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-69
March 2005

TO:	Dental Providers Participating in MassHealth
FROM:	Beth Waldman, Medicaid Director	
RE:	Dental Manual (2005 HCPCS)

This letter transmits revisions to the service codes and descriptions listed in Subchapter 6 and Appendix E of the Dental Manual. These revisions are effective for dates of service on or after March 1, 2005.

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 directly 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 regulation. The Division of Health Care Finance and Policy also has the regulations available on disk. The regulation title is
114.3 CMR 14.00: Dental.

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

Providers with questions about the information in this transmittal letter may contact MassHealth Provider Services at 617-628-4141 or 1-800-325-5231.

The following changes have been made effective March 1, 2005.

Deleted Codes	New Codes		
D7110	D7111	D7410	
D7120	D7140	D7411	
D7281	D7283	D7963	
D7430	D7311		
D7431	D7321		

These changes are effective March 1, 2005.

MASSHEALTH
TRANSMITTAL LETTER DEN-69
March 2005
Page 2

NEW MATERIAL
(The pages listed here contain new or revised language.) Dental Manual
Pages 6-1 through 6-10 and E-3 through E-6

OBSOLETE MATERIAL
(The pages listed here are no longer in effect.) Dental Manual
Pages 6-1 through 6-10 — transmitted by Transmittal Letter DEN-62 Pages E-3 through E-6 — transmitted by Transmittal Letter DEN-66

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

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) (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.)

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)

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 (P.A.) D7230	Removal of impacted tooth—partially bony (P.A.) D7240	Removal of impacted tooth—completely bony (P.A.)

623 Service Codes and Descriptions: Oral and Maxillofacial Surgical Services

Service
Code	Service Description

Introduction

D7280	Surgical access of an unerupted tooth (under 21 only) (P.A.)

Surgical Procedures

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.)
D7350	Vestibuloplasty—ridge extension (including soft-tissue grafts, muscle reattachments, revision of soft-tissue attachment, and management of hypertrophied and hyperplastic tissue) (P.A.)
D7410	Excision of benign lesion up to 1.25 cm D7411	Excision of benign lesion greater than 1.25 cm
D7450	Removal of benign odontogenic cyst or tumor—lesion diameter up to 1.25 cm D7451		lesion diameter greater than 1.25 cm
D7460	Removal of benign nonodontogenic cyst or tumor—lesion diameter up to 1.25 cm D7461		lesion diameter greater than 1.25 cm
D7471	Removal of lateral exostosis (maxilla or mandible) (P.A.) D7960	Frenulectomy (frenectomy or frenotomy)—separate procedure 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 (postsurgical)—unusual circumstances, by report (I.C.)

Unclassified Treatment

D9110	Palliative (emergency) treatment of dental pain—minor procedure D9999	Unspecified adjunctive procedure, by report (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	Incision and drainage of abscess (e.g., carbuncle, suppurative hidradenitis, cutaneous or	

10061	subcutaneous abscess, cyst, furuncle, or paronychia); simple or single
complicated or multiple	
10120	Incision and removal of foreign body, subcutaneous tissues; simple	
10121	complicated	
10140	Incision and drainage of hematoma, seroma, or fluid collection	
10160	Puncture aspiration of abscess, hematoma, bulla, or cyst	
10180	Incision and drainage, complex, postoperative wound infection	
	Excision—Debridement	
11010	Debridement including removal of foreign material associated with open fracture(s) and/or	

11011	dislocation(s); skin and subcutaneous tissues
skin, subcutaneous tissue, muscle fascia, and muscle	
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	

11101	otherwise listed; single lesion
each separate/additional lesion (List separately in addition to code for primary procedure.)	

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 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.

P.A. indicates that service-specific prior authorization is required (see 130 CMR 420.410).

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).

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).

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 Evaluation

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—new or established patient (once per member per dentist) (under 21 and S.C. only)

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) (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) (P.A.) (I.C.)

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 (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)

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)

D2140	Amalgam—one surface, primary or permanent (primary — under 21 only) (permanent — under 21 and S.C. only)
D2150	Amalgam—two surfaces, primary or permanent (primary — under 21 only) (permanent —
under 21 and S.C. only)
D2160	Amalgam—three surfaces, primary or permanent (primary — under 21 only) (permanent —
under 21 and S.C. only)
D2161	Amalgam—four or more surfaces, primary or permanent (under 21 and S.C. only) Resin Restorations (Composite Restorations)
D2330	Resin-based composite—one surface, anterior (under 21 and S.C. only)
D2331	Resin-based composite—two surfaces, anterior (under 21 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 and S.C. only)
D2392	Resin-based composite—two surfaces, posterior (primary — under 21 only) (permanent —
under 21 and S.C. only)
D2393	Resin-based composite—three surfaces, posterior (primary — under 21 only) (permanent —
under 21 and S.C. only)
D2394	Resin-based composite—four or more surfaces, posterior (primary — under 21 only) (permanent — under 21 and S.C. only)

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 and S.C. only) (P.A.)

Other Restorative Services
D2910	Recement inlay, onlay, or partial coverage restoration (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) (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)—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 and S.C. only) (P.A.) D3320	Bicuspid (excluding final restoration) (under 21 only) (P.A.)
D3330	Molar (excluding final restoration) (under 21 only) (P.A.)

Apicoectomy/Periradicular 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.)

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 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 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 and S.C. only) (P.A.) D5120	Complete denture—mandibular (under 21 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 and S.C. only) (P.A.)
D5212	Mandibular partial denture—resin base (including any conventional clasps, rests, and teeth) (under 21 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 and S.C. only)
D5520	Replace missing or broken teeth—complete denture (each tooth) (under 21 and S.C. only)

608 Service Codes and Descriptions: Prosthodontic (Removable) Services (cont.)

Repairs to Partial Dentures

D5610	Repair resin denture base (under 21 and S.C. only)
D5620	Repair cast framework (under 21 and S.C. only)
D5630	Repair or replace broken clasp (under 21 and S.C. only) D5640	Replace broken teeth—per tooth (under 21 and S.C. only) D5650	Add tooth to existing partial denture (under 21 and S.C. only) D5660	Add clasp to existing partial denture (under 21 and S.C. only)

Denture Rebase Procedures

D5710	Rebase complete maxillary denture (under 21 and S.C. only) (P.A.) D5711	Rebase complete mandibular denture (under 21 and S.C. only) (P.A.)
D5750	Reline complete maxillary denture (laboratory) (under 21 and S.C. only) (P.A.) D5751	Reline complete mandibular denture (laboratory) (under 21 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 and S.C. only) (P.A.) (I.C.)

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 (P.A.) D7230	Removal of impacted tooth—partially bony (P.A.) 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.)

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.)

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 Recipients

D9920	Behavior management, by report (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.)

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