Clinical Oral Evaluations
| Code | Procedure Description | Age, limitations, restrictions, prior authorizations for Adults |
|---|---|---|
| D0120 | Periodic oral evaluation | Age 21-00: 1 in 6 months |
| D0140 | Limited oral evaluation | Age 21-00: Specific problem |
| D0150 | Comprehensive evaluation | Age 21-00: 1 in 2 years |
| D0160 | Extensive oral evaluation problem-focus | Age 21-00 |
| D0170 | Re-evaluation, established patient, problem focus | Age 21-00: Narrative on claim |
| D0180 | Periodontal evaluation | Age 21-00: Allowed for periodontist and/or general dentist only; 1 in 2 years |
Diagnostic Imaging
| Code | Procedure Description | Age, limitations, restrictions, prior authorizations for Adults |
|---|---|---|
| D0210 | Intraoral – complete series of radiographic images | Age 21-00: 1 in 3 years; either D0330 or D0210 may be used once in a 3-year period (request patient x-rays if provided by another provider within past 3 years) |
| D0220 | Intraoral – periapical radiographic image | Age 21-00: 6 per year |
| D0230 | Intraoral – periapical radiographic image; each additional | Age 21-00: Bill code on one line# units and total |
| D0272 | Bitewings – two radiographic images | Age 21-00: Once in 6 months |
| D0274 | Bitewings – four radiographic images | Age 21-00: Once in 6 months |
| D0330 | Panoramic radiographic image | Age 21-00: 1 in 3 years; may be billed with D0272 or D0274, but is not a substitute for FMX; either D0330 or D0210 may be used once in a 3-year period (request patient x-rays if provided by another provider within past 3 years) |
Preventive
| Code | Procedure Description | Age, limitations, restrictions, prior authorizations for Adults |
|---|---|---|
| D1110 | Prophylaxis – Adult | Age 21-00: 1 every 6 months |
| D1206 | Topical application of fluoride varnish | Age 21-00: 1 every 12 month; either D1206 or D1208 may be billed once in a 12 month period |
| D1208 | Topical application of fluoride-excluding fluoride varnish | Age 21-00: 1 every 12 months; either D1206 or D1208 may be billed once in a 12 month period |
| D1354 | Interim caries arresting medicament application-per tooth | Age 21-00: Once per tooth every 6 months for up to two years; submit narrative |
Restorative
| Code | Procedure Description | Age, limitations, restrictions, prior authorizations for Adults |
|---|---|---|
| D2140 | Amalgam – one surface, primary or permanent | Age 21-00: Same tooth & surface covered once in 2 years |
| D2150 | Amalgam – two surfaces, primary or permanent | Age 21-00: Same tooth & surface covered once in 2 years |
| D2160 | Amalgam – three surfaces, primary or permanent | Age 21-00: Same tooth & surface covered once in 2 years |
| D2161 | Amalgam – four or more surfaces, primary or permanent | Age 21-00: Same tooth & surface covered once in 2 years |
| D2330 | Resin-based composite; one surface, anterior | Age 21-00: Same tooth & surface covered once in 2 years |
| D2331 | Resin-based composite; two surfaces, anterior | Age 21-00: Same tooth & surface covered once in 2 years |
| D2332 | Resin-based composite; three surfaces, anterior | Age 21-00: Same tooth & surface covered once in 2 years |
| D2335 | Resin-based composite; four or more surfaces, anterior | Age 21-00: Same tooth & surface covered once in 2 years |
| D2390 | Resin-based composite crown, anterior | Age 21-00: Covered one time in 5 years |
| D2391 | Resin-based composite-one surface, posterior | Age 21-00: Same tooth & surface covered once in 2 years |
| D2392 | Resin-based composite; two surfaces, posterior | Age 21-00: Same tooth & surface covered once in 2 years |
| D2393 | Resin-based composite; three surfaces, posterior | Age 21-00: Same tooth & surface covered once in 2 years |
| D2394 | Resin-based composite; four or more surfaces, posterior | Age 21-00: Same tooth & surface covered once in 2 years |
| D2920 | Re-cement crown | Age 21-00: Same tooth & surface covered once in 2 years |
Periodontics
| Code | Procedure Description | Age, limitations, restrictions, prior authorizations for Adults |
|---|---|---|
| D4341 | Periodontal scaling and root planning 4 or more teeth per quadrant | Age 21-00: Prior Authorization with full series of x-rays and periodontal charting; 1/2 mouth per visit |
| D4342 | Periodontal scaling and root planning 1-3 teeth per quadrant | Age 21-00: Prior authorization with full series of x-rays and periodontal charting; 1/2 mouth per visit |
| D4355 | Full mouth debridement | Age 21-00: 1 time in 3 years; cannot be billed with D1110, D4341, D4342; cannot be billed same day as oral evaluation |
| D4910 | Periodontal maintenance | Age 21-00: Must have had D4341 OR D4342; one (1) time in 3 months and alternate with D1110 |
Prosthodontics – Removable
| Code | Procedure Description | Age, limitations, restrictions, prior authorizations for Adults |
|---|---|---|
| D5511 | Replace broken complete denture base, mandibular | Age 21-00 |
| D5512 | Replace broken complete denture base, maxillary | Age 21-00 |
| D5520 | Replace missing or broken teeth – complete denture | Age 21-00 |
| D5630 | Repair or replace broken clasp | Age 21-00 |
| D5640 | Replace broken teeth; per tooth | Age 21-00: Tooth number on claim |
| D5650 | Add tooth to existing partial denture | Age 21-00: Tooth number on claim |
| D5660 | Add clasp to existing partial denture | Age 21-00 |
| D5750 | Reline complete maxillary denture (laboratory) | Age 21-00: Covered 1 time in 2 years |
| D5751 | Reline complete mandibular denture (laboratory) | Age 21-00: Covered 1 time in 2 years |
Prosthodontics – Fixed
| Code | Procedure Description | Age, limitations, restrictions, prior authorizations for Adults |
|---|---|---|
| D6930 | Re-cement fixed partial denture | Age 21-00: Narrative on claim |
Oral and Maxillofacial Surgery
| Code | Procedure Description | Age, limitations, restrictions, prior authorizations for Adults |
|---|---|---|
| D7140 | Extraction – erupted tooth/exposed root | Age 21-00 |
| D7210 | Extraction – surgical removal of erupted tooth | Age 21-00 |
| D7220 | Removal of impacted tooth – soft tissue | Age 21-00 |
| D7250 | Removal of residual tooth roots (cutting procedure) | Age 21-00 |
| D7510 | Incision and drainage of abscess – intraoral soft tissue | Age 21-00 |
| D7520 | Incision and drainage of abscess – extra-oral soft tissue | Age 21-00 |
| D7521 | Incision and drainage of abscess – extra-oral; soft tissue; complicated | Age 21-00 |
Adjunctive General Services
| Code | Procedure Description | Age, limitations, restrictions, prior authorizations for Adults |
|---|---|---|
| D9110 | Palliative treatment | Age 21-00: Provide narrative; may not be used in conjunction with restorative code on same tooth; may not be billed with D0120 or D0150, or denture repair services; limited to twice per year |
| D9222 | Deep sedation/General Anesthesia – first 15 mins | Age 21-00: Prior authorization required |
| D9223 | Deep sedation/Gen Anesthesia-each subsequent 15-minute increment | Age 21-00: Prior Authorization Required |
| D9230 | Analgesia | Age 21-00: Prior Authorization Required |
| D9239 | Intravenous moderate sedation first 15 min | Age 21-00: Prior authorization required |
| D9243 | IV sedation/analgesia- each subsequent 15-minute increment | Age 21-00: Prior Authorization Required |
| D9248 | Sedation (non-iv) | Age 21-00: Prior Authorization Required |
| D9995 | TELEDENTISTRY – SYNCHRONOUS; REAL-TIME ENCOUNTER | Claim must include one of the following codes: D0140, D0150, D0120 or D0180 |
| D9996 | TELEDENTISTRY – ASYNCHRONOUS | Claim must include procedure code D0140 |
