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CDT 2021 Code on Dental Procedures and Nomenclature

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CDT 2021 Code on Dental Procedures and Nomenclature CDT 2021 Code on Dental Procedures and Nomenclature Arkansas Procedure Guidelines Analysis +.ltl. Arkansas +.~ BlueCross BlueShield Health Advantage An Independent Licensee of the Blue Cross and Blue Shield Association An Independent Licensee of the Blue Cross and Blue Shield Association Revised: May 2021 Table of Contents Diagnostic Services ..................................................................................................................................... 3 Preventive Services ................................................................................................................................... 12 Restorative Services ................................................................................................................................. 14 Endodontic Services ................................................................................................................................. 22 Please note the following: ........................................................................................................................ 22 Periodontal Services ................................................................................................................................. 27 Procedure Billing Guidelines ................................................................................................................... 27 Payment for Surgical Services ................................................................................................................ 27 Prosthodontics, Removable ..................................................................................................................... 31 Coverage ............................................................................................................................................... 38 Implant Services .................................................................................................................................. 38 Prosthodontics, Fixed ............................................................................................................................... 46 Benefits ................................................................................................................................................... 46 When Services Are Non-Covered ........................................................................................................... 47 Oral and Maxillofacial Surgery ................................................................................................................. 51 Orthodontic Services ................................................................................................................................ 62 Orthodontic Benefit Administration ......................................................................................................... 62 How to Submit Claims - Please follow these guidelines when submitting claims for orthodontic treatment: ................................................................................................................................................ 62 Adjunctive Service ..................................................................................................................................... 64 Specific Benefit Limitations...................................................................................................................... 69 Integral Services ..................................................................................................................................... 69 Service Limitations .................................................................................................................................. 70 Excluded Services ................................................................................................................................... 71 i CDT: Diagnostic Services Diagnostic Services Submission Requirements: CDT Code Description of Service Procedure Guidelines Participating Providers CLINICAL ORAL EVALUATIONS: One evaluation code may be billed per dentist per date of service. Evaluations, including diagnosis and treatment planning, are the responsibility of the dentist. A dentist must complete all evaluations. D0120 Periodic oral evaluation Twice per calendar year None Once per calendar year, per patient, per D0140 Limited oral evaluation: problem-focused None dentist Oral evaluation for a patient less than 3 years of age D0145 Twice per calendar year None and counseling with primary caregiver Once in a 24 month period, per patient, per dentist. Additional exams by the same Comprehensive oral evaluation, new or established D0150 dentist within the twenty four month None patient period, change code to D0120 which is subject to the frequency limit for D0120. Detailed, extensive oral evaluation: problem-focused, Once per calendar year, per patient, per D0160 None by report dentist Re-evaluation: limited, problem focused (established D0170 Not a covered benefit None patient, not post-operative visit) D0171 Re-evaluation-post operative visit Not a covered benefit None Comprehensive periodontal evaluation: new or Once per patient per dentist per calendar D0180 None established patient year; PRE-DIAGNOSTIC SERVICES Screening of a patient: A screening, including state or D0190 federally mandated screenings, to determine an Not a covered benefit None individual’s need to be seen by a dentist for diagnosis 3 NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits. Submission Requirements: CDT Code Description of Service Procedure Guidelines Participating Providers Assessment of a patient: A limited clinical inspection that is performed to identify possible signs of oral or D0191 Not a covered benefit None systemic disease, malformation, or injury, and the potential need for referral for diagnosis and treatment DIAGNOSTIC IMAGING: Image Capture With Interpretation; Should be taken only for clinical reasons as determined by the patient’s dentist. Should be of diagnostic quality and properly identified and dated. Is a part of the patient’s clinical record and the original images should be retained by the dentist. Originals should not be used to fulfill requests made by patients or third-parties for copies of records. Intraoral complete series intraoral - complete series of D0210 Once in a 5 year period None radiographic images No limit; panoramic radiograph (D0330) reported with non-itemized charges for the D0220 Intraoral periapical – first radiographic image. same provider and same DOS as None periapical radiograph will merge to the panoramic radiograph No limit; panoramic radiograph (D0330) reported with non-itemized charges for the Intraoral periapical – each additional radiographic D0230 same provider and sameDOS as None image periapical radiograph will merge to the panoramic radiograph D0240 Intraoral occlusal radiographic image No limitation Arch identification D0250 Extraoral, 2D radiographic image No limitation None D0251 Extra-oral posterior dental radiographic image Not covered None D0270 Bitewing – single radiographic image No limitation None 4 NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits. Submission Requirements: CDT Code Description of Service Procedure Guidelines Participating Providers D0272 Bitewings – two radiographic images Once per calendar year, except twice per None calendar yearfor dependent child through age 18 One occurrence of D0272, D0273, D0274 D0273 Bitewings – three radiographic images or D0277 in a calendar year over the age None of 18 One occurrence of D0272, D0273, D0274 D0274 Bitewings – four radiographic images or D0277 in a calendar year over the age None of 18 One occurrence of D0272, D0273, D0274 D0277 Vertical bitewings – 7 to 8 radiographic images or D0277 in a calendar year over the age None of 18 D0310 Sialography Not a covered benefit None Temporomandibular joint arthrogram, including D0320 Not a covered benefit None injection Other temporomandibular joint radiographic image, by D0321 Not a covered benefit None report D0322 Tomographic survey Not a covered benefit None D0330 Panoramic radiographic image Once in a 5 year period None D0340 Cephalometric radiographic image Once per lifetime with orthodontic benefit None 2D oral/facial photographic images obtained D0350 Not a covered benefit None intraorally or extraorally D0351 3D photographic image Not a covered benefit None 5 NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits. Submission Requirements: CDT Code Description of Service Procedure Guidelines Participating Providers D0364 Cone beam CT capture and interpretation
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