11101	each separate/additional lesion (List separately in addition to code for primary procedure.)
Shaving of Epidermal or Dermal Lesions
11310	Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous
membrane; lesion diameter 0.5 cm or less
11311	lesion diameter 0.6 to 1.0 cm
11312	lesion diameter 1.1 to 2.0 cm
11313	lesion diameter over 2.0 cm
Excision—Benign Lesions
11440	Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous
membrane; lesion diameter 0.5 cm or less
11441	lesion diameter 0.6 to 1.0 cm
11442	lesion diameter 1.1 to 2.0 cm
11443	lesion diameter 2.1 to 3.0 cm
11444	lesion diameter 3.1 to 4.0 cm 11446	lesion diameter over 4.0 cm
Excision—Malignant Lesions
11640	Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 0.5 cm or less
11641	lesion diameter 0.6 to 1.0 cm
11642	lesion diameter 1.1 to 2.0 cm
11643	lesion diameter 2.1 to 3.0 cm
11644	lesion diameter 3.1 to 4.0 cm
11646	lesion diameter over 4.0 cm

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DENTAL MANUAL	SUBCHAPTER NUMBER AND TITLE
APPENDIX E: ORAL SURGERY SERVICE CODES AND DESCRIPTIONS	PAGE
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624 Service Codes and Descriptions: Surgical Services (cont.)
Service
Code       Service Description
MISCELLANEOUS
Introduction
11960      Insertion of tissue expander(s) for other than breast, including subsequent expansion
11970	Replacement of tissue expander with permanent prosthesis
11971	Removal of tissue expander(s) without insertion of prosthesis
REPAIR (CLOSURE)
Repair—Simple
12011	Simple repair of superficial wounds of face, ears, eyelids, nose, lips, and/or mucous membranes;
2.5 cm or less
12013	2.6 cm to 5.0 cm
12014	5.1 cm to 7.5 cm
12015	7.6 cm to 12.5 cm
12016	12.6 cm to 20.0 cm
12017	20.1 cm to 30.0 cm
12018	over 30.0 cm
12020	Treatment of superficial wound dehiscence; simple closure
12021	with packing
Repair—Intermediate
12051	Layer closure of wounds of face, ears, eyelids, nose, lips, and/or mucous membranes; 2.5 cm or
less
12052	2.6 cm to 5.0 cm
12053	5.1 cm to 7.5 cm
12054	7.6 cm to 12.5 cm
12055	12.6 cm to 20.0 cm
12056	20.1 cm to 30.0 cm
12057	over 30.0 cm
Repair—Complex
13131	Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; 1.1 cm
to 2.5 cm
13132	2.6 cm to 7.5 cm
13133	each additional 5 cm or less (List separately in addition to code for primary procedure.)
13150	Repair, complex, eyelids, nose, ears, and/or lips; 1.0 cm or less
13151	1.1 cm to 2.5 cm
13152	2.6 cm to 7.5 cm
13153	each additional 5 cm or less (List separately in addition to code for primary procedure.)
13160	Secondary closure of surgical wound or dehiscence, extensive or complicated

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
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APPENDIX E: ORAL SURGERY SERVICE CODES AND DESCRIPTIONS	PAGE
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624 Service Codes and Descriptions: Surgical Services (cont.)
Service
Code       Service Description
Adjacent Tissue Transfer or Rearrangement
14040	Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia,
hands, and/or feet; defect 10 sq cm or less
14041	defect 10.1 sq cm to 30.0 sq cm
14060	Adjacent tissue transfer or rearrangement, eyelids, nose, ears, and/or lips; defect 10 sq cm or less
14061	defect 10.1 sq cm to 30.0 sq cm
Free Skin Grafts
15000      Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues); first 100 sq cm or one percent of body area of infants and children
15120	Split graft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple
digits; first 100 sq cm or less, or one percent of body area of infants and children (except 15050)
15121	each additional 100 sq cm, or each additional one percent of body area of infants and children,
or part thereof (List separately in addition to code for primary procedure.)
15240	Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth,
neck, axillae, genitalia, hands, and/or feet; 20 sq cm or less
15241	each additional 20 sq cm (List separately in addition to code for primary procedure.)
15260	Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; 20
sq cm or less
15261	each additional 20 sq cm (List separately in addition to code for primary procedure.)
Flaps (Skin and/or Deep Tissues)
15570      Formation of direct or tubed pedicle, with or without transfer; trunk
15572	scalp, arms, or legs
15574	forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, or feet
15576	eyelids, nose, ears, lips, or intraoral
15620      Delay of flap or sectioning of flap (division and inset); at forehead, cheeks, chin, neck, axillae,
genitalia, hands, or feet
15630	at eyelids, nose, ears, or lips
15732      Muscle, myocutaneous, or fasciocutaneous flap; head and neck (e.g., temporalis, masseter muscle,
sternocleidomastoid, levator scapulae)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
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APPENDIX E: ORAL SURGERY SERVICE CODES AND DESCRIPTIONS	PAGE
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624 Service Codes and Descriptions: Surgical Services (cont.)
Service
Code       Service Description
Other Flaps and Grafts
15770      Graft; derma-fat-fascia
Other Procedures
15819	Cervicoplasty
15820	Blepharoplasty, lower eyelid (P.A.)
15821	with extensive herniated fat pad (P.A.)
15822	Blepharoplasty, upper eyelid; (P.A.)
15823	with excessive skin weighting down lid (P.A.)
15840	Graft for facial nerve paralysis; free fascia graft (including obtaining fascia)
15841	free muscle graft (including obtaining graft)
15842	free muscle flap by microsurgical technique 15845	regional muscle transfer
Burns, Local Treatment
16000      Initial treatment, first degree burn, when no more than local treatment is required
DESTRUCTION
Destruction, Benign or Premalignant Lesions
17000      Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), all benign or premalignant lesions (e.g., actinic keratoses) other than skin tags or cutaneous vascular proliferative lesions; first lesion
17003	second through 14 lesions, each (List separately in addition to code for first lesion.)
17004	Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement),
all benign or premalignant lesions (e.g., actinic keratoses) other than skin tags or cutaneous
vascular proliferative lesions; 15 or more lesions
17106      Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); less than 10 sq cm
Destruction, Malignant Lesions, Any Method
17280	Destruction, malignant lesion (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery,
surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5
cm or less
17281	lesion diameter 0.6 to 1.0 cm
17282	lesion diameter 1.1 to 2.0 cm
17283	lesion diameter 2.1 to 3.0 cm
17281	
Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
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DEN-61	DATE
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624 Service Codes and Descriptions: Surgical Services (cont.)
Service
Code       Service Description
17284	lesion diameter 3.1 to 4.0 cm
17286	lesion diameter over 4.0 cm
Other Procedures
17999      Unlisted procedure, skin, mucous membrane, and subcutaneous tissue (I.C.)
MUSCULOSKELETAL SYSTEM
GENERAL
Incision
20000      Incision of soft tissue abscess (e.g., secondary to osteomyelitis); superficial
20005	deep or complicated
Excision
20200      Biopsy, muscle; superficial
20205	deep
20206	Biopsy, muscle, percutaneous needle
20220      Biopsy, bone, trocar, or needle; superficial (e.g., ilium, sternum, spinous process, ribs) 20240      Biopsy, bone, excisional; superficial (e.g., ilium, sternum, spinous process, ribs, trochanter of
femur)
20245	deep (e.g., humerus, ischium, femur)
Introduction or Removal
20520	Removal of foreign body in muscle or tendon sheath; simple
20525	deep or complicated
20605	Arthrocentesis, aspiration and/or injection; intermediate joint, bursa or ganglion cyst (e.g.,
temporomandibular, acromioclavicular, wrist, elbow, or ankle, olecranon bursa)
20615	Aspiration and injection for treatment of bone cyst
20670	Removal of implant; superficial (e.g., buried wire, pin, or rod) (separate procedure)
20680	deep (e.g., buried wire, pin, screw, metal band, nail, rod, or plate)
20690	Application of a uniplane (pins or wires in one plane), unilateral, external fixation system
20692	Application of a multiplane (pins or wires in more than one plane), unilateral, external fixation
system (e.g., Ilizarov, Monticelli type)
20693	Adjustment or revision of external fixation system requiring anesthesia (e.g., new pin(s) or wire(s)
and/or new ring(s) or bar(s))
20694	Removal, under anesthesia, of external fixation system

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624 Service Codes and Descriptions: Surgical Services (cont.)
Service
Code       Service Description
Grafts (or Implants)
20900	Bone graft, any donor area; minor or small (e.g., dowel or button)
20902	major or large
20910	Cartilage graft; costochondral
20912	nasal septum
20920	Fascia lata graft; by stripper
20922	by incision and area exposure, complex or sheet
20924	Tendon graft, from a distance (e.g., palmaris, toe extensor, plantaris)
20926	Tissue grafts, other (e.g., paratenon, fat, dermis)
Other Procedures
20955	Bone graft with microvascular anastomosis; fibula
20956	iliac crest
20962	other than fibula, iliac crest, or metatarsal
20969	Free osteocutaneous flap with microvascular anastomosis; other than iliac crest, metatarsal, or
great toe (I.C.)
20970	iliac crest
20999      Unlisted procedure, musculoskeletal system, general (I.C.)
HEAD
Incision
21010      Arthrotomy, temporomandibular joint
Excision
21015      Radical resection of tumor (e.g., malignant neoplasm), soft tissue of face or scalp
21025	Excision of bone (e.g., for osteomyelitis or bone abscess); mandible
21026	facial bone(s)
21029	Removal by contouring of benign tumor of facial bone (e.g., fibrous dysplasia) (P.A.)
21030	Excision of benign tumor or cyst of facial bone other than mandible
21031	Excision of torus mandibularis
21032	Excision of maxillary torus palatinus
21034	Excision of malignant tumor of facial bone other than mandible
21040	Excision of benign cyst or tumor of mandible; simple
21041	complex
21044	Excision of malignant tumor of mandible
21045	radical resection

Commonwealth of Massachusetts
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624 Service Codes and Descriptions: Surgical Services (cont.)
Service
Code       Service Description
21050      Condylectomy, temporomandibular joint (separate procedure)
21060      Meniscectomy, partial or complete, temporomandibular joint (separate procedure)
21070      Coronoidectomy (separate procedure)

21076 21077 21079 21080 21081 21082 21083 21084 21085 21086 21087 21088 21089 21100
21110
21116
21137 21138
21139 21141
21142 21143 21145
21146
21147

Introduction or Removal
Impression and custom preparation; surgical obturator prosthesis
orbital prosthesis
interim obturator prosthesis (P.A.) (I.C.)
definitive obturator prosthesis (P.A.) (I.C.)
mandibular resection prosthesis (P.A.) (I.C.)
palatal augmentation prosthesis (P.A.) (I.C.)
palatal lift prosthesis (P.A.) (I.C.)
speech aid prosthesis (P.A.) (I.C.)
oral surgical splint (P.A.) (I.C.)
auricular prosthesis (P.A.) (I.C.)
nasal prosthesis (P.A.) (I.C.)
facial prosthesis (P.A.) (I.C.) Unlisted maxillofacial prosthetic procedure (P.A.) (I.C.) Application of halo type appliance for maxillofacial fixation, includes removal (separate
procedure) Application of interdental fixation device for conditions other than fracture or dislocation, includes
removal (I.C.) Injection procedure for temporomandibular joint arthrography
Repair, Revision, and/or Reconstruction
Reduction forehead; contouring only (P.A.)
contouring and application of prosthetic material or bone graft (includes obtaining autograft)
(P.A.)
contouring and setback of anterior frontal sinus wall (P.A.) Reconstruction midface, LeFort I; single piece, segment movement in any direction (e.g., for Long
Face Syndrome), without bone graft (P.A.)
two pieces, segment movement in any direction, without bone graft
three or more pieces, segment movement in any direction, without bone graft
single piece, segment movement in any direction, requiring bone grafts (includes obtaining
autografts) (P.A.)
two pieces, segment movement in any direction, requiring bone grafts (includes obtaining
autografts) (e.g., ungrafted unilateral alveolar cleft) (P.A.)
three or more pieces, segment movement in any direction, requiring bone grafts (includes
obtaining autografts) (e.g., ungrafted bilateral alveolar cleft or multiple osteotomies) (P.A.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DENTAL MANUAL	SUBCHAPTER NUMBER AND TITLE
APPENDIX E: ORAL SURGERY SERVICE CODES AND DESCRIPTIONS	PAGE
E-14	

	TRANSMITTAL LETTER
DEN-61	DATE
04/30/02	
624 Service Codes and Descriptions: Surgical Services (cont.)
Service
Code       Service Description
21150	Reconstruction midface, LeFort II; anterior intrusion (e.g., Treacher-Collins Syndrome) (P.A.)
21151	any direction, requiring bone grafts (includes obtaining autografts) (P.A.)
21154	Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes
obtaining autografts); without LeFort I (P.A.)
21155	with LeFort I (P.A.)
21159	Reconstruction midface, LeFort III (extra- and intracranial) with forehead advancement (e.g.,
mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I (P.A.)
21160	with LeFort I (P.A.)
21172      Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or
without grafts (includes obtaining autografts) (P.A.) 21175      Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (e.g., plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes obtaining autografts) (P.A.)
21181	Reconstruction by contouring of benign tumor of cranial bones (e.g., fibrous dysplasia), extracranial
21182	Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and
extracranial excision of benign tumor of cranial bone (e.g., fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting less than 40 sq cm
21183	total area of bone grafting greater than 40 sq cm but less than 80 sq cm
21184	total area of bone grafting greater than 80 sq cm 21188      Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining
autografts) (P.A.)
21193	Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft
(P.A.)
21194	with bone graft (includes obtaining graft) (P.A.)
21195	Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation (P.A.)
21196	with internal rigid fixation (P.A.)
21198      Osteotomy, mandible, segmental (P.A.)
21206      Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard) (P.A.)
21208	Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) (P.A.)
21209	reduction (P.A.)
21210	Graft, bone; nasal, maxillary or malar areas (includes obtaining graft) (P.A.)
21215	mandible (includes obtaining graft) (P.A.)
21230	Graft; rib cartilage, autogenous, to face, chin, nose, or ear (includes obtaining graft) (P.A.)
21235	ear cartilage, autogenous, to nose or ear (includes obtaining graft) (P.A.)
21240	Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft) (P.A.)
21242	Arthroplasty, temporomandibular joint, with allograft (P.A.)
21243	Arthroplasty, temporomandibular joint, with prosthetic joint replacement (P.A.)
21244	Reconstruction of mandible, extraoral, with transosteal bone plate (e.g., mandibular staple bone
plate) (P.A.) 21247      Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining
grafts) (e.g., for hemifacial microsomia) (P.A.) 21255      Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining
autografts) (P.A.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DENTAL MANUAL	SUBCHAPTER NUMBER AND TITLE
APPENDIX E: ORAL SURGERY SERVICE CODES AND DESCRIPTIONS	PAGE
E-15	

	TRANSMITTAL LETTER
DEN-61	DATE
04/30/02	
624 Service Codes and Descriptions: Surgical Services (cont.)
Service
Code       Service Description
21260	Periorbital osteotomies for orbital hypertelorism, with bone grafts; extracranial approach (P.A.)
21261	combined intra- and extracranial approach (P.A.)
21263	with forehead advancement (P.A.)
21267	Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; extracranial approach
(P.A.)
21268	combined intra- and extracranial approach (P.A.)
21270      Malar augmentation, prosthetic material (P.A.)
21275      Secondary revision of orbitocraniofacial reconstruction (P.A.)
21280      Medial canthopexy (separate procedure) (P.A.)
21282      Lateral canthopexy (P.A.)
21295	Reduction of masseter muscle and bone (e.g., for treatment of benign masseteric hypertrophy);
extraoral approach (P.A.)
21296	intraoral approach (P.A.)
Other Procedures
21299	Unlisted craniofacial and maxillofacial procedure (P.A.) (I.C.)
Fracture and/or Dislocation
21300	Closed treatment of skull fracture without operation
21310	Closed treatment of nasal bone fracture without manipulation
21315	Closed treatment of nasal bone fracture; without stabilization
21320	with stabilization
21325	Open treatment of nasal fracture; uncomplicated
21330	complicated, with internal and/or external skeletal fixation
21335	with concomitant open treatment of fractured septum
21336	Open treatment of nasal septal fracture, with or without stabilization
21337	Closed treatment of nasal septal fracture, with or without stabilization
21338	Open treatment of nasoethmoid fracture; without external fixation
21339	with external fixation
21340	Percutaneous treatment of nasoethmoid complex fracture, with splint, wire, or headcap fixation,
including repair of canthal ligaments and/or the nasolacrimal apparatus
21343	Open treatment of depressed frontal sinus fracture
21344	Open treatment of complicated (e.g., comminuted or involving posterior wall) frontal sinus
fracture, via coronal or multiple approaches
21345	Closed treatment of nasomaxillary complex fracture (LeFort II type), with interdental wire fixation
or fixation of denture or splint

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DENTAL MANUAL	SUBCHAPTER NUMBER AND TITLE
APPENDIX E: ORAL SURGERY SERVICE CODES AND DESCRIPTIONS	PAGE
E-16	

	TRANSMITTAL LETTER
DEN-61	DATE
04/30/02	
624 Service Codes and Descriptions: Surgical Services (cont.)
Service
Code       Service Description
21346	Open treatment of nasomaxillary complex fracture (LeFort II type); with wiring and/or local
fixation
21347	requiring multiple open approaches
21348	with bone grafting (includes obtaining graft)
21355	Percutaneous treatment of fracture of malar area, including zygomatic arch and malar tripod, with
manipulation
21356	Open treatment of depressed zygomatic arch fracture (e.g., Gillies approach)
21360      Open treatment of depressed malar fracture, including zygomatic arch and malar tripod
21365	Open treatment of complicated (e.g., comminuted or involving cranial nerve foramina) fracture(s)
of malar area, including zygomatic arch and malar tripod; with internal fixation and multiple
surgical approaches
21366	with bone grafting (includes obtaining graft)
21385	Open treatment of orbital floor blowout fracture; transantral approach (Caldwell-Luc type
operation)
21386	periorbital approach
21387	combined approach
21390	periorbital approach, with alloplastic or other implant
21395	periorbital approach with bone graft (includes obtaining graft)
21400	Closed treatment of fracture of orbit, except blowout; without manipulation
21401	with manipulation
21406	Open treatment of fracture of orbit, except blowout; without implant
21407	with implant
21408	with bone grafting (includes obtaining graft)

21421	Closed treatment of palatal or maxillary fracture (LeFort I type), with interdental wire fixation or fixation of denture or splint
21422	Open treatment of palatal or maxillary fracture (LeFort I type)
21423	complicated (comminuted or involving cranial nerve foramina), multiple approaches
21431	Closed treatment of craniofacial separation (LeFort III type) using interdental wire fixation of denture or splint
21432	Open treatment of craniofacial separation (LeFort III type); with wiring and/or internal fixation
21433	complicated (e.g., comminuted or involving cranial nerve foramina), multiple surgical
approaches
21435	complicated, utilizing internal and/or external fixation techniques (e.g., head cap, halo device, and/or intermaxillary fixation)
21436	complicated, multiple surgical approaches, internal fixation, with bone grafting (includes obtaining graft)
21440      Closed treatment of mandibular or maxillary alveolar ridge fracture (separate procedure) 21445      Open treatment of mandibular or maxillary alveolar ridge fracture (separate procedure)
21450	Closed treatment of mandibular fracture; without manipulation
21451	with manipulation
21452	Percutaneous treatment of mandibular fracture, with external fixation
21453	Closed treatment of mandibular fracture with interdental fixation
21452	
Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DENTAL MANUAL	SUBCHAPTER NUMBER AND TITLE
APPENDIX E: ORAL SURGERY SERVICE CODES AND DESCRIPTIONS	PAGE
E-17	

	TRANSMITTAL LETTER
DEN-61	DATE
04/30/02	
624 Service Codes and Descriptions: Surgical Services (cont.)
Service
Code       Service Description
21454      Open treatment of mandibular fracture with external fixation
21461	Open treatment of mandibular fracture; without interdental fixation
21462	with interdental fixation
21465      Open treatment of mandibular condylar fracture
21470      Open treatment of complicated mandibular fracture by multiple surgical approaches including
internal fixation, interdental fixation, and/or wiring of dentures or splints
21480      Closed treatment of temporomandibular dislocation; initial or subsequent
21485	complicated (e.g., recurrent requiring intermaxillary fixation or splinting), initial or
subsequent 21490      Open treatment of temporomandibular dislocation
21493	Closed treatment of hyoid fracture; without manipulation
21494	with manipulation
21495	Open treatment of hyoid fracture
21497      Interdental wiring, for condition other than fracture
Other Procedures
21499      Unlisted musculoskeletal procedure, head (I.C.)
ARTHROSCOPY
29800      Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate
procedure) (P.A.) (I.C.) 29804      Arthroscopy, temporomandibular joint, surgical (P.A.) (I.C.) 29999      Unlisted procedure, arthroscopy
RESPIRATORY SYSTEM
NOSE
Excision
30130      Excision turbinate, partial or complete, any method
30140      Submucous resection turbinate, partial or complete, any method
Repair
30520      Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement
with graft
30580      Repair fistula; oromaxillary (combine with 31030 if antrotomy is included) (I.C.)
30600	oronasal

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DENTAL MANUAL	SUBCHAPTER NUMBER AND TITLE
APPENDIX E: ORAL SURGERY SERVICE CODES AND DESCRIPTIONS	PAGE
E-18	

	TRANSMITTAL LETTER
DEN-61	DATE
04/30/02	
624 Service Codes and Descriptions: Surgical Services (cont.)
Service
Code       Service Description
Other Procedures
30901      Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method 30903      Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method
30905	Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial
30906	subsequent
30999	Unlisted procedure, nose
ACCESSORY SINUSES Incision
31000	Lavage by cannulation; maxillary sinus (antrum puncture or natural ostium)
31020	Sinusotomy, maxillary (antrotomy); intranasal
31030	radical (Caldwell-Luc) without removal of antrochoanal polyps
31032	radical (Caldwell-Luc) with removal of antrochoanal polyps
Excision
31225      Maxillectomy; without orbital exenteration
Endoscopy
31233      Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy (via inferior meatus or canine fossa
puncture)
31256      Nasal/sinus endoscopy, surgical, with maxillary antrostomy
31267	with removal of tissue from maxillary sinus
31290      Nasal/sinus endoscopy, surgical, with repair of cerebrospinal fluid leak; ethmoid region
31292	Nasal/sinus endoscopy, surgical; with medial or inferior orbital wall decompression
31293	with medial orbital wall and inferior orbital wall decompression
31294	with optic nerve decompression
Other Procedures
31299      Unlisted procedure, accessory sinuses (I.C.)
LARYNX
Introduction
31500      Intubation, endotracheal, emergency procedure
31502      Tracheotomy tube change prior to establishment of fistula tract

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DENTAL MANUAL	SUBCHAPTER NUMBER AND TITLE
APPENDIX E: ORAL SURGERY SERVICE CODES AND DESCRIPTIONS	PAGE
E-19	

	TRANSMITTAL LETTER
DEN-61	DATE
04/30/02	
624 Service Codes and Descriptions: Surgical Services (cont.)
Service
Code       Service Description
TRACHEA AND BRONCHI
Incision
31600      Tracheostomy, planned (separate procedure)
31603      Tracheostomy, emergency procedure; transtracheal
31605	cricothyroid membrane
HEMIC AND LYMPHATIC SYSTEMS
LYMPH NODES AND LYMPHATIC CHANNELS
Excision
38500      Biopsy or excision of lymph node(s); open, superficial
38505	by needle, superficial (e.g., cervical, inguinal, axillary)
38510	open, deep cervical node(s)
DIGESTIVE SYSTEM
LIPS
Excision
40490	Biopsy of lip
40500	Vermilionectomy (lip shave), with mucosal advancement
40510	Excision of lip; transverse wedge excision with primary closure
40520	V-excision with primary direct linear closure
40525	full thickness, reconstruction with local flap (e.g., Estlander or fan)
40527	full thickness, reconstruction with cross lip flap (Abbe-Estlander)
40530	Resection of lip, more than one-fourth, without reconstruction
Repair (Cheiloplasty)
40650	Repair lip, full thickness; vermilion only
40652	up to half vertical height
40654	over one-half vertical height, or complex
40700	Plastic repair of cleft lip/nasal deformity; primary, partial or complete, unilateral
40701	primary bilateral, one stage procedure
40702	primary bilateral, one of two stages
40720	secondary, by recreation of defect and reclosure (P.A.)
40761	with cross lip pedicle flap (Abbe-Estlander type), including sectioning and inserting of
pedicle (P.A.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DENTAL MANUAL	SUBCHAPTER NUMBER AND TITLE
APPENDIX E: ORAL SURGERY SERVICE CODES AND DESCRIPTIONS	PAGE
E-20	

	TRANSMITTAL LETTER
DEN-61	DATE
04/30/02	
624 Service Codes and Descriptions: Surgical Services (cont.)
Service
Code       Service Description
Other Procedures
40799	Unlisted procedure, lips (I.C.)
VESTIBULE OF MOUTH Incision
40800	Drainage of abscess, cyst, hematoma, vestibule of mouth; simple
40801	complicated
40804	Removal of embedded foreign body, vestibule of mouth; simple
40805	complicated
40806	Incision of labial frenum (frenotomy)
Excision, Destruction
40808	Biopsy, vestibule of mouth
40810	Excision of lesion of mucosa and submucosa, vestibule of mouth; without repair
40812	with simple repair
40814	with complex repair
40816	complex, with excision of underlying muscle
0	Excision of mucosa of vestibule of mouth as donor graft
1	Excision of frenum, labial or buccal (frenumectomy, frenulectomy, frenectomy)
2	Destruction of lesion or scar of vestibule of mouth by physical methods (e.g., laser, thermal, cryo, chemical)
Repair
40830	Closure of laceration, vestibule of mouth; 2.5 cm or less
40831	over 2.5 cm or complex
40840      Vestibuloplasty; anterior (P.A.)
0	posterior, unilateral (P.A.)
1	posterior, bilateral (P.A.)
2	entire arch (P.A.)
3	complex (including ridge extension, muscle repositioning) (P.A.)
Other Procedures
40899      Unlisted procedure, vestibule of mouth (I.C.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DENTAL MANUAL	SUBCHAPTER NUMBER AND TITLE
APPENDIX E: ORAL SURGERY SERVICE CODES AND DESCRIPTIONS	PAGE
E-21	

	TRANSMITTAL LETTER
DEN-61	DATE
04/30/02	
624 Service Codes and Descriptions: Surgical Services (cont.)
Service
Code       Service Description
TONGUE AND FLOOR OF MOUTH
Incision
41000	Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; lingual
0	sublingual, superficial
1	sublingual, deep, supramylohyoid
2	submental space
3	submandibular space
4	masticator space
41010	Incision of ligual frenum (frenotomy)
41015	Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; sublingual
0	submental
1	submandibular
2	masticator space
Excision
41100	Biopsy of tongue; anterior two-thirds
41105	posterior one-third
41108	Biopsy of floor of mouth
41110	Excision of lesion of tongue without closure
41112	Excision of lesion of tongue with closure; anterior two-thirds
0	posterior one-third
1	with local tongue flap
41115	Excision of lingual frenum (frenectomy)
41116	Excision, lesion of floor of mouth
41120	Glossectomy; less than one-half tongue
41130	hemiglossectomy
41135	partial, with unilateral radical neck dissection
41140	complete or total, with or without tracheostomy, without radical neck dissection
41145	complete or total, with or without tracheostomy, with unilateral radical neck dissection
41150	composite procedure with resection floor of mouth and mandibular resection, without radical
neck dissection
41153	composite procedure with resection floor of mouth, with suprahyoid neck dissection
41155	composite procedure with resection floor of mouth, mandibular resection, and radical neck
dissection (Commando type)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DENTAL MANUAL	SUBCHAPTER NUMBER AND TITLE
APPENDIX E: ORAL SURGERY SERVICE CODES AND DESCRIPTIONS	PAGE
E-22	

	TRANSMITTAL LETTER
DEN-61	DATE
04/30/02	
624 Service Codes and Descriptions: Surgical Services (cont.)
Service
Code       Service Description
Repair
41250	Repair of laceration 2.5 cm or less; floor of mouth and/or anterior two-thirds of tongue
41251	posterior one-third of tongue
41252	Repair of laceration of tongue, floor of mouth, over 2.6 cm or complex
Other Procedures
41500	Fixation of tongue, mechanical, other than suture (e.g., K-wire)
41510	Suture of tongue to lip for micrognathia (Douglas type procedure)
41520	Frenoplasty (surgical revision of frenum, e.g., with Z-plasty)
41599	Unlisted procedure, tongue, floor of mouth (I.C.)
DENTOALVEOLAR STRUCTURES
Incision
41800      Drainage of abscess, cyst, hematoma from dentoalveolar structures
41805	Removal of embedded foreign body from dentoalveolar structures; soft tissues
41806	bone
Excision, Destruction
0	Gingivectomy, excision gingiva, each quadrant (P.A.) (I.C.)
1	Operculectomy, excision pericoronal tissues
2	Excision of fibrous tuberosities, dentoalveolar structures
3	Excision of osseous tuberosities, dentoalveolar structures
41825	Excision of lesion or tumor (except listed above), dentoalveolar structures; without repair
0	with simple repair
1	with complex repair
41828	Excision of hyperplastic alveolar mucosa, each quadrant (specify)
41830      Alveolectomy, including curettage of osteitis or sequestrectomy
41850      Destruction of lesion (except excision), dentoalveolar structures (I.C.)
Other Procedures
41874      Alveoloplasty, each quadrant (specify)
41899      Unlisted procedure, dentoalveolar structures (I.C.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DENTAL MANUAL	SUBCHAPTER NUMBER AND TITLE
APPENDIX E: ORAL SURGERY SERVICE CODES AND DESCRIPTIONS	PAGE
E-23	

	TRANSMITTAL LETTER
DEN-61	DATE
04/30/02	
624 Service Codes and Descriptions: Surgical Services (cont.)
Service
Code       Service Description
PALATE AND UVULA
Incision
42000      Drainage of abscess of palate, uvula
Excision, Destruction
42100	Biopsy of palate, uvula
42104	Excision, lesion of palate, uvula; without closure
42106	with simple primary closure
42107	with local flap closure
42120	Resection of palate or extensive resection of lesion
42140	Uvulectomy, excision of uvula (P.A.)
42145	Palatopharyngoplasty (e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty) (P.A.)
42160	Destruction of lesion, palate or uvula (thermal, cryo, or chemical)
Repair
42180	Repair, laceration of palate; up to 2 cm
42182	over 2 cm or complex
42200	Palatoplasty for cleft palate, soft and/or hard palate only
42205	Palatoplasty for cleft palate, with closure of alveolar ridge; soft tissue only
42210	with bone graft to alveolar ridge (includes obtaining graft)
42215	Palatoplasty for cleft palate; major revision
42220	secondary lengthening procedure
42225	attachment pharyngeal flap
42226	Lengthening of palate, and pharyngeal flap
42227	Lengthening of palate, with island flap
42235	Repair of anterior palate, including vomer flap
42260	Repair of nasolabial fistula
0	Maxillary impression for palatal prosthesis (P.A.)
1	Insertion of pin-retained palatal prosthesis (P.A.)
Other Procedures
42299      Unlisted procedure, palate, uvula (I.C.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
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APPENDIX E: ORAL SURGERY SERVICE CODES AND DESCRIPTIONS	PAGE
E-24	

	TRANSMITTAL LETTER
DEN-61	DATE
04/30/02	
624 Service Codes and Descriptions: Surgical Services (cont.)
Service
Code       Service Description
SALIVARY GLAND AND DUCTS
Incision
42300	Drainage of abscess; parotid, simple
42305	parotid, complicated
42310	Drainage of abscess; submaxillary or sublingual, intraoral
42320	submaxillary, external
42325	Fistulization of sublingual salivary cyst (ranula);
42326	with prosthesis
42330	Sialolithotomy; submandibular (submaxillary), sublingual or parotid, uncomplicated, intraoral
42335	submandibular (submaxillary), complicated, intraoral
42340	parotid, extraoral or complicated intraoral
Excision
42400	Biopsy of salivary gland; needle
42405	incisional
0	Excision of sublingual salivary cyst (ranula)
1	Marsupialization of sublingual salivary cyst (ranula)
42410	Excision of parotid tumor or parotid gland; lateral lobe, without nerve dissection
42415	lateral lobe, with dissection and preservation of facial nerve
42420	total, with dissection and preservation of facial nerve
42425	total, en bloc removal with sacrifice of facial nerve
42440	Excision of submandibular (submaxillary) gland
42450	Excision of sublingual gland
Repair
42500	Plastic repair of salivary duct, sialodochoplasty; primary or simple
42505	secondary or complicated
42507	Parotid duct diversion, bilateral (Wilke type procedure);
0	with excision of one submandibular gland
1	with excision of both submandibular glands
2	with ligation of both submandibular (Wharton's) ducts
0	
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Provider Manual Series
DENTAL MANUAL	SUBCHAPTER NUMBER AND TITLE
APPENDIX E: ORAL SURGERY SERVICE CODES AND DESCRIPTIONS	PAGE
E-25	

	TRANSMITTAL LETTER
DEN-61	DATE
04/30/02	
624 Service Codes and Descriptions: Surgical Services (cont.)
Service
Code       Service Description
Other Procedures
42550	Injection procedure for sialography
42600	Closure salivary fistula
42650	Dilation salivary duct
42660	Dilation and catheterization of salivary duct, with or without injection
42665	Ligation salivary duct, intraoral
42699	Unlisted procedure, salivary glands or ducts (I.C.)
PHARYNX, ADENOIDS, AND TONSILS Incision
42700	Incision and drainage abscess; peritonsillar
42720	retropharyngeal or parapharyngeal, intraoral approach
42725	retropharyngeal or parapharyngeal, external approach
Excision, Destruction
42800	Biopsy; oropharynx
42802	hypopharynx
42804	nasopharynx, visible lesion, simple
42806	nasopharynx, survey for unknown primary lesion
0	Excision or destruction of lesion of pharynx, any method
1	Removal of foreign body from pharynx
42810	Excision branchial cleft cyst or vestige, confined to skin and subcutaneous tissues
42815	Excision branchial cleft cyst, vestige, or fistula, extending beneath subcutaneous tissues and/or
into pharynx 42842      Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; without closure
0	closure with local flap (e.g., tongue, buccal)
1	closure with other flap 42860      Excision of tonsil tags 42870      Excision or destruction lingual tonsil, any method (separate procedure)
Repair
42900      Suture pharynx for wound or injury

Commonwealth of Massachusetts
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APPENDIX E: ORAL SURGERY SERVICE CODES AND DESCRIPTIONS	PAGE
E-26	

	TRANSMITTAL LETTER
DEN-61	DATE
04/30/02	
624 Service Codes and Descriptions: Surgical Services (cont.)
Service
Code       Service Description
Other Procedures
42960	Control oropharyngeal hemorrhage, primary or secondary (e.g., post-tonsillectomy); simple
0	complicated, requiring hospitalization
1	with secondary surgical intervention
42970	Control of nasopharyngeal hemorrhage, primary or secondary (e.g., post-adenoidectomy); simple,
with posterior nasal packs, with or without anterior packs and/or cautery
0	complicated, requiring hospitalization
1	with secondary surgical intervention 42999      Unlisted procedure, pharynx, adenoids, or tonsils (I.C.)
NERVOUS SYSTEM
EXTRACRANIAL NERVES, PERIPHERAL NERVES, AND AUTONOMIC NERVOUS SYSTEM
Introduction/Injection of Anesthetic Agent (Nerve Block), Diagnostic and Therapeutic
Somatic Nerves
64400      Injection, anesthetic agent; trigeminal nerve, any division or branch
Destruction by Neurolytic Agent (e.g., Chemical, Thermal, Electrical, Radiofrequency, or Chemodenervation)
Somatic Nerves
64600      Destruction by neurolytic agent, trigeminal nerve, supraorbital, infraorbital, mental, or inferior alveolar branch
Neuroplasty (Exploration, Neurolysis or Nerve Decompression)
64722      Decompression, unspecified nerve(s) (specify)
64727      Internal neurolysis, requiring use of operating microscope (List separately in addition to code for neuroplasty) (Neuroplasty includes external neurolysis)
Transection or Avulsion
64732	Transection or avulsion of; supraorbital nerve
64734	infraorbital nerve
64736	mental nerve
64738	inferior alveolar nerve by osteotomy
64740	lingual nerve

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APPENDIX E: ORAL SURGERY SERVICE CODES AND DESCRIPTIONS	PAGE
E-27	

	TRANSMITTAL LETTER
DEN-61	DATE
04/30/02	
624	Service Codes and Descriptions: Surgical Services (cont.)
Service
Code       Service Description
Neurorrhaphy
64864      Suture of facial nerve; extracranial
Neurorrhaphy with Nerve Graft
64885      Nerve graft (includes obtaining graft), head or neck; up to 4 cm in length
Other Procedures
64999      Unlisted procedure, nervous system (I.C.)
OPERATING MICROSCOPE
69990      Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure.)
625	Service Codes and Descriptions: Radiology Services
The following service codes are reimbursable only when performed in an office location.
DIAGNOSTIC RADIOLOGY (DIAGNOSTIC IMAGING)
HEAD AND NECK
70100	Radiologic examination, mandible; partial, less than four views
70110	complete, minimum of four views
70140	Radiologic examination, facial bones; less than three views
70150	complete, minimum of three views
70160	Radiologic examination, nasal bones, complete, minimum of three views
70210	Radiologic examination, sinuses, paranasal, less than three views
70220	Radiologic examination, sinuses, paranasal, complete, minimum of three views
70240	Radiologic examination, sella turcica
70328	Radiologic examination, temporomandibular joint, open and closed mouth; unilateral
70330	bilateral
70360	Radiologic examination; neck, soft tissue
70380	Radiologic examination, salivary gland for calculus
This publication contains codes that are copyrighted by the American Medical Association. Certain terms used in the service descriptions for HCPCS codes are defined in the Current Procedural Terminology (CPT) code book.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DENTAL MANUAL	SUBCHAPTER NUMBER AND TITLE
APPENDIX E: ORAL SURGERY SERVICE CODES AND DESCRIPTIONS	PAGE
E-28	

	TRANSMITTAL LETTER
DEN-61	DATE
04/30/02	
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