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

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download