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§ 10:56-3.1 Introduction

(a) The New Jersey Medicaid/NJ FamilyCare program utilizes the American Dental Association's Code on Dental Procedures and Nomenclature as published in the Current Dental Terminology (CDT) and incorporated herein by reference, as amended and supplemented, and designated by the Centers for Medicare & Medicaid Services (CMS) as the national standard for reporting dental services under the Health Insurance Portability and Accountability Act of 1996, P.L. 104-191. The CDT is published by, and may be obtained from, the American Dental Association, 211 East Chicago Ave., Chicago, Illinois 60611, http://www.ada.org/ and/or PMIC, 4727 Wilshire Blvd., Suite 300, Los Angeles, CA 90010, http://www.medicalcodingbooks.com. Revisions to the CDT (code additions, code deletions and replacement codes) will be reflected in this chapter through publication of a notice of administrative change in the New Jersey Register. Revisions to existing reimbursement amounts specified by the Department and specification of new reimbursement amounts for new codes will be made by rulemaking in accordance with the Administrative Procedure Act, N.J.S.A. 52:14B-1 et seq.

(b) The HCPCS codes listed in this subchapter are divided into 11 sections.

Section 3.2-Diagnostic

Section 3.3-Preventive

Section 3.4-Restorative

Section 3.5-Endodontics

Section 3.6-Periodontics

Section 3.7-Prosthodontics, Removable

Section 3.8-Maxillofacial Prosthetics

Section 3.9-Prosthodontics, Fixed

Section 3.10-Oral Surgery

Section 3.11-Orthodontics

Section 3.12-Adjunctive General Services

(c) The basic categories and their assigned code series are as follows:

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(d) Specific elements of the HCPCS which require the attention of the dental provider are as follows:

1. The lists of HCPCS in the 11 separate sections of this subchapter are arranged in tabular form with specific information for a code given under columns with titles such as: "IND," "HCPCS CODES," "MOD," "DESCRIPTION," and "MAXIMUM FEE ALLOWANCE." The information given under each column is summarized below in (d)2 through 6.

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(e) Alphabetic and numeric symbols under "IND" & "MOD" and notes under "DESCRIPTION"

1. These symbols and notes when listed under the "IND", "MOD" and "DESCRIPTION" columns are elements of the HCPCS coding system. They assist the dentist in determining the appropriate procedure codes to be used, the area to be covered, the minimum requirements needed, and any additional parameters required for reimbursement purposes.

2. These symbols and/or letters and/or notes must not be ignored because in certain instances requirements are created in addition to the narrative which accompanies the HCPCS code. THE PROVIDER WILL THEN BE LIABLE FOR THE ADDITIONAL REQUIREMENTS AND NOT JUST THE HCPCS CODE NARRATIVE. These requirements must be fulfilled in order to receive reimbursement.

3. If there is no identifying symbol or note listed, the HCPCS code narrative prevails.

(f) Listed throughout this subchapter are some general and specific policies of New Jersey Medicaid/NJ FamilyCare program relevant to HCPCS. For complete and specific policies in addition to those outlined herein, the practitioner must consult N.J.A.C. 10:56-1 and/or 2.

1. When requesting prior authorization or filing a claim, the HCPCS codes, including the referenced modifiers, must be used in conjunction with the narratives in this subchapter.

2. The use of a procedure code will be interpreted by the New Jersey Medicaid/NJ FamilyCare programs as evidence that the dentist personally furnished, as a minimum, the service for which it stands.

3. For purposes of reimbursement, a dentist, dental group, shared health care facility or dentists sharing a common record shall be considered a single provider.

4. When billing, the provider shall enter into the procedure code column (Item 17B) of the Dental Services Claim Form (MC-10), a HCPCS code as listed in this subchapter. If an appropriate code cannot be found, the provider shall leave the procedure code column blank and shall submit a narrative description of the service for authorization and fee assignment on the Dental Prior Authorization Form MC-10A part 1 of 2 and the Dental Claim Form MC-10 part 2 of 2.

5. Date(s) of service(s) must be indicated on the Dental Services Claim form (MC-10).

6. When submitting a claim, the dentist shall always use her or his usual and customary fee. The fee designated for the HCPCS procedure codes represents the New Jersey Medicaid/NJ FamilyCare fee-for-service programs' maximum reimbursement for the given procedure.

(g) This subsection sets forth an index by dental procedure of codes in this subchapter.

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35 of 46 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 56. MANUAL FOR DENTAL SERVICES

SUBCHAPTER 3. HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS)
N.J.A.C. 10:56-3.2 (2014)
§ 10:56-3.2 D0100-D0999 DIAGNOSTIC
(a) Clinical Oral Examination:




Maximum Fee




HCPCS







Allowance

IND

Code

Mod

Procedure Description

S

$

NS




D0150




Comprehensive oral evaluation

15.00




14.00

NOTE 1: This code is to be used for comprehensive clinical oral evaluation of a Medicaid/NJ FamilyCare fee-for-service beneficiary.

NOTE 2: This code requires a thorough observation of all conditions present in the oral cavity and contiguous structures to include:

a. An oral cancer screening;

b. Charting of all abnormalities;

c. Development of a complete treatment plan to be recorded in its entirety, including provisions for further treatment and follow-up, by referral if necessary;

NOTE 3: For reimbursement of the comprehensive oral evaluation with code D0150:

a. The examination is limited to once every six months for patients under 21 years of age and every 12 months for patients over 21 years of age, except as authorized by a dental consultant of the New Jersey Medicaid/NJ FamilyCare program;

b. All items on the Dental Services Claim form (MC-10) should be completed;

c. If no other treatment is necessary, this fact must be noted on the Dental Services Claim form (MC-10) in the diagnosis box (20). The abbreviation "NOTN" may be used to indicate no other treatment needed.




D0150

76

Comprehensive oral evaluation

14.00




13.00

NOTE 1: This code is to be used only if a beneficiary is developmentally disabled or neurologically impaired (see N.J.A.C. 10:56-2.9(a)1ii), in which case an examination may be provided as often as every three months and may be submitted directly to the fiscal agent for payment without prior authorization. The nature of the beneficiary's disability must be recorded under "Remarks" on the Dental Services Claim form (MC-10).




D0150

EP

Comprehensive oral evaluation

25.00




21.00

NOTE 1: a. This code is to be used for comprehensive oral evaluation of a Medicaid/NJ FamilyCare fee-for-service beneficiary through and including the age of 20.

b. This code is to be used for comprehensive oral evaluation referred from EPSDT screenings.

NOTE 2: This code requires a thorough observation of all conditions present in the oral cavity and contiguous structures to include:

a. An oral cancer screening;

b. Assessment of dental development;

c. Charting of all abnormalities;

d. Development of a complete treatment plan to be recorded in its entirety, including provisions for further treatment and follow-up, by referral if necessary;

e. Anticipatory guidance concerning dental health to the patient or parent/guardian;

f. Assessment of the caries index and nutritional needs relating to oral health and oral hygiene practices;

g. Assessment of systemic or topical fluoride needs.

NOTE 3: For reimbursement of the comprehensive oral evaluation with code D0150 EP:

a. The examination is limited to once every six months for patients under 21 years of age, except as authorized by a dental consultant of the New Jersey Medicaid/NJ FamilyCare program;

b. All items on the Dental Services Claim form (MC-10) should be completed;

c. If no other treatment is necessary, this fact must be noted on the Dental Services Claim form (MC-10) in the diagnosis box (20). The abbreviation "NOTN" may be used to indicate no other treatment needed.






D0120




Periodic Oral Evaluation

15.00




14.00

NOTE: An evaluation performed on a patient of record to determine any changes in the patient's oral health status since a previous initial or periodic examination.




D0120

EP

Periodic Oral Evaluation

15.00




14.00

NOTE: This code is to be used with an EPSDT referral on a patient of record to determine any changes in the patient's oral health status since a previous initial or periodic examination.

d

D0140




Limited oral evaluation

4.00




3.00

NOTE: Make note of diagnosis and/or observation(s) on the Dental Services Claim form (MC-10).




D0160




Detailed and extensive oral

14.00




13.00










evaluation problem focused by



















report.













D0170




Re-evaluation--limited, problem

14.00




13.00










focused (Established patient; not



















post-operative visit)










(b) Radiographs:

1. Intraoral Radiographs: (Periapicals/Bitewing/Occlusal)

i. Indicate number of films in item 13 of the Dental Services Claim form (MC-10);

ii. For a complete series of radiographs, limitations pertaining to age are found in the first note below each code, and the maximum number of radiographs reimbursable as a single radiographic study every three years without prior authorization is found in the second note below each code.






Maximum Fee




HCPCS







Allowance

IND

Code

Mod

Procedure Description

S

$

NS




D0210

52

Intraoral-Complete Series

18.00




18.00

NOTE 1: Limited to patients up to and including age six.

NOTE 2: Eight films.






D0210




Intraoral--Complete Series

22.00




22.00










(including bitewings)










NOTE 1: Limited to patients age seven up to and including age 14.

NOTE 2: Twelve films.






D0210

22

Intraoral--Complete Series

26.00




26.00










(including bitewings)










NOTE 1: Limited to patients age 15 or older.

NOTE 2: Minimum of 16 films.






D0220




Intraoral--Periapical--First Film

3.75




3.75




D0230




Intraoral--Periapical--Each

2.75




2.75










Additional Film










NOTE 1: Indicate complete number of films (D0220 Plus D0230) in item 13.




D0240




Intraoral--Occlusal Film

5.00




5.00

NOTE 1: Per film (maximum--two films).

NOTE 2: Indicate number of films in item 13.

2. Extraoral Radiographs




D0250




Extraoral, First Film

10.00




10.00

NOTE: Code to be used for lateral, anteroposterior, temporo-mandibular radiographs, etc. (one view).




D0260




Extraoral--

5.00




5.00










Each Additi



















onal Film










NOTE 1: Indicate number of views in item 13.

NOTE 2: Maximum reimbursable--two additional views.






D0270




Bitewing--Single film

3.00




3.00




D0272




Bitewings--Two films

5.00




5.00




D0274




Bitewings--Four films

9.00




9.00




D0290




Posterior--anterior or lateral

10.00




10.00










skull and facial bone survey film













D0310




Sialography

15.00




15.00




D0310

22

Sialography

30.00




30.00

NOTE: Includes injection of contrast material (filling and/or emptying phases).




D0320




Temporomandibular joint

30.00




30.00










anthrogram, including injection













D0321




Other temporomandibular joint

BR




BR










films, by report













D0322




Tomographic survey

125.00




90.00




D0330




Panoramic Film

15.75




15.75




D0340




Cephalometric Film

15.00




15.00




D0340

22

Cephalometric Film

22.50




22.50

NOTE: Includes tracing.

(c) Test and laboratory examinations:






D0470




Diagnostic Casts

11.50




10.00

NOTE 1: Casts must have bases and be trimmed to permit articulation, per cast.

NOTE 2: Code not to be used in conjunction with denture construction.






D0472




Accession of tissue, gross

9.35




9.35










examination, preparation and



















transmission of written report













D0473




Accession of tissue, gross and

20.85




20.85










microscopic examination,



















preparation and transmission of



















written report













D0474




Accession of tissue, gross and

40.00




40.00










microscopic examination, including



















assessment of surgical margins for



















presence of disease, preparation



















and transmission of written report













D0480




Processing and interpretation of

12.00




12.00










cytologic smears, including the



















preparation and transmission of



















written report













D0350




Oral/facial images (includes intra

1.00




1.00










and extraoral images)










NOTE: Or slides, per view.

d

D0501




Histopathologic Examination

10.00




10.00

NOTE 1: The gross and microscopic examination of oral tissues, both hard and soft.

NOTE 2: Limited to specialists in oral pathology, and Oral Diagnosis (Pathology) Departments of dental schools.






D0502




Other oral pathology procedures,

BR




BR










by report










d*

D0999




Unspecified Diagnostic Procedure,

BR




BR










By Report










NOTE: Complete description of procedure and the reason the procedure was performed.

36 of 46 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 56. MANUAL FOR DENTAL SERVICES

SUBCHAPTER 3. HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS)
N.J.A.C. 10:56-3.3 (2014)

1   2   3   4   5   6   7   8   9   ...   14


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