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TO:                  ALL DENTAL PROVIDERS


FROM:            PAM MASON, Acting Bureau Chief

                        Bureau of Medicaid Programs & Resource Management


Following are procedure codes which have been added to our Medicaid Dental covered benefits as of May 1, 2001:






Re-evaluation, Limited, problem focused (established patient, not post operative visit)



Vertical bitewings. Single film. Total of four bitewings allowed every 6 months.



Resin based composite crown, anterior. Permanent teeth.  Tooth designation required.



Resin based composite. Four or more surfaces. Posterior. Permanent teeth. Tooth designation required.



Crown, porcelain fused to high noble metal. Tooth designation required.



Crown, porcelain fused to noble metal. Tooth designation required.



Crown, full cast, high noble. Tooth designation required.



Crown, full cast, noble metal.  Tooth designation required.



Gross pulpal debridement, primary & permanent teeth. For relief of acute pain prior to conventional root canal therapy.  Tooth designation required.



Retreatment of previous root canal therapy-anterior tooth designation required.



Retreatment of previous root canal therapy-bicuspid.  Tooth designation required.



Retreatment of previous root canal therapy molar.  Tooth designation required.



Excision of bone tissue-removal of exostosis.  Maxilla or mandible. Arch designation required.



Repair of orthodontic appliances. Limited to one occurrence.



Intravenous sedation/analgesia – first 30 minutes. A dental provider must be certified to administer intravenous sedation.



Intravenous sedation/analgesia-each additional 15 minutes. A dental provider must be certified to administer intravenous sedation.



House/extended care facility call. Includes visits to nursing homes, long-term care facilities hospice sites, institutions etc. Report in addition to reporting appropriate code numbers for actual services performed. Limited to once per day per patient.



Following are Medicaid dental procedure codes that are no longer benefits as of May 1, 2001: 


D7470             Removal of exostosis                                    

D9240             IV sedation                                                     

D9910             Application of desensitizing medicament                  


Following is a  Medicaid dental procedure fee change and limitation change as of May 1, 2001:


D0460             Pulp vitality test, per tooth. Tooth designation required.       New fee: $15.00

                                                 Limited to 6 teeth per visit.


Other Medicaid dental limitation changes as of May 1, 2001:


D0330                                     Panoramic film. Allowed once in a 36 month period.                        


D1520 and D1525                   Space maintainer, removable –(unilateral & bilateral).

Allowed once every two years up to 21 years of age. 

Arch designation required.

                                                (Tooth designation is no longer required)


D2954                                     Prefabricated post & core in addition to crown.

                                                          Tooth designation required.


D8670                                     Orthodontic monthly adjustments.  ALWAYS REQUIRES PRIOR AUTHORIZATION.  When utilizing treatment codes D8050, D8060, D8070, D8080 or D8090  a maximum of 24 adjustments over 2 years will be allowed (12  per year).  When utilizing treatment codes D8210 or D8220 two adjustments will be allowed per treatment.  Transfers: Clients already in orthodontic treatment who transfer to Idaho Medicaid must have their continuing treatment justified  and authorized by the Department. 


D9420                                     Hospital call… to once per day per patient.

                                                If procedures are done in other than hospital or

                                                surgery center use procedure code D9410.                                 


D9920                                     Behavior management. Limited to once per patient per day.

                                                (no longer reported in 15 minute increments) Fee: $22.00


D9951                                     Occlusal adjustment.  Quadrant designation no longer required.


Crown codes D2710, D2721, D2750, D2751, D2752, D2790, D2791 and D2792,  require prior authorization and are allowed in primary teeth with justification.


The following  are  updated descriptions of  Medicaid procedure codes  D9310 and D9920 as of May 1, 2001:


D9310     Consultation:


Provided by a dentist or physician whose opinion or advice regarding the evaluation, management and/or treatment of a specific problem or condition is requested by another dentist or physician.  The written or verbal request for a consult must be documented in the patient’s medical record.  The consultant’s opinion and any services that were ordered or performed must also be documented in the patient’s medical record and communicated to the requesting dentist or physician.  A dental consultant my initiate diagnostic and/or therapeutic services at the same or subsequent visit.


D9920      Behavior Management:


May be reported in addition to treatment provided when the patient is developmentally disabled, mentally ill, or is especially uncooperative and difficult to manage, resulting in the dental staff providing additional time, skill and/or assistance to render treatment.  Notation and justification must be written in the patient record identifying the specific behavior problem and the technique used to manage it.  Allowed once per patient per day.  (This code will not longer be reported in 15-minute increments.)


Replacement pages for the Medicaid Dental Guidelines Handbook will be mailed out from EDS within  six to eight weeks.  A Dental Fee Schedule will be mailed out to all Medicaid Dental providers from the Bureau of Medicaid Programs within a few weeks.


If you have questions regarding this information please contact the Medicaid Dental Unit at (208) 364-1839.