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NEW YORK STATE
    MEDICAID PROGRAM




         DENTAL




POLICY AND PROCEDURE CODE
          MANUAL
                                             Dental Policy and Procedure Code Manual



Table of Contents
DENTAL POLICY SECTION:
SECTION I - REQUIREMENTS FOR PARTICIPATION IN MEDICAID .......................... 4
       QUALIFICATIONS OF SPECIALISTS.......................................................................................................................4
       GROUP PROVIDERS .............................................................................................................................................5
       APPLICATION OF FREE CHOICE ...........................................................................................................................5
       CREDENTIAL VERIFICATION REVIEWS................................................................................................................5
SECTION II - DENTAL SERVICES................................................................................. 7
       CHILDREN'S DENTAL SERVICES ..........................................................................................................................6
       STANDARDS OF QUALITY ...................................................................................................................................7
       SCOPE OF HOSPITALIZATION SERVICES ..............................................................................................................7
       CHILD/TEEN HEALTH PROGRAM ........................................................................................................................8
       CHILD HEALTH PLUS PROGRAM .........................................................................................................................8
       DENTAL MOBILE VAN ........................................................................................................................................8
       REQUIREMENTS AND EXPECTATIONS OF DENTAL CLINICS .................................................................................9
       SERVICES NOT WITHIN THE SCOPE OF THE MEDICAID PROGRAM ......................................................................9
       SERVICES WHICH DO NOT MEET EXISTING STANDARDS OF PROFESSIONAL PRACTICE ................................... 10
       MISCELLANEOUS ISSUES .................................................................................................................................. 10
SECTION III - BASIS OF PAYMENT FOR SERVICES PROVIDED............................. 12
       PAYMENT FOR SERVICES NOT LISTED ON THE DENTAL FEE SCHEDULE ........................................................... 12
       PAYMENT FOR ORTHODONTIC CARE ................................................................................................................ 12
       MANAGED CARE................................................................................................................................................ 12
       DENTAL SERVICES INCLUDED IN A FACILITY RATE .......................................................................................... 12
       PAYMENT IN FULL ............................................................................................................................................ 13
       MEDICARE AND OTHER THIRD-PARTY INSURERS............................................................................................. 14
       UNSPECIFIED PROCEDURE CODES .................................................................................................................... 14
       PRIOR APPROVAL / PRIOR AUTHORIZATION REQUIREMENTS ............................................................................ 14
       RECIPIENT RESTRICTION PROGRAM ................................................................................................................. 17
       UTILIZATION THRESHOLD ................................................................................................................................ 17
SECTION IV - DEFINITIONS ........................................................................................ 19
       ATTENDING DENTIST........................................................................................................................................ 19
       REFERRAL ........................................................................................................................................................ 19




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SECTION V  DENTAL PROCEDURE CODES:
GENERAL INFORMATION AND INSTRUCTIONS ...................................................... 20
I.     DIAGNOSTIC (D0100 - D0999) ........................................................................... 25
II.    PREVENTIVE (D1000 - D1999) ........................................................................... 29
III.   RESTORATIVE (D2000 - D2999) ........................................................................ 31
IV.    ENDODONTICS (D3000 - D3999) ....................................................................... 34
V.     PERIODONTICS (D4000 - D4999) ...................................................................... 37
VI.    PROSTHODONTICS, REMOVABLE (D5000 - D5899) ....................................... 38
VII. MAXILLOFACIAL PROSTHETICS (D5900 - D5999) .......................................... 42
VIII. IMPLANT SERVICES (D6000 - D6199).............................................................. 43
IX.    PROSTHODONTICS, FIXED (D6200 - D6999) ................................................... 44
X.     ORAL AND MAXILLOFACIAL SURGERY (D7000 - D7999) .............................. 46
XI.    ORTHODONTICS (D8000 - D8999)..................................................................... 52
XII. ADJUNCTIVE GENERAL SERVICES (D9000 - D9999) ..................................... 59



       MISCELLANEOUS PROCEDURES (T1013) ...................................................... 62




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Section I - Requirements for Participation in Medicaid
Dental providers must be licensed and currently registered by the New York State
Education Department (NYSED), or, if in practice in another state, by the appropriate
agency of that state, and must be enrolled as providers in the New York State Medicaid
program.

No provider who has been suspended or disqualified from the Medicaid program may
receive reimbursement by the Medicaid program, either directly or indirectly, while such
sanctions are in effect.

Qualifications of Specialists
A specialist is one who:

    Is a diplomate of the appropriate American Board; or

    Has successfully completed a full time course of graduate or postgraduate
     specialty training in a specialty program approved by the American Dental
     Association Council on Dental Education as an accredited advanced dental
     education program; or,

    Is listed as a specialist in the section on character of practice in the American
     Dental Association's American Dental Directory, and such listing was attained prior
     to December 31, 1967; or

    Is listed as a specialist on the roster of approved dental specialists of the New York
     State Department of Health (DOH).

All dental providers enrolled in the Medicaid program are eligible for reimbursement for
all types of services except for orthodontic care, dental anesthesia and those
procedures where a specialty is indicated. There is no differential in levels of
reimbursement between general practitioners and specialists.

    Orthodontic care is reimbursable only when provided by a board certified or board
     eligible orthodontist or an Article 28 facility which have met the qualifications of the
     DOH and are enrolled with the appropriate specialty code.
    General anesthesia and parenteral conscious sedation are reimbursable only when
     provided by a qualified dental provider who has the appropriate level of certification
     in dental anesthesia by the NYSED. The NYSED issues certificates in three titles:
        i. Dental General Anesthesia, which authorizes a licensed dental provider to
           employ general anesthesia, deep sedation, or conscious sedation (parenteral
           or enteral route with or without inhalation agents); and




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        ii. Dental Parenteral Conscious Sedation, which authorizes a licensed dental
            provider to employ conscious sedation (parenteral or enteral route with or
            without inhalation agents); and
       iii. Dental Enteral Conscious Sedation, which authorizes a licensed dental
            provider to employ conscious sedation (enteral route only with or without
            inhalation agents).
       Additional information can be found at the NYSED website at:
                   http://www.op.nysed.gov/prof/dent/dentanesthes.htm


Group Providers
A group of practitioners is defined in 18 NYCRR 502.2 as:
      "...two or more health care practitioners who practice their profession at a
      common location (whether or not they share common facilities, common
      supporting staff, or common equipment)."

Regardless of the arrangement among practitioners (associates, employer-employee,
principal-independent contractor), practitioners who practice in a group setting are
required to enroll as a group and to comply with the requirements associated with group
practices.

Regardless of the nature of the practice (group, employer-employee, associate, etc.),
the name, NPI and other required information of the dentist actually providing the
service or treatment must be entered in the "Servicing Provider" on all claims and prior
approval requests.

Application of Free Choice
A Medicaid recipient is guaranteed free choice of a dental provider in obtaining the
dental care available under the New York State Medicaid program.

Credential Verification Reviews
Credential Verification Reviews (CVRs) are periodic onsite visits of a provider's place of
business to ensure overall compliance with Medicaid regulations. These visits are
conducted by the Medicaid program and the Office of the Medicaid Inspector General
(OMIG), and assess such areas as:

      provider and staff identification and credentialing
      physical attributes of the place of business
      recordkeeping protocols and procedures regarding Medicaid claiming.

CVRs are conducted for such sites as:

      medical and dental offices


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