ADA Dental Code List Microsoft
2023 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 Documentation Required Review or Pre-D
N/A
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
N/A
evaluation ? 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-
N/A
operative 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
Class
Yes
Narrative or description of the type Preventive
of extraoral x-ray performed.
D0251 D0270 D0272 D0273 D0274 D0277 D0310
Extra-oral posterior dental
N/A
radiographic image
Bitewing ? single
N/A
radiographic image
Bitewings ? two radiographic N/A
images
Bitewings ? three
N/A
radiographic 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
N/A
joint radiographic images, by
report
D0322
Tomographic survey
Yes
D0330
Panoramic radiographic
Yes
image
Narrative or description of the type Preventive
of extraoral x-ray performed.
N/A
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.
Preventive Not covered Not covered Preventive
Preventive
055366 (05-17-2023)
An Independent Licensee of the Blue Cross Blue Shield Association
ADA CODE Description
Dental Documentation Required Review or
Pre-D
Class
D0340
2D cephalometric
Yes
radiographic image ?
acquisition, measurement,
and analysis
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
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) 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)
Preventive Not covered/ Orthodontia Preventive
Preventive
Preventive
055366 (05-17-2023)
An Independent Licensee of the Blue Cross Blue Shield Association
ADA CODE Description
Dental Documentation Required Review or
Pre-D
Class
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
D0369
Maxillofacial MRI capture
N/A
and interpretation
D0370
Maxillofacial ultrasound
Yes
capture and interpretation
D0371
Sialo endoscopy capture and Yes interpretation
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 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.
Preventive Not covered Not covered Preventive Preventive
055366 (05-17-2023)
An Independent Licensee of the Blue Cross Blue Shield Association
ADA CODE Description
Dental Documentation Required Review or
Pre-D
Class
D0372 D0373 D0374 D0380 D0381 D0382 D0383
D0384
D0385
Intraoral Tomosynthesis ? comprehensive series of radiographic images Intraoral Tomosynthesis ? Bitewing radiographic image Intraoral Tomosynthesis ? Periapical radiographic image -Cone beam CT image capture 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 for TMJ series including two or more exposures
N/A N/A N/A Yes
Yes, for medical
Maxillofacial MRI image
Yes
capture
Medical policy 9.02.503 (Computerized Diagnostic Imaging for Complex Maxillofacial Procedures) Not Covered
Not Covered Not Covered
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)
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) 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
Not covered under dental; may be covered under medical
Preventive
055366 (05-17-2023)
An Independent Licensee of the Blue Cross Blue Shield Association
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