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-71 November 2005 TO: Dental Providers Participating in MassHealth FROM: Beth Waldman, Medicaid Director RE: Elimination of Prior Authorization and Reduction of Limitations for Certain Service Codes Effective for dates of service on or after November 14, 2005, MassHealth is eliminating the prior- authorization requirement for certain services and is reducing the limitations for certain other services. These changes are reflected in the attached revised Subchapter 6 and Appendix E of the Dental Manual, and will be further reflected in revised regulations to be issued within the coming months. Changes described in this transmittal letter, however, will be effective November 14, 2005, regardless of the effective date of the regulations. Important Note: All other conditions of payment in 130 CMR 420.000 and 450.000 still apply, including, but not limited to, age limitations and specifications for services provided to members aged 21 and older with “special circumstances” designation (see, for example, 130 CMR 420.401(C) and 420.410(D)). Elimination of Prior Authorization Requirement For dates of service on or after November 14, 2005, the following services no longer require prior authorization. D0350 Oral/facial photographic images D7220 Removal of impacted tooth—soft tissue D7230 Removal of impacted tooth—partially bony D9941 Fabrication of athletic mouthguard Reduced Limitations for Preventive Services MassHealth has reduced the limitations for the following preventive services, effective November 14, 2005. • MassHealth will cover periodic oral examination (D0120) twice per 12-month period, instead of once per 12-month period. • MassHealth will cover oral prophylaxis (D1110 and D1120) twice per 12-month period without prior authorization, instead of once per 12-month period without prior authorization. • MassHealth will cover topical application of fluoride (D1203) without limitations or prior authorization for members under age 21. • MassHealth will cover sealants (D1351) for primary or permanent first and second non-carious molars, first and second non-carious bicuspids (premolars) with deep pits and fissures, and non- carious third molars with deep pits and fissures for members under age 21, instead of limiting this service to members aged 5 through 20 for permanent first molars and second molars only. MASSHEALTH TRANSMITTAL LETTER DEN-71 November 2005 Page 2 Additional Program Changes MassHealth has made the following additional program changes, effective for dates of service on or after November 14, 2005. • MassHealth will cover other nonemergency medically necessary treatment provided during the same visit as an emergency care visit. That is, other nonemergency service codes may be billed in conjunction with the code for an emergency visit—D9110 (Palliative treatment). • MassHealth has reduced the minimum number of radiographs required for a full-mouth series (D0210), from 12 periapical and two posterior bitewing radiographs to 10 periapical and two posterior bitewing radiographs. • MassHealth is further clarifying that its regulations at 130 CMR 420.425(B) will be updated to indicate that four or more surface composite restorations are allowed on a single anterior or posterior tooth, as reflected in the Subchapter 6 currently in effect (D2335 and D2394). Accordingly, as reflected in Subchapter 6, MassHealth providers are not limited to the maximum allowable amount for two-surface restorations for anterior teeth (D2335) or to the maximum allowable amount for three-surface restorations for posterior teeth (D2394). • MassHealth has eliminated the restriction on the number of teeth on which root canal therapy (D3310, D3320, and D3330) may be performed during a period of treatment. Prior-authorization requirements still apply to root canal therapy. If you have any questions about the information in this transmittal letter please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. NEW MATERIAL (The pages listed here contain new or revised language.) Dental Manual Pages 6-1 through 6-10 and E-1 through E-6 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Dental Manual Pages 6-1 through 6-10 and E-3 through E-6— transmitted by Transmittal Letter DEN-69 Pages E-1 and E-2 — transmitted by Transmittal Letter DEN-66 • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-1 DENTAL MANUAL TRANSMITTAL LETTER DEN-71 DATE 11/14/05 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 “to age 14,” “6 through 12,” “13 through 20,” “14 through 20,” “16 through 20,” “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. Note that prior authorization may be requested for unlisted or noncovered services and codes for members under age 21, pursuant to 130 CMR 450.144(A). 601 Explanation of Abbreviations The following abbreviations are used in Subchapter 6. (A) P.A. indicates that service-specific prior authorization is required (see 130 CMR 420.410). (B) I.C. indicates that the claim will receive individual consideration to determine payment. A descriptive report must accompany the claim (see 130 CMR 420.412). (C) S.P. indicates that the procedure is commonly performed as part of a total service and does not usually warrant a separate fee. The procedure must be performed separately to receive the separate fee (see 130 CMR 420.413). (D) S.C. indicates that the procedure is covered for members aged 21 and older who meet the Special Circumstances criteria (see 130 CMR 420.410(D)). 602 Service Codes and Descriptions: Diagnostic Services See 130 CMR 420.422, 420.433, and 420.443 for limitations. Service Code Service Description Clinical Oral Evaluation D0120 Periodic oral examination (twice per 12-month period) (under 21 and S.C. only) D0150 Comprehensive oral evaluation—new or established patient (once per member per dentist) (under 21 and S.C. only) • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-2 DENTAL MANUAL TRANSMITTAL LETTER DEN-71 DATE 11/14/05 603 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 10 periapical films and two posterior bitewings) (S.C.: minimum of 10 periapical films and two posterior bitewings) (21 & older—other: minimum of 10 periapical films and two posterior bitewings as separate procedure as related to diagnosing an emergency-care condition, extracting a tooth, or to document a condition for covered treatment related to P.A. requirements) D0220 Intraoral—periapical, first film D0230 Intraoral—periapical, each additional film D0270 Bitewing—single film D0272 Bitewings—two films (under 21 and S.C., twice per calendar year) (21 and 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 to support a P.A. request for another service) Test and Laboratory Examinations D0470 Diagnostic casts (only when requested by MassHealth) (P.A.) 604 Service Codes and Descriptions: Preventive Services See 130 CMR 420.424, 420.435, and 420.445 for limitations. Service Code Service Description Dental Prophylaxis (twice per 12-month period) D1110 Prophylaxis—adult (ages 14 through 20 and S.C. only) D1120 Prophylaxis—child (to age 14) • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-3 DENTAL MANUAL TRANSMITTAL LETTER DEN-71 DATE 11/14/05 604 Service Codes and Descriptions: Preventive Services (cont.) Topical Fluoride Treatment (Office Procedure) D1203 Topical application of fluoride (prophylaxis not included)—child (under 21 only) (S.C. and 21 and older—other require P.A.) Other Preventive Services D1351 Sealant—per tooth (primary or permanent first and second non-carious molars, first and second non-carious bicuspids (premolars) with deep pits and fissures, and non-carious third molars with deep pits and fissures) (once per three years per tooth) (under 21 only) 605 Service Codes and Descriptions: Restorative Services See 130 CMR 420.425, 420.436, and 420.446 for limitations. Service Code Service Description Amalgam Restorations (Including Polishing) D2140 Amalgam—one surface, primary or permanent (primary — under 21 only) (permanent — under 21 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) • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-4 DENTAL MANUAL TRANSMITTAL LETTER DEN-71 DATE 11/14/05 605 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.) (no limitation on number performed per treatment period) D3320 Bicuspid (excluding final restoration) (under 21 only) (P.A.) (no limitation on number performed per treatment period) D3330 Molar (excluding final restoration) (under 21 only) (P.A.) (no limitation on number performed per treatment period) Apicoectomy/Periradicular Services D3410 Apicoectomy/periradicular surgery—anterior (per tooth) (includes retrograde filling) (under 21 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.) • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-5 DENTAL MANUAL TRANSMITTAL LETTER DEN-71 DATE 11/14/05 607 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) • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-6 DENTAL MANUAL TRANSMITTAL LETTER DEN-71 DATE 11/14/05 608 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.) • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-7 DENTAL MANUAL TRANSMITTAL LETTER DEN-71 DATE 11/14/05 610 Service Codes and Descriptions: Exodontic Services See 130 CMR 420.429, 420.439, and 420.449 for limitations. Service Code Service Description Extractions (Includes Local Anesthesia and Routine Postoperative Care) (Place of Service Excludes Emergency Room and Hospital Inpatient) D7111 Extraction, coronal remnants—deciduous tooth D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth D7220 Removal of impacted tooth—soft tissue D7230 Removal of impacted tooth—partially bony D7240 Removal of impacted tooth—completely bony (P.A.) D7280 Surgical access of an unerupted tooth (under 21 only) (P.A.) D7283 Placement of device to facilitate eruption of impacted tooth (under 21 only) (P.A.) Surgical Procedures (Place of Service Excludes Emergency Room and Hospital Inpatient) D7310 Alveoplasty in conjunction with extractions—per quadrant D7311 Alveoplasty in conjunction with extractions—one to three teeth or tooth spaces, per quadrant (I.C.) D7320 Alveoplasty not in conjunction with extractions—per quadrant D7321 Alveoplasty not in conjunction with extractions—one to three teeth or tooth spaces, per quadrant (I.C.) D7340 Vestibuloplasty—ridge extension (second epithelialization) (P.A.) D7410 Excision of benign lesion up to 1.25 cm D7411 Excision of benign lesion greater than 1.25 cm D7960 Frenulectomy (frenectomy or frenotomy)—separate procedure (S.P.) D7963 Frenuloplasty D7970 Excision of hyperplastic tissue—per arch (P.A.) D7999 Unspecified oral surgery procedure, by report (P.A.) (I.C.) D9930 Treatment of complications (post surgical)—unusual circumstances, by report (I.C.) • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-8 DENTAL MANUAL TRANSMITTAL LETTER DEN-71 DATE 11/14/05 611 Service Codes and Descriptions: Orthodontic Services See 130 CMR 420.428 for limitations. Service Code Service Description Orthodontic Diagnosis and Full Orthodontic Treatment D8080 Comprehensive orthodontic treatment of the adolescent dentition (under 21 only) (P.A.) D8660 Pre-orthodontic treatment visit (consultation) (accredited orthodontists only) (once per six months) (under 21 only) D8670 Periodic orthodontic treatment visit (as part of a contract) (full orthodontic treatment, active, first year and second year, and first half of third year, if necessary, including retainer—quarterly treatment visits) (under 21 only) (P.A.) D8690 Orthodontic treatment (alternative billing to a contract fee) (under 21 only) (P.A.) Space Maintenance (Passive Appliances) D1510 Space maintainer—fixed-unilateral (under 21 only) D1515 Space maintainer—fixed-bilateral (under 21 only) D1520 Space maintainer—removable unilateral (under 21 only) D1525 Space maintainer—removable-bilateral (under 21 only) D1550 Recementation of space maintainer (under 21 only) Other Orthodontic Services D8680 Orthodontic retention (removal of appliances, construction and replacement of retainer(s)) (under 21 only) D8692 Replacement of lost or broken retainer (under 21 only) (P.A.) D8999 Unspecified orthodontic procedure, by report (under 21 only) (P.A.) (I.C.) • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-9 DENTAL MANUAL TRANSMITTAL LETTER DEN-71 DATE 11/14/05 612 Service Codes and Descriptions: General Anesthesia and IV Sedation Services — All Members See 130 CMR 420.452 for limitations. The allowable fees include payment for cardiac monitoring and other related costs, per 15 minutes. Service Code Service Description D9220 Deep sedation/general anesthesia—first 30 minutes D9221 Deep sedation/general anesthesia—each additional 15 minutes (from 31 to 90 minutes) 613 Service Codes and Descriptions: Other Services — All Members See 130 CMR 420.456 and 420.457 for limitations. Service Code Service Description Treatment of Physically or Developmentally Disabled Members D9920 Behavior management, by report (P.A.) Unclassified Treatment D9110 Palliative (emergency) treatment of dental pain—minor procedure (Other nonemergency medically necessary treatment may be provided during the same visit—that is, nonemergency codes may be billed in conjunction with D9110.) D9941 Fabrication of athletic mouthguard (under 21 only) D9999 Unspecified adjunctive procedure, by report (P.A.) (I.C.) This publication contains codes that are copyrighted by the American Dental Association and American Medical Association. • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-10 DENTAL MANUAL TRANSMITTAL LETTER DEN-71 DATE 11/14/05 This page is reserved. • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX E: ORAL SURGERY SERVICE CODES AND DESCRIPTIONS PAGE E-1 DENTAL MANUAL TRANSMITTAL LETTER DEN-71 DATE 11/14/05 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 MassHealth. 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 Code D7999. Note that prior authorization may be requested for unlisted or noncovered services and codes for members under age 21, pursuant to 130 CMR 450.144(A). 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 • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX E: ORAL SURGERY SERVICE CODES AND DESCRIPTIONS PAGE E-2 DENTAL MANUAL TRANSMITTAL LETTER DEN-71 DATE 11/14/05 620 Service Codes and Descriptions: Medical Services (cont.) Service Code Service Description 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 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 • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX E: ORAL SURGERY SERVICE CODES AND DESCRIPTIONS PAGE E-3 DENTAL MANUAL TRANSMITTAL LETTER DEN-71 DATE 11/14/05 620 Service Codes and Descriptions: Medical Services (cont.) Service Code Service Description 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 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 SUBCHAPTER NUMBER AND TITLE APPENDIX E: ORAL SURGERY SERVICE CODES AND DESCRIPTIONS PAGE E-4 DENTAL MANUAL TRANSMITTAL LETTER DEN-71 DATE 11/14/05 620 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 D7230 Removal of impacted tooth—partially bony D7240 Removal of impacted tooth—completely bony (P.A.) • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX E: ORAL SURGERY SERVICE CODES AND DESCRIPTIONS PAGE E-5 DENTAL MANUAL TRANSMITTAL LETTER DEN-71 DATE 11/14/05 623 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 (Other nonemergency medically necessary treatment may be provided during the same visit—that is, nonemergency codes may be billed in conjunction with D9110.) D9999 Unspecified adjunctive procedure, by report (P.A.) (I.C.) • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX E: ORAL SURGERY SERVICE CODES AND DESCRIPTIONS PAGE E-6 DENTAL MANUAL TRANSMITTAL LETTER DEN-71 DATE 11/14/05 624 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 subcutaneous abscess, cyst, furuncle, or paronychia); simple or single 10061 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 dislocation(s); skin and subcutaneous tissues 11011 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 otherwise listed; single lesion 11101 each separate/additional lesion (List separately in addition to code for primary procedure.)