Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter DEN-88 June 2012 TO: Dental Providers Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: Dental Manual (New Modifiers for Provider Preventable Conditions That Are National Coverage Determinations) This letter transmits updates to Subchapter 6 of the Dental Manual to add modifiers for Provider Preventable Conditions (PPCs) that are National Coverage Determinations. For more information about PPCs and related billing instructions, see Transmittal Letter ALL-195. These updates are effective for dates of service on or after July 1, 2012. MassHealth Website This transmittal letter and attached pages are available on the MassHealth website at www.mass.gov/masshealth. Questions If you have any questions about the information in this transmittal letter, please contact MassHealth Dental Customer Service 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 Dental Manual Pages vi and 6-1 through 6-6 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Dental Manual Pages vi and 6-1 through 6-6 — transmitted by Transmittal Letter DEN-87 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Dental Manual Transmittal Letter DEN-88 Date 07/01/12 6. Service Codes and Descriptions Introduction .................................................................................................................................. 6-1 Explanation of Abbreviations and Service Code Requirements .................................................. 6-1 Service Codes: Diagnostic Services ............................................................................................ 6-2 Service Codes: Radiographs ........................................................................................................ 6-3 Service Codes: Preventive Services ............................................................................................ 6-3 Service Codes: Restorative Services ........................................................................................... 6-4 Service Codes: Endodontic Services. .......................................................................................... 6-6 Service Codes: Periodontic Services ........................................................................................... 6-8 Service Codes: Prosthodontic (Removable) Services ................................................................. 6-9 Service Codes: Prosthodontic (Fixed) Services .......................................................................... 6-11 Service Codes: Exodontic Services ............................................................................................. 6-11 Service Codes: Orthodontic Services .......................................................................................... 6-13 Service Codes: General Anesthesia and IV Sedation Services.................................................... 6-18 Service Codes: Other Services..................................................................................................... 6-18 Service Codes: Oral and Maxillofacial Surgery Services............................................................ 6-20 Appendix A. Directory ..................................................................................................................... A-1 Appendix B. Enrollment Centers ...................................................................................................... B-1 Appendix C. Third-Party-Liability Codes ........................................................................................ C-1 Appendix D. Handicapping Labio-Lingual Deviations Form .......................................................... D-1 Appendix E. (Reserved) Appendix F. (Reserved) Appendix G. Utilization Management Program ............................................................................... G-1 Appendix H. Admission Guidelines.................................................................................................. H-1 Appendix I. (Reserved) Appendix U. DPH-Designated Serious Reportable Events That Are Not Provider Preventable Conditions……………………………………………………………………………… U-1 Appendix V. MassHealth Billing Instructions for Provider Preventable Conditions………………. V-1 Appendix W. EPSDT Services: Medical and Dental Protocols and Periodicity Schedules.............. W-1 Appendix X. Family Assistance Copayments and Deductibles........................................................ X-1 Appendix Y. EVS/Codes Messages ................................................................................................. Y-1 Appendix Z. EPSDT/PPHSD Screening Services Codes ................................................................. Z-1 601 Introduction Dental providers who bill using Current Dental Terminology (CDT) codes must refer to the American Dental Association’s (ADA) 2012 code book for the service descriptions for codes listed in Subchapter 6 of the Dental Manual. Dentists who are specialists in oral surgery in accordance with 130 CMR 420.405(A)(7) must refer to the American Medical Association’s (AMA) Current Procedural Terminology (CPT) 2012 code book for the service descriptions for codes listed in Subchapter 6 of the Dental Manual. MassHealth pays for dental services as described in MassHealth regulations at 130 CMR 420.000 and 450.000. A dental provider may request prior authorization for any medically necessary service payable in accordance with the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) provisions set forth in 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 under the age of 21. This applies even if the service is not listed in Subchapter 6 of the Dental Manual. For each dental service code, the description indicates any limitations, such as age and frequency, and if prior authorization is required for the member. Dentists Who Are Specialists in Oral Surgery A dentist who is a specialist in oral surgery in accordance with 130 CMR 420.405(A)(7) must submit all requests for prior authorization and claims containing Current Procedural Terminology (CPT) codes directly to MassHealth rather than to any third-party administrator or other MassHealth vendor, as described in 130 CMR 420.000. When billing for multiple surgeries, performed during the same operative session or on the same day, dental providers who are specialists in oral surgery in accordance with 130 CMR 420.405(A)(7) are reminded that Modifier 51 must be added to the second, third, and subsequent lines as appropriate. The primary procedure must be on line one. Modifiers The following modifiers are for Provider Preventable Conditions that are National Coverage Determinations. PA Surgical or other invasive procedure on wrong body part PB Surgical or other invasive procedure on wrong patient PC Wrong surgery or other invasive procedure on patient For more information on the use of these modifiers, see Appendix V of your provider manual. Public Health Dental Hygienists Public health dental hygienists may claim payment for Service Codes D0220, D0272, D0273, D0274, D1110, D1120, D1203, D1204, D1206, D1351, D4341, D4342, D9110, and D9410. 602 Explanation of Abbreviations and Service Code Requirements The following abbreviations are used in Subchapter 6 with certain services that may require special reporting, as described below. (A) “PA” indicates that service-specific prior authorization is required (see 130 CMR 420.410). The provider must include in any request for prior authorization sufficiently detailed, clear information documenting the medical necessity of the service requested and, where specified, the information described in this Subchapter 6. 602 Explanation of Abbreviations and Service Code Requirements (cont.) The MassHealth agency may require any additional information it deems necessary. If prior authorization is not required, the provider must maintain in the member’s dental record, all information necessary to disclose the medical necessity for the services provided. Pursuant to 130 CMR 420.410(B)(3) prior authorization may be requested for any exception to a limitation on a service otherwise covered for that member. (For example, MassHealth limits prophylaxis to two per member per calendar year, but will pay for additional prophylaxis for a member within a calendar year if medically necessary.) (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). Reports must accompany the claim and be sufficiently detailed to enable the MassHealth agency to assess the extent and nature of the services provided and include the following where applicable: (1) the amount of time required to perform the service; (2) the degree of skill required to perform the service; (3) the severity and complexity of the member’s disease, disorder, or disability; and (4) any extenuating circumstances or complications. (C) “Separate procedure” within the service code description 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) “By report” in the service code description column indicates that the provider must include with the claim a narrative documenting the medical necessity for the procedure. 603 Service Codes: Diagnostic Services See 130 CMR 420.422 for service descriptions and limitations. Service Code and Limitations Covered Under Age 21? Covered DDS Clients Aged 21 and Older? Covered Aged 21 and Older? Prior Authorization Requirements, Report Requirements, and Notations D0120 Twice per calendar year Yes Yes Yes D0140 Twice per calendar year Yes Yes Yes D0145 Twice per calendar year Yes (IC) No No See 602(B) above. D0150 Once per member per dentist Yes Yes Yes D0160 Yes Yes Yes See 602(D) above. 604 Service Codes: Radiographs See 130 CMR 420.423 for service descriptions and limitations. Service Code and Limitations Covered Under Age 21? CoveredDDS Clients Aged 21 and Older? Covered Aged 21 and Older? Prior Authorization Requirements, Report Requirements, and Notations D0210 (FMx) (including bitewings) (once every three calendar years) Yes Yes Yes D0220 Yes Yes Yes D0230 Yes Yes Yes D0270 Yes Yes Yes D0272 Twice per calendar year Yes Yes Yes D0273 Twice per calendar year Yes (IC) Yes (IC) Yes (IC) See 602(B) above. D0274 Twice per calendar year Yes Yes Yes D0330 Yes Yes Yes D0340 Yes Yes Yes 605 Service Codes: Preventive Services See 130 CMR 420.424 for service descriptions and limitations. Service Code and Limitations Covered Under Age 21? CoveredDDS Clients Aged 21 and Older? Covered Aged 21 and Older? Prior Authorization Requirements, Report Requirements, and Notations D1110 Twice per calendar year – permanent dentition Yes (Use this code for ages 14- 21.) Yes Yes D1120 Twice per calendar year – primary or mixed dentition Yes (Use this code for ages up to 14.) No No D1203 Prophylaxis not included Yes No No 605 Service Codes: Preventive Services (cont.) Service Code and Limitations Covered Under Age 21? CoveredDDS Clients Aged 21 and Older? Covered Aged 21 and Older? Prior Authorization Requirements, Report Requirements, and Notations D1204 Prophylaxis not included No No* No* * Exception for members who have a medical or dental condition that significantly interrupts the flow of saliva - (PA). See 602(A) above and 130 CMR 420.424(B)(1)(b). D1206 Yes No No Other Preventive Services D1351 Primary or permanent first, second, and third noncarious, nonrestored molars Yes No No Space Maintenance (Passive Appliances) D1510 Yes No No D1515 Yes No No D1520 Yes No No D1525 Yes No No D1550 Yes No No 606 Service Codes: Restorative Services See 130 CMR 420.425 for service descriptions and limitations. Service Code and Limitations Covered Under Age 21? CoveredDDS Clients Aged 21 and Older? Covered Aged 21 and Older? Prior Authorization Requirements, Report Requirements, and Notations Amalgam Restorations (Including Polishing) D2140 Yes Yes No D2150 Yes Yes No D2160 Yes Yes No D2161 Yes Yes No Resin-Based Composite Restorations D2330 Yes Yes No D2331 Yes Yes No D2332 Yes Yes No D2335 Yes Yes No 606 Service Codes: Restorative Services (cont.) Service Code and Limitations Covered Under Age 21? Covered DDS Clients Aged 21 and Older? Covered Aged 21 and Older? Prior Authorization Requirements, Report Requirements, and Notations D2390 Yes No No D2391 Yes Yes No D2392 Yes Yes No D2393 Yes Yes No D2394 Yes Yes No Crowns – Single Restoration Only D2710 Indirect Yes No No D2740 Yes No No D2750 Yes No No D2751 Yes Yes (PA) No Include periapical film of the tooth. See 602(A) above and 130 CMR 420.425(C)(2). D2752 Yes No No D2790 Yes No No Other Restorative Services D2910 Yes Yes No D2920 Yes Yes No D2930 Yes No No D2931 Yes No* No * Exception for members with undue medical risk. See 130 CMR 420.425(C)(2). D2932 Primary anterior teeth only Yes No No D2934 Yes No No D2951 Yes Yes No D2954 Yes Yes (PA) No Include periapical film of the tooth. See 602(A) above and 130 CMR 420.425(C)(1)(c). D2980 Chairside Yes Yes No See 602(D) above. D2999 Outside laboratory Yes (PA) (IC) Yes (PA) (IC) No Include documentation to substantiate why the repair could not be done chairside. See 602(A) and (B) above and 130 CMR 420.425(E). 607 Service Codes: Endodontic Services See 130 CMR 420.426 for service descriptions and limitations. Service Code and Limitations Covered Under Age 21? CoveredDDS Clients Aged 21 and Older? Covered Aged 21 and Older? Prior Authorization Requirements, Report Requirements, and Notations Pulpotomy D3220 Yes No No Root Canal Therapy (Including Pre- and Post-Treatment Radiographs and Follow-up Care) D3310 Excluding final restoration Yes Yes No D3320 Excluding final restoration Yes No* No * Exception for members with undue medical risk. See 130 CMR 420.426(B)(3). PA required. D3330 Excluding final restoration Yes No* No * Exception for members with undue medical risk. See 130 CMR 420.426(B)(3). PA required. D3346 Yes Yes No D3347 Yes No* No * Exception for members with undue medical risk or with one or more medical conditions listed in 130 CMR 420.425(C)(2). See 130 CMR 420.426(C)(2). PA required. Endodontic Retreatment D3348 Yes No* No * Exception for members with undue medical risk or with one or more medical conditions listed in 130 CMR 420.425(C)(2). See 130 CMR 420.426(C)(2). PA required.