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Manual Review Page

This page is for the review of manual changes.


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Dental Manual - Update Log Chapter

Update Log

 

Publication History

This publication supersedes all previous Physician-Related Services handbooks. Published by the Montana Department of Public Health & Human Services, January 2005.

 Updated January 2011, December 2011, March 2012, October 2016, April 2017,August 2017 and March 2018.

CPT codes, descriptions and other data only are copyright 2014 American Medical Association (or such other date of publication of CPT). All Rights reserved. Applicable FARS/DFARS Apply.

Update Log

10/01/2018
Dental and Denturist Services, September 2018
Reinstates dental and denturist services to adult members.

03/01/2018
Dental and Denturist Services, March 2018
Reduces dental and denturist services to adult members.

08/08/2017
Dental and Denturist Program Manual converted to an HTML format and adapted to 508 Accessibility Standards.

06/08/2016
Dental and Denturist Services, July 2016
In summary the Cover Page had the date only changed, the Covered Services Limitations section had nearly all of pages 2.2 and 2.10 updated, and the Orthodontia Services and Requirements Section had the fee cap amount updated on page 3.5.
 
12/31/2015
Dental and Denturist Services, January 2016, HELP Plan-Related Updates and Others

07/01/2015
Dental and Denturist Services, July 2015: Entire Manual

07/01/2014
Dental and Denturist Services, July 2014
The manual has been streamlined. Information found elsewhere is not repeated in this manual; instead, a link to the source of the information is provided.

07/01/2013
Dental and Denturist Program, July 2013
This set of replacement pages includes the entire manual. Content changes are indicated by the addition of a change bar (black line). For a complete manual without the change bars, see the Provider Manuals section at the top of this page.

05/18/2011
Dental and Denturist Program, April 2011: Covered Services and Limitations and Orthodontia Services and Requirements

07/01/2005
Dental and Denturist Program, July 2005: Updated Fees

10/01/2018
Dental and Denturist Services, September 2018 Reinstates dental and denturist services to adult members.

09/02/2004
Dental and Denturist Program, August 2004: Added "Per Quadrant" Requirements to Codes D4240–D4261

07/01/2004
Dental and Denturist Program, July 2004: Covered Services Update

07/02/2003
Dental and Denturist Program: July 2003: Procedure Limits and Requirements Table

07/01/2002
Dental and Denturist Program, July 2002: Covered Services and Limitations and Billing Procedures

 

End of Update Log Chapter

Dental Manual - Covered Services and Limitations Chapter

Covered Services and Limitations

 

General Coverage Principles

Medicaid covers almost all dental and denturist services when they are medically necessary for members under age 21. This chapter provides covered services information that applies specifically to dental and denturist services. Like all healthcare services received by Medicaid members, these services must also meet the general requirements listed in the Provider Requirements chapter of the General Information for Providers manual.

The rules, regulations, and policies described in this manual apply to services provided by dentists, denturists, orthodontists, and oral surgeons. Providers may be reimbursed for Medicaid covered services when the following requirements are met:

  • Provider must be enrolled in Medicaid. (ARM 37.85.402)
  • Services must be performed by practitioners licensed and operating within the scope of their practice as defined by law. (ARM 37.85.401)
  • Member must be Medicaid eligible and non-restricted. (ARM 37.85.415)
  • Service must be medically necessary. (ARM 37.82.102(18)) The Department may review medical necessity at any time before or after payment. (ARM 37.85.410)
  • Medical records must be maintained and available. (ARM 37.85.414)
  • Service must be covered by Medicaid and not be considered cosmetic, experimental or investigational. (ARM 37.86.206–207, and ARM 37.86.1006)
  • Charges must be usual and customary. (ARM 37.85.406)
  • Claims must meet timely filing requirements. (ARM 37.86.406)
  • Prior authorization requirements must be met. (ARM 37.86.1006)
  • Procedure code definitions as written by ADA, CDT manual.

Fee Schedule

All procedures listed in the Montana Medicaid fee schedule are covered by the Medicaid program and must be used in conjunction with the limits listed in this manual and the Age and Notes columns on the fee schedule. If current CDT codes exist and are not listed in the Montana Medicaid fee schedule, the items are not a covered service of the Medicaid program. Services that are not covered or exceed the specified limits can be billed to the member as long as the provider informs the member, prior to providing the services, that the member will be billed and the member agrees in writing to privately pay (ARM 37.85.406(11)(a)). Fee schedules are available on the Provider Information website.

Covered Dental Services

Standard Medicaid
All members under age 21 and some members age 21 and over who have Standard Medicaid coverage are eligible for the following benefits, however, always check the fee schedule for plan of benefits per age group:

  • Diagnostic (D0XXX);
  • Preventative (D1XXX);
  • Fillings (D2XXX);
  • Crowns  (D2XXX) some codes available through age 20 only;
  • Root Canals (D3XXX) some codes available through age 20 only; 
  • Periodontal Services (D4XXX) some codes available through age 20 only;
  • Dentures (immediate, full and partial) (D5XXX) 
  • Bridges (D6XXX);
  • Dental Surgery (D7XXX);
  • Anesthesia Services

For members 21 and older, some limits can be waived if the member is handicapped, disabled, or developmentally disabled. Add one of these phrases in the Remarks box.

Some Standard Medicaid services are only available to those age 20 and under. Please review the applicable Department dental fee schedule for specific code coverage available for specific ages. Fee schedules are available on the Provider Information website.

Adults age 21 and older with Standard Medicaid, HELP Medicaid, or HELP TPA Covered services, are subject to an annual treatment services cap of $1,125 per benefit year. A benefit year begins on July 1 and ends the following June 30. Members determined categorically eligible for Aged, Blind, and Disabled (ABD) Medicaid in accordance with ARM 37.82.204 are not subject to the annual cap.

Treatment services that count toward the $1125 financial cap are:

  • Fillings and Crowns (D2XXX);
  • Root Canals (D3XXX);
  • Periodontal Services (D4XXX); and
  • Dental Surgery (D7XXX).

Service limits do not apply to individuals up to and including age 20.

Covered but not counting toward the limit are:

  • Diagnostic (D2XXX);
  • Preventative (D1XXX)
  • Denture Services (D5XXX); and
  • Anesthesia services (D9223, D9243, D9248).

Once a member reaches their $1125 limit (Medicaid reimbursed amount) for treatment services a private pay agreement or Advanced Beneficiary Notice (ABN) must be in place in order to charge the member for further treatment services or services outside of their plan of benefits. All Medicaid rules apply for purposes of Billing procedures (37.85.406), TPL (37.85.407) and Cost Share (37.85.204).

Pregnant women who present a Presumptive Eligibility Notice of Decision are eligible for dental services. To verify presumptive eligibility, providers should call 1-406-655-7683 or 1-406-883-7843. At that point, if a provider needs to determine whether specific services are covered, he/she should contact Provider Relations.

EPSDT Services for Individuals Age 20 and Under
Limits on medically necessary services (e.g., exams, prophylaxis, x-rays) do not apply to members age 20 and younger as part of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services program. Medicaid has a systematic way of exempting children from the service limits. Therefore, providers no longer need to indicate EPSDT on the claim form for the limits to be overridden. Ensure the medical record clearly documents the medical condition needing extra services.

If you are providing a medically necessary procedure to a child, and the procedure is not listed in the Montana Medicaid fee schedule, contact the Dental Program Officer for claims processing instructions.

Access to Baby and Child Dentistry (AbCd)
The Access to Baby and Child Dentistry (AbCd) program was established to increase access to dental services for Medicaid-eligible children under age 6. AbCd focuses on preventive and restorative dental care for children from birth to age 6, with emphasis on the first dental appointment by age 1, if not sooner. It is based upon the premise that starting dental visits early will yield positive behaviors by both parents and children, thereby helping control the caries process and reduce the need for costly future restorative work.

Dentists must receive continuing education in early pediatric dental techniques to qualify as an AbCd specialist. This specialty endorsement will allow AbCd dentists to be reimbursed for the following procedures:

  • D0145, Oral evaluation, for members under 3
  • D0425, Caries susceptibility test, for members under 3
  • D1310, Nutritional counseling (age 0–5)
  • D1330, Oral hygiene instruction (age 0–5)
  • For children aged 0–2 years, Caries Risk Assessment (D0425) must be completed at least once every 12 months and the results of the assessment retained in the dental record. When submitting a dental claim for Caries Risk Assessment (D0425) also submit the outcome of the assessment as the appropriate and corresponding Caries Risk Assessment Finding Code (D0601, D0602, or D0603).
  • Children aged 0–2 years with a Caries Risk Assessment Finding of High (D0603) may have up to 6 AbCd MT visits per year. The frequency of treatment should be supported in the dental record by noting the condition being treated or prevented and the associated level of ongoing risk. For children aged 0–2 years, all of the associated CDT codes may be provided
    again at each subsequent AbCd MT visit as is determined by the dentist to be medically necessary. Current CDT definitions apply to all procedures performed, regardless of program advice.

Family oral health education is a strong component of this program. This is completed at the dental office. Other components of the program include proper training in oral hygiene techniques and the application of fluoride varnish. Restorative and radiographic services are used as determined necessary by the dentist.

Tamper-Resistant Prescription Pads
All fee-for-service Medicaid prescriptions that are either handwritten or printed from an EMR/ePrescribing application must contain three different tamper-resistant features, one from each of the three categories described below.

Medicaid allowable procedure codes and limitations can be found online under Fee Schedules. Please use the ADA CDT resource for a complete description of each code.

Feature descriptions:

  • One or more industry recognized features designed to prevent unauthorized copying of a completed or blank prescription.
  • One or more industry recognized features designed to prevent the erasure or modification of information written on the prescription by the prescriber.
  • One or more industry recognized features designed to prevent the use of counterfeit prescriptions.

When more than one film has been taken, add the number of units in the description box and multiply the fee by the units in the fee box.

Prescriptions for Medicaid members that are telephoned, faxed or e-prescribed are exempt from these tamper-resistance requirements.

Noncovered Services

  1. Porcelain/ceramic crowns, noble metal crowns and bridges are not covered for members 21 years of age and older.
  2. No-show appointments. A no-show appointment occurs when a member fails to arrive at a provider’s office for a scheduled visit and did not cancel or reschedule the appointment in advance. No-show appointments are not a covered service and cannot be billed to Medicaid.
  3. Cosmetic dentistry. Medicaid does not cover cosmetic dental services.
  4. Mouthguards. Mouthguards for members 21 years of age and older are not a covered service of the Medicaid program. (D9940)
  5. Qualified Medicare Beneficiary (QMB). Medicaid does not cover dental services for members that have QMB on their Medicaid eligibility information. See the General Information for Providers manual, Member Eligibility and Responsibilities chapter for more information on QMB.
  6. Dental implants.

Coverage of Specific Services (ARM 37.86.1006)

Medicaid allowable procedure codes and limitations can be found on the Provider Information website, on the provider type pages in the Fee Schedules pane. Use the CDT resource for a complete description of each code.

Diagnostic
The collection and recording of some data and components of the dental examination may be delegated; however, the evaluation, diagnosis, and treatment planning are the responsibility of the dentist. As with all ADA procedure codes, there is no distinction made between the evaluations provided by general practitioners or specialists.

Radiographs
Radiographs should be taken only for clinical reasons as determined by the member’s dentist. They should be of diagnostic quality, properly identified and dated. They are considered to be part of the member’s clinical record.

If additional panoramic films are needed for medical purposes (i.e., to check healing of a fractured jaw), they can be billed on an ADA form as long as it was done in an office setting. Otherwise, they should be billed on the CMS-1500 claim form using the CPT Code 70355 for panoramic x-ray.

When more than one film has been taken, add the number of units in the description box and multiply the fee by the units in the fee box.

Preventive
Prophylaxis and fluoride treatments are allowed every six months.

  • If providers are treating individuals with a developmental disability who require a prophylaxis treatment more often than six months intervals, indicate developmentally disabled in the remarks section of the ADA claim form.
  • Billed code choices of adult or child prophylaxis are up to the professional expertise of the provider (i.e., D1110, D1120, D1208).
  • Physicians and mid-level practitioners may also provide and will be reimbursed by Montana Medicaid for applying fluoride varnish (Code D1206) to children under age 21 at well-child appointments. Providers and mid-levels are encouraged to make referrals when appropriate in an effort to help the child establish a dental home. Providers and mid-levels should bill Code D1206 on a CMS-1500 claim form. If the child is determined high-risk for early childhood caries, up to six treatments per year will be allowed.
  • Dentists and dental hygienists were added to the list of healthcare practitioners permitted to perform smoking and tobacco cessation counseling services. The procedure code dental providers may bill Montana Medicaid for smoking and tobacco use cessation counseling services is D1320, Tobacco counseling for the control and prevention of oral disease.
  • Dental sealants (D1351) are covered on first and second molars on the primary arch and permanent arch for ALL ages on tooth letters A, B, I, J, K, L, S, and T, and tooth numbers 2, 3, 14, 15, 18, 19, 30, and 31.

Restoration
Fillings. For complete restoration of a tooth (filling of all surfaces currently damaged by caries), the following policies apply:

  • When more than one surface is involved, and one continuous filling is used, select the appropriate code from the range of D2140 through D2394.
  • When there are separate fillings on each surface, the one-surface codes (D2140 and D2330) are to be used. Your records must clearly indicate each filling is treatment for a separate cavity.
  • The ADA views restorative work done on the same day and same tooth as one tooth with five surfaces.
  • Only one payment will be allowed for each surface.
  • When more than one filling is included on a surface, combine the code. For example, MO and LO on a permanent molar restored in the same day should be coded as MOL. This should be coded this way whether the filling on the occlusal is a continuous filling or two separate fillings. The ADA views work done on the occlusal as one of the five surfaces that are billable.
  • When more than one filling is included on a surface and restored on different days, they should be coded on different days. For example, if MO and LO on a permanent molar are restored on subsequent days, they should be coded as a MO on the first day and LO on the second day.
  • Amalgam restorations (including polishing). All adhesives (including amalgam bonding agents), liners, and base are included as part of the restoration. If pins are used, they should be reported separately. (Code D2951.)
  • Silicate and resin restorations. Resin refers to a broad category of materials including, but not limited to, composites. Also included may be bonded composite, light-cured composite, etc. Light-curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the restoration. If pins are used, they should be reported separately. (Code D2951.)

Crowns
Crowns are covered only for members with Standard Medicaid coverage. Crowns are limited to situations where the tooth is periodontally healthy and without pulpal pathology and the tooth cannot be restored by any means other than a full coverage restoration.

  • Prefabricated crowns. Prefabricated stainless steel and prefabricated resin crowns D2930–D2933 are available for all members, regardless of age and regardless of tooth number. There is a limit for crowns of one per tooth, every five years.
  • All other crowns: porcelain/ceramic, high noble metal, non-prefab, high metal, gold, porcelain. All crowns, other than:
    • Prefabricated porcelain, ceramic, or stainless steel (D2929, D2930, and D2931)
    • Prefabricated resin (D2932)
    • Porcelain/Ceramic substrate (D2740)
    • Porcelain fused to high noble metal (2750)
  • Are only available to members with Standard Medicaid age 20 and under for anterior teeth (6–11 and 22–27). Generally, crowns on posterior teeth are limited to pre-fabricated resin and/or pre-fabricated stainless steel, except when necessary for partial denture abutments. Indicate in the Remarks section of the claim form which teeth are abutment teeth. For adults, crowns are limited to treatment of one per tooth every five years.
  • For adults, crown coverage is available using procedure codes D2751, D2781, and D2791 (porcelain fused to base metal crowns) for anterior or posterior teeth. These codes are open to children and adults on Standard Medicaid. Limits have been established for adults age 21 and over for porcelain fused to base metal crowns (D2751). Limited to two per person per calendar year, total. Second molars (2, 15, 18, and 31) will receive base metal crowns only (D2791). Retreatment for crown services per tooth is once per 5 years.

Endodontics
Canal therapy includes primary teeth without succedaneous teeth and permanent teeth.

  • Complete root canal therapy. Pulpectomy is part of root canal therapy (dental pulp and root canal are completely removed). It includes all appointments necessary to complete treatment and intra-operative radiographs. It does not include diagnostic evaluation and necessary radiographs/diagnostic images.
  • Pulpotomy (pulp tissue in crown removed, but tissue in root canal remains) (covered for ages 20 and under only) cannot be billed on the same day as endodontic therapy for the same tooth. Per guidance from the American Dental Association coding department, Code D3220 should never be billed if a root canal is to be performed by the same provider.

A dentist’s prescription is required for all partial and immediate denture work.

Periodontics

  • Surgical services (ages 20 and under only).
  • Gingivectomy/Gingivectoplasty per Quadrant. Is limited to cases involving gingival hyperplasia due to medication reaction or pregnancy. One quad equals one unit of service. Per quadrant should be listed in the Tooth Number column as (initials only) LL, UL, LR, or UR.
  • Full mouth debridement. Full mouth debridement is to be used prior to periodontal scaling and root planning only if the provider cannot determine the extent of periodontal scaling and root planning without this procedure. It is limited to one time per year if medically indicated. If providers are treating individuals with a developmental disability who require this treatment more often than once a year, indicate developmentally disabled in the Remarks section of the ADA claim form.

Fixed prosthodontics services are only available to members age 20 and under.

Prosthodontics, Removable
These services are available to members of all ages with Standard Medicaid. A partial denture five years or older may be replaced by full and/or partial dentures. Full dentures, ten years old or older, may be replaced when the treating dentist documents the need for replacement. Payment for the denture includes payment for any tissue conditioners provided. Payment for denture adjustments during the first year after delivery of the dentures is available only to a dentist or denturist who did not make the dentures. The first three adjustments after dentures are placed are included in the denture price. Complete and partial dentures include routine post delivery care. Call Provider Relations to verify if a member is eligible for a new denture or replacement for a lost one.

Medicaid will replace lost dentures for eligible members with a lifetime limit of one set. The claim form must include the term lost dentures or once in a lifetime replacement written in the Remarks section of the claim.

A dentist’s prescription is required and must be kept in the member file in the following circumstances:

  • All partial denture work
  • All immediate denture work

Limitations or requirements for the dental codes are listed with the procedure codes on the fee schedule. No prescription is necessary when a new member requires repairs to existing dentures or partials.

If dentures are prepared and the member never shows to get the dentures placed, send the member a letter advising him/her to come pick the dentures up. Retain the dentures in your office as long as possible.

The above limits may be exceeded when the dentist and the Department consultant agree the current dentures are causing the member serious physical health problems. In these situations, the provider should submit a prior authorization request. See the Prior Authorization chapter in the General Information for Providers manual and the Prior Authorization Information webpage on the Provider Information website.

Denture Billing Date
Dentures must be billed using the date of service the member receives the dentures. The only exception is when the member is not eligible on the date of service, then the date of impression may be used.

Prosthodontics, Fixed
These services are only available to members age 20 and under. Tooth colored, fixed partial denture pontics are only available for anterior teeth 6–11 and 22–27. Fixed partial denture pontics are not allowed for posterior teeth unless used to replace an anterior tooth. As an example, if tooth 6 is missing, the fixed denture pontic will cover teeth 5–7. In this example, tooth 5 can be tooth colored. In cases where a posterior tooth is to be replaced, a partial denture must be used. Review the Prosthodontics, Removable section for information regarding partial dentures. Fixed partial denture pontics are limited to one every tooth, every five years.

Oral Surgery
Impacted third molars or supernumerary teeth are covered only when they are symptomatic; that is, causing pain, infected, preventing proper alignment of permanent teeth or proper development of the arch.

Providers may use current CPT procedure codes for medical services provided in accordance of practice permitted under state licensure laws and other mandatory standards applicable to the provider. Medical services are those that involve the structure of the mouth (i.e., jaw bone). Any services involving the tooth, are considered dental services. Medical services can be billed on an ADA form if the services were provided in an office. If the procedures were done in a hospital or nursing facility setting, they must be billed on the CMS-1500 claim form with valid CPT procedure codes and valid ICD diagnosis codes. Providers who frequently bill for medical services should obtain a copy of the Physician-Related Services manual, which is available on the Provider Information website.

These procedures will be reimbursed through the Resource-Based Relative Value Scale (RBRVS) fee schedule. All current CPT codes billed will comply with rules as set forth in the Administrative Rules of Montana (ARM) for physicians. General anesthesia is listed in the current CPT procedures codes and must be billed using a CMS-1500 claim form.

Surgical extractions include local anesthesia and routine postoperative care.

Orthodontics
See the Orthodontia Services and Requirements chapter in this manual for more information on covered orthodontia services and limitations.

Date of Service

Date of service is the date a procedure is completed. However, there are instances where Medicaid will allow a date other than the completion date.

Dentures must be billed using the date of service the member receives the dentures. The only exception is when the member is not eligible on the date of service, then the date of impression may be used.

If a crown or bridge has been sent to the laboratory for final processing, and the member never shows for the appointment to have the final placement, providers may bill the date of service as the date the crown or bridge was sent to the laboratory for final processing. However, the member must have Medicaid eligibility at the time the crown or bridge is sent to the lab. Bridges are limited to members age 20 and under.

If a provider has opened the area for a root canal but anticipates the member will not return for completion or is referring member to another provider for root canal completion, procedure D3220 (covered for ages 20 and under only) may be billed. However, root canal codes must be billed to Medicaid at the time of completion.

Member Acknowledgment (Highly Recommended)

Once the final impression is sent to the lab (crown or denture) the provider should have the member sign a statement acknowledging the fact that this has been sent to the lab for final processing and they will schedule a future appointment for placement. If the member does not show for the appointment to have the item placed the provider should send the member a letter reminding them the item is completed and ready for placement. The provider should retain the item for as long as possible. With regard to dentures, the provider should not give them to the member without placing them first. For immediate dentures, the denturist/dentist may give them to the oral surgeon for placement immediately following surgery.

Calculating Service Limits

Any service which is covered only at specified intervals for adults will have a notation next to the procedure code with information about the limit in the Coverage of Specific Services section of this chapter. When scheduling appointments, be aware limits are controlled by our computerized claims payment system in this manner. Limits on these services are controlled by matching the date on the last service against the current service date to assure the appropriate amount of time (six months, one year, or three years) has elapsed. Procedure codes that have limits are described on the fee schedule.

For example, if an adult received an examination on February 27, and the same service was provided again on February 26 of the following year, the claim would be denied as a complete year would not have passed between services. If the service were provided on February 27 of the following year, or after, it would be paid.

Providers should call Provider Relations to get the last date of service for those procedure codes with time limits or other limitations of dental services. This information will allow the provider to calculate service limitations, but it does not guarantee payment of service for service-limited procedures. In certain circumstances, prior authorization may be granted for services when limits have been exceeded.

 

End of Covered Services and Limitations Chapter