New American Dental Association Procedure Codes

January 4, 2018

Author: Dental Program, DMA, 919-855-4280

Effective with date of service Jan. 1, 2018, the following dental procedure codes were added for the N.C. Medicaid and Health Choice Dental Programs. These additions are a result of updates to the Current Dental Terminology (CDT) 2018 American Dental Association (ADA) Code. Clinical Coverage Policy 4A, Dental Services, will be updated to reflect these changes.

CDT 2018 Code	Description and Limitations	PA Indicator
D5511	Repair broken complete denture base, mandibular Reimbursement rate – same as D5510	N
D5512	Repair broken complete denture base, maxillary Reimbursement rate – same as D5510	N
D5611	Repair resin partial denture base, mandibular Reimbursement rate – same as D5610	N
D5612	Repair resin partial denture base, maxillary Reimbursement rate – same as D5610	N
D5621	Repair cast partial framework, mandibular Reimbursement rate – same as D5620	N
D5622	Repair cast partial framework, maxillary Reimbursement rate – same as D5620	N
D7979	Non-surgical sialolithotomy Not allowed on the same date of service as D7980 (surgical sialolithotomy) Reimbursement rate (to be determined)	Y
D9222	Deep sedation/general anesthesia – first 15 minutes Allowed once per date of service Allowed only in an office setting Deep sedation/general anesthesia performed in the dental office must include documentation in the record of pharmacologic agents, monitoring of vital signs, and complete anesthesia time Reimbursement includes all drugs and/or medicaments necessary for adequate anesthesia Reimbursement includes monitoring and management Reimbursement rate – same as D9223	N

CDT 2018
Code

Description and Limitations

PA Indicator

D9239

Intravenous moderate (conscious) sedation/analgesia – first 15 minutes

Allowed once per date of service
Allowed only in an office setting
Intravenous conscious sedation performed in the dental office must include documentation in the record of pharmacologic agents, IV site, monitoring of vital signs, and complete anesthesia time
Reimbursement includes all drugs or medicaments necessary for adequate anesthesia
Reimbursement includes monitoring and management
Reimbursement rate – same as D9243

D9995

Teledentistry – synchronous; real-time encounter
Reported in addition to other procedures delivered on the same date of service
The originating site is the facility in which the beneficiary is located
The distant site is the facility from which the provider furnishes the teledentistry service
All service sites/providers must be Medicaid or Health Choice enrolled
Consultation must take place by an encrypted two-way real-time interactive audio and video telecommunications system
Reimbursement rate (to be determined)

The following procedure codes were end-dated effective with date of service Dec. 31, 2017.

Procedure Code	Description
D5510	Repair broken complete denture base
D5610	Repair resin denture base
D5620	Repair cast framework

The following procedure codes descriptions were revised effective with date of service Jan. 1, 2018.

Procedure Code	Description
D1354	Interim caries arresting medicament application – per tooth
D3320	Endodontic therapy, premolar tooth (excluding final restoration)
D3330	Endodontic therapy, molar tooth (excluding final restoration)
D4355	Full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit
D7111	Extraction, coronal remnants – primary tooth
D7980	Surgical sialolithotomy
D9223	Deep sedation/general anesthesia – each subsequent 15-minute increment
D9243	Intravenous moderate (conscious) sedation/analgesia - each subsequent 15-minute increment

The following procedure code criteria was updated due to the description revision effective Jan. 1, 2018.

Procedure Code

Description

D1354

Interim caries arresting medicament application – per tooth

Interim caries arresting medicament application
Conservative treatment of an active, non-symptomatic carious lesion by topical application of a caries arresting or inhibiting medicament and without mechanical removal of sound tooth structure
Limited to beneficiaries ages 1 to 5
Allowed once every six calendar months per tooth
Limited to a total of four applications per tooth prior to age 6
Valid tooth numbers (A-T, AS-TS, 03, 14, 19, 30)
Recommended for beneficiaries who are deemed to be at risk for progression of disease to pulpal infection
Since the potential for staining of carious enamel and dentin exists, providers must obtain informed consent from the beneficiary’s parent or caregiver prior to rendering the service
Reapplication of the caries arresting medicament at recall visits is only indicated if the carious lesions do not appear arrested
Treated carious lesions can be restored after treatment with a caries arresting medicament
Reimbursement rate of $10 for the first tooth and cutback to 50 percent or $5 for three additional teeth for a total of four teeth reimbursed per date of service (maximum reimbursement of $25 per date of service)

Providers are reminded to bill their usual and customary charges rather than the Medicaid rate. For coverage criteria and additional billing guidelines, refer to Clinical Coverage Policy 4A, Dental Services, on the N.C. Medicaid website.

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