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-79 August 2007 TO: Dental Providers Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Addition of New Service Codes (Revisions to Service Codes and Descriptions) Effective for dates of services on or after May 1, 2007, MassHealth covers the services listed below. These changes are reflected in the attached revised Subchapter 6 of the Dental Manual. The dental regulations will also be issued at a later date. Changes described in this transmittal letter, however, are effective May 1, 2007, regardless of the effective date of the regulations. New Service Codes D1204 Topical application of fluoride (prophylaxis not included)—adult (age 21 and older) (PA) D2934 Prefabricated esthetic coated stainless steel crown—primary tooth (under 21 only) D4211 Gingivectomy or gingivoplasty—one to three contiguous teeth or bounded teeth spaces per quadrant (once per quadrant per three-year period) (PA) D4342 Periodontal scaling and root planing—one to three teeth, per quadrant (includes curettage) (once per quadrant per three-year period) (PA) D9230 Analgesia, anxiolysis, inhalation of nitrous oxide D9241 Intravenous conscious sedation/analgesia—first 30 minutes D9242 Intravenous conscious sedation/analgesia—each additional 15 minutes (from 31 to 90 minutes) Clarification of the Following Services Panoramic Films MassHealth pays for panoramic films when medically necessary. Surgical Conditions: Panoramic films are payable when used as a diagnostic tool for surgical conditions. These films are payable whether or not the film is taken prior to the surgical procedure or on the same date of service as the surgical procedure. Surgical conditions include, but are not limited to: (a) impactions; (b) teeth requiring extractions in more than one quadrant; (c) large cysts or tumors that are not fully visualized by intraoral films or clinical examination; (d) salivary-gland disease; (e) maxillary-sinus disease; (f) facial trauma; and (g) trismus where an intraoral film placement is impossible. Nonsurgical Conditions: Panoramic films are not payable when used as a diagnostic tool for removable and fixed prosthodontics, endodontics, periodontics, or restorative services. For members under the age of 21, MassHealth requires prior authorization for more than one panoramic film per member per three year period for nonsurgical conditions for members to monitor the growth and development of permanent dentition. Cephalometric Films MassHealth pays for cephalometric films in conjunction with surgical conditions, when medically necessary. Surgical conditions include, but are not limited to: (a) status post-facial trauma, such as La Fort (b) mandibular fractures (c) dentoalveolar fractures (d) mandibular atrophy (e) jaw dislocations Oral and Maxillofacial Surgery (Elective) Cases Performed in Operating Room (OR) Prior authorization (PA) is not required before services can be performed in an operating room (OR) of an acute hospital outpatient department, a hospital-licensed health center, a chronic disease and rehabilitation hospital outpatient department, or a freestanding ambulatory surgical center in order to allow the member to be sedated. The facility must be a MassHealth provider. Member apprehension alone is not sufficient justification for the use of a hospital (inpatient or outpatient setting) or a freestanding ambulatory surgery center. Lack of facilities for administering general anesthesia when the procedure can be routinely performed with local anesthesia does not justify use of a hospital or a freestanding ambulatory surgery center. Trauma, Urgent, and Accident (Nonelective) Cases Dental services provided in a hospital emergency room are billed by the hospital to MassHealth as a hospital claim and do not require dental prior authorization. If the dentist/oral surgeon is salaried or contracted to a hospital and satisfies the Acute Hospital Request for Applications (RFA) definition of a Hospital-Based Physician, the hospital may bill for the professional (dental) services. If the dentist/oral surgeon is not a Hospital-Based Physician, the dentist/oral surgeon may bill for the professional (dental) services. If you have any questions about the information in this transmittal letter please contact Doral at 1-800-207-5019 or e-mail your inquiry to inquiries@masshealth-dental.net. NEW MATERIAL (The pages listed here contain new or revised language.) Dental Manual Pages 6-1 through 6-8 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Dental Manual Pages 6-1 through 6-8 — transmitted by Transmittal Letter DEN-77 MassHealth pays for the services represented by the codes listed in Subchapter 6 in effect at the time of service, subject to all conditions and limitations in MassHealth regulations at 130 CMR 420.000 and 450.000. A dental provider may request prior authorization for any medically necessary service reimbursable under the federal Medicaid Act in accordance with 130 CMR 450.144, 42 U.S.C. 1396d(a), and 42 U.S.C. 1396d(r)(5) for a MassHealth Standard or CommonHealth member younger than 21 years of age, even if it is not designated as covered or payable in Subchapter 6 of the Dental Manual. 601 Explanation of Abbreviations The following abbreviations are used in Subchapter 6. (A) PA indicates that service-specific prior authorization is required (see 130 CMR 420.410). (B) IC indicates that the claim will receive individual consideration to determine payment. A descriptive report must accompany the claim (see 130 CMR 420.412). (C) SP 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). 602 Service Codes and Descriptions: Diagnostic Services See 130 CMR 420.422 for limitations. Service Code Service Description Clinical Oral Evaluation D0120 Periodic oral examination (twice per 12-month period) D0150 Comprehensive oral evaluation—new or established patient (once per member per dentist) D0160 Detailed and extensive oral evaluation—problem focused, by report (to be billed only for oral screening for members undergoing radiation treatment, chemotherapy, or organ transplant) 603 Service Codes and Descriptions: Radiographs See 130 CMR 420.423 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 and older: minimum of 10 periapical films and two posterior bitewings) D0220 Intraoral—periapical, first film D0230 Intraoral—periapical, each additional film D0270 Bitewing—single film D0272 Bitewings—two films (twice per calendar year) D0274 Bitewings—four films (twice per calendar year) D0330 Panoramic film (nonsurgical condition—under 21 only) (surgical conditions—all members) D0340 Cephalometric film (PA) D0350 Oral/facial photographic images (includes intra- and extraoral images) excludes conventional radiographs) Test and Laboratory Examinations D0470 Diagnostic casts (only when requested by MassHealth) (PA) 604 Service Codes and Descriptions: Preventive Services See 130 CMR 420.424 for limitations. Service Code Service Description Dental Prophylaxis (twice per 12-month period) D1110 Prophylaxis—adult (ages 14 and older) D1120 Prophylaxis—child (to age 14) Topical Fluoride Treatment (Office Procedure) D1203 Topical application of fluoride (prophylaxis not included)—child (under 21 only) D1204 Topical application of fluoride (prophylaxis not included)—adult (age 21 and older) (PA) Other Preventive Services D1351 Sealant—per tooth (primary or permanent first and second noncarious molars, first and second non-carious bicuspids (premolars) with deep pits and fissures, and noncarious third molars with deep pits and fissures) (once per three years per tooth) (under 21 only) 604 Service Codes and Descriptions: Preventive Services (cont.) 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) 605 Service Codes and Descriptions: Restorative Services See 130 CMR 420.425 for limitations. Service Code Service Description Amalgam Restorations (Including Polishing) D2140 Amalgam—one surface, primary or permanent D2150 Amalgam—two surfaces, primary or permanent D2160 Amalgam—three surfaces, primary or permanent D2161 Amalgam—four or more surfaces, primary or permanent Resin Restorations (Composite Restorations) D2330 Resin-based composite—one surface, anterior D2331 Resin-based composite—two surfaces, anterior D2332 Resin-based composite—three surfaces, anterior 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 D2392 Resin-based composite—two surfaces, posterior D2393 Resin-based composite—three surfaces, posterior D2394 Resin-based composite—four or more surfaces, posterior Crowns—Single Restoration Only D2710 Crown—resin-based composite (indirect) (under 21 only) (PA) D2751 Crown—porcelain fused to predominantly base metal (PA) Other Restorative Services D2910 Recement inlay, onlay or partial coverage restoration D2920 Recement crown 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) D2934 Prefabricated esthetic coated stainless steel crown—primary tooth (under 21 only) D2951 Pin retention—per tooth, in addition to restoration (two or more surfaces) (commercial amalgam bonding) 605 Service Codes and Descriptions: Restorative Services (cont.) D2954 Prefabricated post and core in addition to crown (PA) D2980 Crown repair, by report D2999 Unspecified restorative procedure, by report (PA) (IC) 606 Service Codes and Descriptions: Endodontic Services See 130 CMR 420.426 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) (no limitation on number performed per treatment period) (PA) D3320 Bicuspid (excluding final restoration) (under 21 only) (no limitation on number performed per treatment period) (PA) D3330 Molar (excluding final restoration) (under 21 only) (no limitation on number performed per treatment period) (PA) Apicoectomy/Periradicular Services D3410 Apicoectomy/periradicular surgery—anterior (per tooth) (includes retrograde filling) (PA) D3421 Apicoectomy/periradicular surgery—bicuspid (first root) (PA) D3426 Apicoectomy/periradicular surgery (each additional root) (PA) 607 Service Codes and Descriptions: Periodontic Services See 130 CMR 420.424 for limitations. Service Code Service Description Surgical Services (Including Usual Postoperative Services) D4211 Gingivectomy or gingivoplasty—one to three contiguous teeth or bounded teeth spaces per quadrant (once per quadrant per three-year period) (PA) D4341 Periodontal scaling and root planing—four or more teeth per quadrant (includes curettage) (once per quadrant per three-year period) (PA) D4342 Periodontal scaling and root planing—one to three teeth, per quadrant (includes curettage) (once per quadrant per three-year period) (PA) 608 Service Codes and Descriptions: Prosthodontic (Removable) Services See 130 CMR 420.427 for limitations. Service Code Service Description Complete Dentures (Including Routine Post-Delivery Care) D5110 Complete denture—maxillary (PA) D5120 Complete denture—mandibular (PA) D5130 Immediate denture—maxillary (under 21 only) (PA) D5140 Immediate denture—mandibular (under 21 only) (PA) Partial Dentures (Including Routine Post-Delivery Care) D5211 Maxillary partial denture—resin base (including any conventional clasps, rests, and teeth) (PA) D5212 Mandibular partial denture—resin base (including any conventional clasps, rests, and teeth) (PA) D5213 Maxillary partial denture—cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) (under 21 only) (PA) D5214 Mandibular partial denture—cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) (under 21 only) (PA) Repairs to Complete Dentures D5510 Repair broken complete denture base D5520 Replace missing or broken teeth—complete denture (each tooth) Repairs to Partial Dentures D5610 Repair resin denture base D5620 Repair cast framework D5630 Repair or replace broken clasp D5640 Replace broken teeth—per tooth D5650 Add tooth to existing partial denture D5660 Add clasp to existing partial denture Denture Rebase Procedures D5710 Rebase complete maxillary denture (PA) D5711 Rebase complete mandibular denture (PA) D5720 Rebase maxillary partial denture (cast partial denture only) (under 21 only) (PA) D5721 Rebase mandibular partial denture (cast partial denture only) (under 21 only) (PA) Denture Reline Procedures D5750 Reline complete maxillary denture (laboratory) (PA) D5751 Reline complete mandibular denture (laboratory) (PA) D5760 Reline maxillary partial denture (laboratory) (cast partial denture only) (under 21 only) (PA) D5761 Reline mandibular partial denture (laboratory) (cast partial denture only) (under 21 only) (PA) 609 Service Codes and Descriptions: Prosthodontic (Fixed) Services See 130 CMR 420.427 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 (ages 16 through 20 only) (PA) D6751 Crown—porcelain fused to predominantly base metal (ages 16 through 20 only) (PA) 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) (PA) D6999 Unspecified, fixed prosthodontic procedure, by report (PA) (IC) 610 Service Codes and Descriptions: Exodontic Services See 130 CMR 420.429 for limitations. Service Code Service Description Extractions (Includes Local Anesthesia 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 (PA) D7280 Surgical access of an unerupted tooth (under 21 only) (PA) D7283 Placement of device to facilitate eruption of impacted tooth (under 21 only) (PA) 610 Service Codes and Descriptions: Exodontic Services (cont) 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 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 D7340 Vestibuloplasty—ridge extension (secondary epithelialization) (PA) 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 (SP) D7963 Frenuloplasty D7970 Excision of hyperplastic tissue—per arch (PA) D7999 Unspecified oral surgery procedure, by report (PA) (IC) D9930 Treatment of complications (postsurgical)—unusual circumstances, by report (IC) 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) (PA) D8660 Pre-orthodontic treatment visit (consultation) (accredited orthodontists only) (once per six months) (under 21 only) D8670 Periodic orthodontic treatment visit (as part of 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) (PA) D8690 Orthodontic treatment (alternative billing to a contract fee) (under 21 only) (PA) 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) (PA) D8999 Unspecified orthodontic procedure, by report (under 21 only) (PA) (IC) 612 Service Codes and Descriptions: General Anesthesia and IV Sedation Services 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) D9230 Analgesia, anxiolysis, inhalation of nitrous oxide D9241 Intravenous conscious sedation/analgesia—first 30 minutes D9242 Intravenous conscious sedation/analgesia—each additional 15 minutes (from 31 to 90 minutes) 613 Service Codes and Descriptions: Other Services 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 (PA) 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.) D9940 Occlusal guard, by report (under 21 only) (PA) D9941 Fabrication of athletic mouthguard (under 21 only) D9999 Unspecified adjunctive procedure, by report (PA) (IC) This publication contains codes that are copyrighted by the American Dental Association and American Medical Association.