Cmr division of health care finance and policy 114. 3 Cmr 14. 00: Dental Services



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114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY
114.3 CMR 14.00: Dental Services


Section
14.01:   General Provisions

14.02:   General Definitions

14.03:   General Rate Provisions and Maximum Fees

14.04:   Allowable Fees: Anesthesia Services (Hospital)

14.05:   Allowable Fees: Non-Hospital Services

14.06:   Allowable Fees: Hospital Services

14.07:   Severability


14.01:   General Provisions
(1)   Scope, Purpose and Effective Date. 114.3 CMR 14.00 governs the rates of payments to be used by all governmental units in making payments to eligible dental providers for dental services rendered to publicly-aided individuals on or after January 22, 2011. The rates set forth in 114.3 CMR 14.00 do not apply to individuals covered by M.G.L. c. 152 (the Workers' Compensation Act), as most recently amended by St. 1991, c. 398. Rates for service rendered to such individuals are set forth at 114.3 CMR 40.00. The codes used in 114.3 CMR 14.00 are the Health Care Financing Administration’s Common Procedure Coding System (HCPCS).
(2)   Coverage. The rates of payment contained herein, or rates of payment determined in accordance with the provisions of 114.3 CMR 14.00, are full compensation for dental services rendered to publicly-aided individuals as well as for any related administrative or supervisory duties in connection with the provision of services, without regard to where these services are rendered.
(3)   Authority. 114.3 CMR 14.00 is adopted pursuant to M.G.L. c. 118G.
(4) Disclaimer of Authorization of Services. 114.3 CMR 14.00 is neither authorization for nor approval of the substantive services for which rates are determined pursuant to 114.3 CMR 14.00. Governmental units that purchase services from eligible providers are responsible for the definition, authorization, and approval of services extended to publicly-aided patients.


  1. Coding Updates and Corrections. The Division may publish procedure code updates and corrections in the form of an Informational Bulletin. Updates may reference coding systems including but not limited to the American Medical Association’s Current Procedural Terminology (CPT). The publication of such updates and corrections will list:

  1. codes for which only the code numbers change, with the corresponding cross references between existing and new codes;

  2. deleted codes for which there are no corresponding new codes; and

  3. codes for entirely new services that require pricing. The Division will list these codes and apply individual consideration (I.C.) reimbursement for these codes until appropriate rates can be developed.


14.02:   General Definitions
Confirmatory (Additional Opinion) Consultation. When the consulting physician or dentist is aware of the confirmatory nature of the opinion that is sought (e.g., when a patient requests a second/third opinion on the necessity or appropriateness of a recommended medical treatment or surgical procedure).
Consultation. A type of service provided by a physician or dentist whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or dentist or other appropriate source. A physician consultant may initiate diagnostic and/or therapeutic services.

The request for a consultation from the attending physician or dentist or other appropriate source and the need for consultation must be documented in the patient's medical record. The consultant's opinion and any services that were ordered or performed must also be documented in the patient's medical record and communicated to the requesting physician or other appropriate source.

Any specifically identifiable procedure (i.e., identified with a specific HCPCS code) performed on or subsequent to the date of the initial consultation should be reported separately.

If a consultant subsequently assumes responsibility for management of a portion or all of the patient's condition(s), the consultation codes should not be used.


Dental Enhancement Fee. D9450 or case presentation; detailed and extensive treatment planning is a dental enhancement fee for Community Health Centers and Hospital Licensed Health Centers who have signed an agreement with MassHealth. This code is used as a Dental Enhancement Fee per Dental User. This code may be billed when other dental procedures are performed on the same day and can only be billed once per dental user per day.
Division: The Division of Health Care Finance and Policy, established under M.G.L. c. 118G.
Eligible Provider. A provider of dental services who meets such conditions of participation as have been or may be adopted from time to time by a governmental unit purchasing such services and:

(a)   Dentists registered by the Massachusetts Board of Registration in Dentistry in accordance with the provisions of M.G.L. c. 112; or

(b)   Authorized governmental, nonprofit or charitably incorporated dental clinics not involved with teaching dental students; or

(c)   Authorized dental clinics that wholly or partially derive support from Title V funds under the Social Security Act; or

(d)   Teaching dental clinics operated by dental education institutions; or

(e) Qualified physicians, physician assistants, nurse practitioners, registered nurses, and licensed practical nurses who provide D1206 therapeutic application Fluoride Varnish for moderate to high caries risk patients in accordance with the applicable MassHealth program regulations; or

(f) Public health dental hygienists who are certified by the Massachusetts Board of Registration in Dentistry and provide services in public health settings that include schools, long-term nursing facilities, medical facilities and shelters.


Established Patient. A patient who has received professional services from the physician or dentist within the past three years.
Evaluation and Management (E/M) Services. . The E/M section is divided into broad categories such as office visits, hospital visits and consultations. Most of the categories are further divided into two or more subcategories of E/M services. For a full discussion of these services, refer to the most current Physician’s Current Procedural Terminology (CPT) Handbook.
Governmental Unit. The Commonwealth, any department, division, agency board, or commission of the Commonwealth, and any political subdivision of the Commonwealth.
Levels of E/M Services. Within each category or subcategory of E/M service, there are three to five levels of E/M services available for reporting purposes. Levels of E/M services are not interchangeable among the different categories or subcategories of service.

The levels of E/M services include examinations, evaluations, treatments, conferences with or concerning patients, preventive pediatric and adult health supervision and similar medical services. The levels of E/M services encompass the wide variations in skill, effort, time, responsibility and medical knowledge required for the prevention or diagnosis and treatment of illness or injury and the promotion of optimal health. Each level of E/M services may be used by all physicians or dentists. Coordination of care with other providers or agencies without a patient encounter on that day is reported using the case management codes. For a full discussion of the levels of E/M services, please refer to the most current CPT handbook.


New Patient. A patient who has not received any professional services from the physician or dentist within the past three years.
Publicly Aided Individual. A person who receives medical or dental care and services for which a governmental unit is liable, in whole or in part, under a statutory program of public assistance.
14.03:   General Rate Provisions and Maximum Fees
(1)   Rate Determination. Rates of payment for authorized dental services to which 114.3 CMR 14.00 applies will be the lower of:

(a)   The eligible dentist provider's usual fee to patients other than publicly-aided individuals or industrial accident patients; or



  1. The fees listed in 114.3 CMR 14.04, 14.05, 14.06.




  1. Early Periodic Screening, Diagnosis and Treatment (EPSDT). Division of Medical Assistance regulation 130 CMR 420.421 states that dental services provided to members under age 21 must comply with all applicable requirements for Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services set forth in Division of Medical Assistance regulation 130 CMR 450. 140-149.



  1. Individual Consideration (I.C.). Non-listed procedures and dental procedures designated I.C. are individually considered items. Determination of appropriate payment for procedures designated I.C. will be in accordance with the following standards and criteria:

(a)   Time required to perform the procedure;

(b)   Degree of skill required in the procedure performed;

(c)   Severity and/or complexity of the patient's dental disease or condition;

(d)   Policies, procedures and practices of other third-party purchasers of dental services, both governmental and private;



(e)   Should an eligible provider believe that any such procedure merits a higher fee than recommended, the provider may submit the prescribed claim form with supporting documentation. Such claims will be individually processed.


  1. Prior Approval. A number of procedures require authorization of the appropriate purchasing agency prior to the rendering of service and before payment will be made. Providers should refer to the appropriate purchasing agency manual before providing services.


14.04:   Allowable Fees: Anesthesia Services (Hospital)
Reimbursement of anesthesia services is set forth in 114.3 CMR 16.00: Surgery and Related Anesthesia Services.

14.05:   Allowable Fees: Non-Hospital Services



Code

Allowed Fee

EPSDT Rate

Description

 

 

 

I. Diagnostic

D0120

$20

$29

Periodic oral evaluation - established patient

D0140

$39

$49

Limited oral evaluation - problem focused

D0145

I.C.

I.C.

Oral evaluation for a patient under three years of age and counseling with primary caregiver

D0150

$37

$58

Comprehensive oral evaluation - new or established patient

D0160

$60

$77

Detailed and extensive oral evaluation - problem focused, by report

D0170

$36

$45

Re-evaluation - limited, problem focused (established patient; not postoperative visit)

D0180

I.C.

I.C.

Comprehensive periodontal evaluation - new or established patient

D0210

$69

$88

Intraoral - complete series (including bitewings)

D0220

$14

$20

Intraoral - periapical, first film

D0230

$12

$16

Intraoral - periapical, each additional film

D0240

$20

$26

Intraoral - occlusal film

D0250

$21

$28

Extraoral - first film

D0260

$21

$26

Extraoral - each additional film

D0270

$13

$17

Bitewing - single film

D0272

$22

$30

Bitewings - two films

D0273

I.C.

I.C.

Bitewings - three films

D0274

$33

$43

Bitewings - four films

D0277

$44

$55

Vertical bitewings - 7 to 8 films

D0290

$41

$53

Posterior-anterior or lateral skull and facial bone survey film

D0310

$42

$48

Sialography

D0320

$214

$321

Temporomandibular joint arthrogram, including injection

D0321

$89

$114

Other temporomandibular joint films, by report

D0322

I.C.

I.C.

Tomographic survey

D0330

$62

$88

Panoramic film

D0340

$69

$85

Cephalometric film

D0350

$36

$47

Oral/facial photographic images

D0360

I.C.

I.C.

Cone beam CT - craniofacial data capture

D0362

I.C.

I.C.

Cone beam - two-dimensional image reconstruction using existing data, includes multiple images

D0363

I.C.

I.C.

Cone beam - three-dimensional image reconstruction using existing data, includes multiple images

D0415

I.C.

I.C.

Collection of microorganisms for culture and sensitivity

D0416

I.C.

I.C.

Viral culture

D0421

I.C.

I.C.

Genetic test for susceptibility to oral diseases

D0425

I.C.

I.C.

Caries susceptibility tests

D0431

I.C.

I.C.

Adjunctive pre-diagnostic test that aids In detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures

D0460

$29

$37

Pulp vitality tests

D0470

$58

$72

Diagnostic casts

 

 

 

 

D0472

$67

$87

Accession of tissue, gross examination, preparation, and transmission of written report

D0473

I.C.

I.C.

Accession of tissue, gross and microscopic examination, preparation and transmission of written report

D0474

I.C.

I.C.

Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report

D0475

I.C.

I.C.

Decalcification procedure

D0476

I.C.

I.C.

Special stains for microorganisms

D0477

I.C.

I.C.

Special stains, not for microorganisms

D0478

I.C.

I.C.

Immunohistochemical stains

D0479

I.C.

I.C.

Tissue in-situ hybridization, including interpretation

D0480

$50

$65

Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report

D0481

I.C.

I.C.

Electron microscopy - diagnostic

D0482

I.C.

I.C.

Direct immunofluorescence

D0483

I.C.

I.C.

Indirect immunofluorescence

D0484

I.C.

I.C.

Consultation on slides prepared elsewhere

D0485

I.C.

I.C.

Consultation, including preparation of slides from biopsy material supplied by referring source

D0486

I.C.

I.C.

Accession of brush biopsy sample, microscopic examination, preparation and transmission of written report

D0502

I.C.

I.C.

Other oral pathology procedures, by report

D0999

I.C.

I.C.

Unspecified diagnostic procedure, by report

 

 

 

II. Preventative

D1110

$49

$70

Prophylaxis - adult

D1120

$36

$51

Prophylaxis - child

D1203

n/a

$26

Topical application of fluoride (prophylaxis not included) - child

D1204

$29

n/a

Topical application of fluoride (prophylaxis not included) - adult

D1206

$26

$26

Topical fluoride varnish; therapeutic application for moderate to high caries risk patients

D1310

I.C.

I.C.

Nutritional counseling for the control of dental disease

D1320

I.C.

I.C.

Tobacco counseling for the control and prevention of oral disease

D1330

$14

$21

Oral hygiene instruction

D1351

$28

$41

Sealant - per tooth

D1510

$178

$229

Space maintainer - fixed-unilateral

D1515

$285

$345

Space maintainer - fixed-bilateral

D1520

$214

$244

Space maintainer - removable-unilateral

D1525

$321

$368

Space maintainer - removable-bilateral

D1550

$33

$40

Recementation of space maintainer

D1555

I.C.

I.C.

Removal of fixed space maintainer

 

 

 

III. Restorative

D2140

$58

$77

Amalgam-one surface, primary or permanent

D2150

$72

$95

Amalgam-two surfaces, primary or permanent

D2160

$86

$110

Amalgam-three surfaces, primary or permanent

D2161

$108

$137

Amalgam-four or more surfaces, primary or permanent

D2330

$67

$91

Resin - one surface, anterior

D2331

$86

$110

Resin - two surfaces, anterior

D2332

$108

$137

Resin - three surfaces, anterior

D2335

$136

$175

Resin - four or more surfaces or involving incisal angle (anterior)

D2390

$99

$124

Resin-based composite crown, anterior

D2391

$51

$92

Resin-based composite - one surface, posterior

D2392

$65

$115

Resin-based composite - two surfaces, posterior

D2393

$77

$124

Resin-based composite - three surfaces, posterior

D2394

$106

$170

Resin-based composite - four or more surfaces, posterior

D2410

I.C.

I.C.

Gold foil - one surface

D2420

I.C.

I.C.

Gold foil - two surfaces

D2430

I.C.

I.C.

Gold foil - three surfaces

D2510

I.C.

I.C.

Inlay - metallic - one surface

D2520

I.C.

I.C.

Inlay - metallic - two surfaces

D2530

$286

$367

Inlay - metallic - three or more surfaces

D2542

$465

$596

Onlay - metallic - two surfaces

D2543

$643

$788

Onlay - metallic - three surfaces

D2544

$666

$800

Onlay - metallic - four or more surfaces

D2610

I.C.

I.C.

Inlay - porcelain/ceramic - one surface

D2620

$393

$504

Inlay - porcelain/ceramic - two surfaces

D2630

$596

$744

Inlay - porcelain/ceramic - three or more surfaces

D2642

$629

$722

Onlay - porcelain/ceramic - two surfaces

D2643

$607

$768

Onlay - porcelain/ceramic - three surfaces

D2644

$615

$788

Onlay - porcelain/ceramic - four or more surfaces

D2650

I.C.

I.C.

Inlay - resin-based composite - one surface

D2651

I.C.

I.C.

Inlay - resin-based composite - two surfaces

D2652

I.C.

I.C.

Inlay - resin-based composite - three or more surfaces

D2662

$571

$656

Onlay - resin-based composite - two surfaces

D2663

$570

$727

Onlay - resin-based composite - three surfaces

D2664

$570

$731

Onlay - resin-based composite - four or more surfaces



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