The Commonwealth of Massachusetts



553466016192500-139700-8064500The Commonwealth of MassachusettsExecutive Office of Health and Human ServicesOne Ashburton Place, Room 1109Boston, Massachusetts 02108 522859027940Tel: (617) 573-1600Fax (617) 573-1891eohhs00Tel: (617) 573-1600Fax (617) 573-1891eohhs-47117017780CHARLES D. BAKERGovernorKARYN E. POLITOLieutenant GovernorMARYLOU SUDDERSSecretary00CHARLES D. BAKERGovernorKARYN E. POLITOLieutenant GovernorMARYLOU SUDDERSSecretaryAdministrative Bulletin 20-10101 CMR 314.00: Dental ServicesEffective January 1, 2020Updated CDT Dental CodesPursuant to 101 CMR 314.01(5) and (6), the Executive Office of Health and Human Services (EOHHS) has added 37 new codes, deleted six codes (which have been cross-walked to 13 new codes), and revised descriptions for 18 codes, as specified in the 2020 Current Dental Terminology (CDT) set by the American Dental Association. Except for a one-to-two crosswalk listed in the following chart where the rates for the new codes are set at the current payment rate of the deleted code, all new codes in this bulletin that require pricing are reimbursed at individual consideration (IC). Rates listed in this administrative bulletin are applicable until EOHHS issues revised rates. The deleted codes are no longer available for use for dates of service after December 31, 2019. There is no change in the rates for the 18 codes with revised descriptions.The following procedure codes are added.Added CodeNew Allowed FeeNew EPSDT FeeDescriptionD0419ICICAssessment of salivary flow by measurementD1551ICICRe-cement or re-bond bilateral space maintainer - maxillaryD1552ICICRe-cement or re-bond bilateral space maintainer - mandibularD1553ICICRe-cement or re-bond unilateral space maintainer - per quadrantD1556ICICRemoval of fixed unilateral space maintainer - per quadrantD1557ICICRemoval of fixed bilateral space maintainer - maxillaryD1558ICICRemoval of fixed bilateral space maintainer - mandibularD2753ICICCrown - porcelain fused to titanium and titanium alloysD5284ICICRemovable unilateral partial denture - one piece flexible base (including clasps and teeth) - per quadrant D5286ICICRemovable unilateral partial denture - one piece resin (including clasps and teeth) - per quadrantD6082ICICImplant supported crown - porcelain fused to predominantly base alloyD6083ICICImplant supported crown - porcelain fused to noble alloysD6084ICICImplant supported crown - porcelain fused to titanium and titanium alloysD6086ICICImplant supported crown - predominantly base alloysD6087ICICImplant supported crown - noble alloysD6088ICICImplant supported crown - titanium and titanium alloysD6097ICICAbutment supported crown - porcelain fused to titanium and titanium alloysD6098ICICImplant supported retainer - porcelain fused to predominantly base alloysD6099ICICImplant supported retainer for FPD - porcelain fused to alloysD6120ICICImplant supported retainer - porcelain fused to titanium and titanium alloysD6121ICICImplant supported retainer for metal FPD - predominantly base alloysD6122ICICImplant supported retainer for metal FPD - noble alloysD6123ICICImplant supported retainer for metal FPD - titanium and titanium alloysD6195ICICAbutment supported retainer - porcelain fused to titanium and titanium alloysD6243ICICPontic - porcelain fused to titanium and titanium alloysD6753ICICRetainer crown - porcelain fused to titanium and titanium alloysD6784ICICRetainer crown ? - titanium and titanium alloysD7922ICICPlacement of intra-socket biological dress to aid in hemostasis or clot stabilization, per siteD8696ICICRepair of orthodontic appliance - maxillaryD8697ICICRepair of orthodontic appliance - mandibularD8698ICICRe-cement or re-bond fixed retainer - maxillaryD8699ICICRe-cement or re-bond fixed retainer - mandibularD8701ICICRepair of fixed retainer, includes reattachment - maxillaryD8702ICICRepair of fixed retainer, includes reattachment - mandibularD8703$79$95Replacement of lost or broken retainer - maxillaryD8704$79$95Replacement of lost or broken retainer - mandibularD9997ICICDental case management - patients with special health care needsThe following procedure codes are deleted.Deleted CodeDescriptionD1550Re-cement or re-bond space maintainerD1555Removal of fixed space maintainerD8691Repair of orthodontic applianceD8692Replacement of lost or broken retainerD8693Re-cement or re-bond fixed retainerD8694Repair of fixed retainers, includes reattachmentThe following deleted procedure codes are cross-walked to the replacement codes below.Deleted CodeReplacement CodesD1550D1551, D1552, D1553D1555D1556, D1557D8691D8696, D8697D8692D8703, D8704D8693D8698, D8699D8694D8701, D8702The descriptions for the following procedure codes are revised. There is no change in the rate for these codes.CodeDescriptionD1510Space maintainer - fixed, unilateral - per quadrant. Excludes a distal shoe space maintainer.D1520Space maintainer - removable, unilateral- per quadrantD1575Distal shoe space maintainer - fixed, unilateral - per quadrantD2794Crown - titanium and titanium alloysD5213Maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests, and teeth)D5214Mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests, and teeth) D5221Immediate maxillary partial denture - resin base (including retentive/clasping materials, rests, and teeth)D5222Immediate mandibular partial denture - resin base (including retentive/clasping materials, rests, and teeth)D5223Immediate maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rest, and teeth)D5224Immediate mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasps materials, rests, and teeth)D6066Implant supported crown - porcelain fused to high noble metal alloysD6067Implant supported crown - high noble alloysD6076Implant supported retainer for FPD - porcelain fused to high noble alloysD6077Implant supported retainer for cast metal FPD - allow, high noble alloysD6094Abutment supported crown - titanium and titanium alloysD6194Abutment supported retainer crown for FPD - titanium and titanium alloysD6214Pontic - titanium and titanium alloysD6794Retainer crown - titanium and titanium alloys ................
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