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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