Department of Human Services Letterhead

THOMAS J. VILSACK, GOVERNOR DEPARTMENT OF HUMAN SERVICES SALLY J. PEDERSON, LT. GOVERNOR KEVIN W. CONCANNON, DIRECTOR INFORMATIONAL LETTER NO. 553

DATE: December 12, 2006

TO: All Iowa Medicaid Participating Dental Providers

ISSUED BY: Iowa Department of Human Services, Iowa Medicaid Enterprise

RE: Procedure Code Updates

EFFECTIVE DATE: January 1, 2007

The following new CDT codes are covered by Medicaid:

Code Description D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver D0273 Bitewings, three films D1206 Topical fluoride varnish; therapeutic application for moderate to high caries risk patients D1555 Removal of fixed space maintainer D9120 Fixed partial denture sectioning

The following obsolete codes are no longer covered by Medicaid:

Code Description D1201 Topical application of fluoride (including prophylaxis), child (12 and under) D1205 Topical application of fluoride (including prophylaxis), 13 and over D2381 Resin, two surface, posterior, primary D6971 Cast post as part of fixed denture D7222 Impaction, soft tissue, lower D7232 Impaction, partial bony impaction, lower D7242 Impaction, complete bony impaction, lower D7425 Excision, pericoronal gingival D8549 Maxillary fixed lingual appliance D8550 Construct and place maxillary appliance D8551 Construct and place mandibular appliance D8552 Three month active treatment, mandibular arch D8553 Three month active treatment, maxillary arch D8557 Appliance without clasps, no teeth D8558 Anterior ortho wire (labial), 2 clasps

If you have any questions, please contact IME Provider Services, 1-800-338-7909, locally 515- 725-1004 or by e-mail at [email protected]

IOWA MEDICAID ENTERPRISE - 100 ARMY POST ROAD - DES MOINES, IA 50315