ADA Dental Code List Microsoft
2021 ADA Code List for Microsoft Plans
Use this list or our code check tool to confirm if pre-determination (pre-D) or dental review is required. If more than one class is listed, refer to benefit details for the correct class or submit a pre-D. See PACAAR (PCM) ADA code list or non-individual employer groups ADA code list for all other Premera prefixes.
KEY: Red: Authorization/documentation requirements Blue: Not covered services Grey: Deleted codes
ADA
Description
Procedure
Code
D0120
Periodic oral evaluation ? established patient
Dental Review or Pre-D
N/A
Documentation Required
N/A
Class
Preventive
D0140 D0145
D0150 D0160
D0170
D0171 D0180
D0190 D0191 D0210 D0220 D0230 D0240
Limited oral evaluation ?
N/A
problem focused
Oral evaluation for a patient N/A under three years of age and
counseling with primary caregiver
Comprehensive oral evaluation N/A
? new or established patient
Detailed and extensive oral
N/A
evaluation ? problem focused, by report
Re-evaluation ? limited,
N/A
problem focused (established
patient; not post-operative
visit)
Re-evaluation ? post-operative N/A
office visit
Comprehensive periodontal N/A
evaluation ? new or established
patient
Screening of a patient
N/A
Assessment of a patient
N/A
Intraoral ? complete series of N/A
radiographic images
Intraoral ? periapical first
N/A
radiographic image
Intraoral ? periapical each
N/A
additional radiographic image
Intraoral ? occlusal
N/A
radiographic image
N/A N/A
N/A N/A
N/A
N/A N/A
Narrative Narrative N/A N/A N/A N/A
Preventive Preventive
Preventive Preventive
Preventive
Preventive Preventive
Preventive Preventive Preventive Preventive Preventive Preventive
ADA CODE Description
D0250
Extra-oral ? 2D projection radiographic image created using a stationary radiation source, and detector
Dental Documentation Required Review or
Pre-D
Yes
Narrative or description of the type
of extraoral x-ray performed.
Class Preventive
D0251 D0270 D0272 D0273 D0274 D0277 D0310
Extra-oral posterior dental
N/A
radiographic image
Bitewing ? single radiographic N/A
image
Bitewings ? two radiographic N/A
images
Bitewings ? three radiographic N/A
images
Bitewings ? four radiographic N/A
images
Vertical bitewings ? 7 to 8
N/A
radiographic images
Sialography
Yes
D0320
Temporomandibular joint
N/A
arthrogram, including injection
D0321
Other temporomandibular joint N/A radiographic images, by report
D0322
Tomographic survey
Yes
D0330 D0340
Panoramic radiographic image Yes
2D cephalometric radiographic Yes image ? acquisition, measurement, and analysis
Narrative or description of the type of extraoral x-ray performed. N/A
Preventive Preventive
N/A
Preventive
N/A
Preventive
N/A
Preventive
N/A
Preventive
If submitting under medical, submit diagnosis and/or narrative.
Medical Policy 2.01.21 (Temporomandibular Joint Dysfunction)
Not covered under dental. If submitting under medical, submit diagnosis and/or narrative.
Medical Policy 2.01.21 (Temporomandibular Joint Dysfunction)
Not covered under dental. If submitting under medical, submit diagnosis and/or narrative.
Medical Policy 2.01.21 (Temporomandibular Joint Dysfunction)
If submitted on a dental claim form: Diagnosis and/or narrative of condition describing the need for a tomographic survey
If submitting under medical: Submit diagnosis and/or narrative.
Medical Policy 2.01.21 (Temporomandibular Joint Dysfunction)
Provider will need to indicate if taken for orthodontia.
If submitted on a dental claim form: Diagnosis and narrative or treatment plan; If submitting under medical: Submit diagnosis and/or narrative.
Medical Policy 2.01.21 (Temporomandibular Joint Dysfunction)
Preventive Not covered Not covered Preventive
Preventive Preventive
055366 (07-09-2021)
An Independent Licensee of the Blue Cross Blue Shield Association
ADA CODE Description
Dental Documentation Required Review or
Pre-D
Class
D0350
2D oral/facial photographic
N/A
image obtained intra-orally or
extra-orally
D0364
Cone beam CT capture and
Yes
interpretation with limited field
of view ? less than one whole
jaw
D0365
Cone beam CT capture and
Yes
interpretation with field of
view of one full dental arch ?
mandible
D0366
Cone beam CT capture and
Yes
interpretation with field of
view of one full dental arch ?
maxilla, with or without
cranium
D0367
Cone beam CT capture and
Yes
interpretation with field of
view of both jaws; with or
without cranium
D0368
Cone beam CT capture and
N/A
interpretation for TMJ series
including two or more
exposures
Not covered ? unless billed for orthodontia work up and orthodontia benefit are available. Provider will need to indicate if taken for orthodontia.
If submitted on a dental claim form: Diagnosis or narrative of condition (pathology or operative report if applicable) If submitting under medical, submit diagnosis or narrative.
Medical policy 9.02.503 (Computerized Diagnostic Imaging for Complex Maxillofacial Procedures)
If submitted on a dental claim form: Diagnosis or narrative of condition (pathology or operative report if applicable) If submitting under medical, submit diagnosis or narrative.
Medical policy 9.02.503 (Computerized Diagnostic Imaging for Complex Maxillofacial Procedures)
If submitted on a dental claim form: Diagnosis or narrative of condition (pathology or operative report if applicable) If submitting under medical, submit diagnosis or narrative.
Medical policy 9.02.503 (Computerized Diagnostic Imaging for Complex Maxillofacial Procedures)
If submitted on a dental claim form: Diagnosis or narrative of condition (pathology or operative report if applicable) If submitting under medical, submit diagnosis or narrative.
Medical policy 9.02.503 (Computerized Diagnostic Imaging for Complex Maxillofacial Procedures)
Not covered under dental. Review medical plan for TMJ benefits. If submitting under medical, submit diagnosis or narrative.
Medical policy 9.02.503 (Computerized Diagnostic Imaging for Complex Maxillofacial Procedures)
Not covered/ Orthodontia Preventive
Preventive
Preventive
Preventive
Not covered
055366 (07-09-2021)
An Independent Licensee of the Blue Cross Blue Shield Association
ADA CODE Description
Dental Documentation Required Review or
Pre-D
Class
D0369
Maxillofacial MRI capture and N/A interpretation
D0370
Maxillofacial ultrasound
Yes
capture and interpretation
D0371
Sialo endoscopy capture and Yes interpretation
D0380 D0381 D0382
D0383 D0384
-Cone beam CT image capture Yes with limited field of view ? less than one whole jaw -Cone beam CT image capture with field of view of one full dental arch ? mandible -Cone beam CT image capture with field of view of one full dental arch ? maxilla, with or without cranium -Cone beam CT image capture with field of view of both jaws, with or without cranium Cone beam CT image capture N/A for TMJ series including two or more exposures
Not covered under dental. Review medical plan for TMJ benefits. If submitting under medical, submit diagnosis or narrative.
Medical policy 9.02.503 (Computerized Diagnostic Imaging for Complex Maxillofacial Procedures)
If submitted on a dental claim form: Diagnosis or narrative of condition (pathology or operative report if applicable) If submitting under medical, submit diagnosis or narrative.
Medical policy 9.02.503 (Computerized Diagnostic Imaging for Complex Maxillofacial Procedures)
If submitted on a dental claim form: Diagnosis or narrative of condition (pathology or operative report if applicable) If submitting under medical, submit diagnosis or narrative.
Medical policy 9.02.503 (Computerized Diagnostic Imaging for Complex Maxillofacial Procedures)
If submitted on a dental claim form: Diagnosis or narrative of condition (pathology or operative report if applicable) If submitting under medical, submit diagnosis or narrative.
Medical policy 9.02.503 (Computerized Diagnostic Imaging for Complex Maxillofacial Procedures)
Not covered Preventive Preventive Preventive
Not covered under dental. Review medical plan for TMJ benefits. If submitting under medical, submit diagnosis or narrative.
Medical policy 9.02.503 (Computerized Diagnostic Imaging for Complex Maxillofacial Procedures)
Not covered
055366 (07-09-2021)
An Independent Licensee of the Blue Cross Blue Shield Association
ADA CODE Description
Dental Documentation Required Review or
Pre-D
Class
D0385
Maxillofacial MRI image
Yes
capture
D0386
Maxillofacial ultrasound image Yes capture
D0391
Interpretation of diagnostic
Yes
image by a practitioner not
associated with capture of the
image, including report
D0393 D0394
Treatment simulation using 3D N/A image volume Digital subtraction of two or Yes more images or image volumes of the same modality
D0395
Fusion of two or more 3D
Yes
image volumes of one or more
modalities
D0411 D0412 D0414
HbA1c in-office point of service N/A
testing
blood glucose level test ? in- N/A
office using a glucose meter
Laboratory processing of
N/A
microbial specimen to include
If submitted on a dental claim form: Diagnosis or narrative of condition (pathology or operative report if applicable) If submitting under medical, submit diagnosis or narrative.
Medical policy 9.02.503 (Computerized Diagnostic Imaging for Complex Maxillofacial Procedures)
If submitted on a dental claim form: Diagnosis or narrative of condition (pathology or operative report if applicable) If submitting under medical, submit diagnosis or narrative.
Medical policy 9.02.503 (Computerized Diagnostic Imaging for Complex Maxillofacial Procedures)
If submitted on a dental claim form: Diagnosis or narrative of condition (pathology or operative report if applicable) If submitting under medical, submit diagnosis or narrative.
Medical policy 9.02.503 (Computerized Diagnostic Imaging for Complex Maxillofacial Procedures)
Not covered
Preventive Preventive Preventive Not covered
If submitted on a dental claim form: Narrative and/or chart notes; If submitting under medical, submit diagnosis or narrative.
Medical policy 9.02.503 (Computerized Diagnostic Imaging for Complex Maxillofacial Procedures)
If submitted on a dental claim form: Narrative and/or chart notes If submitting under medical, submit diagnosis or narrative.
Medical policy 9.02.503 (Computerized Diagnostic Imaging for Complex Maxillofacial Procedures)
Not covered
Preventive Preventive Not covered
Not covered
Not covered
N/A
Preventive
055366 (07-09-2021)
An Independent Licensee of the Blue Cross Blue Shield Association
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