New American Dental Association Procedure Codes

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

N

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)

Y

Procedure Code

Description

D5510

Repair broken complete denture base

D5610

Repair resin denture base

D5620

Repair cast framework

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

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)