Codes and Descriptions Special Dental Services



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Codes and Descriptions - Special Dental Services






Code

Description




Code

Description

APX1

Apexification/root filling teeth with an open apex




PDT1

Treatment of Periodontal Disease




PST1

Cast post and core

CON3

Initial oral consultation for school dental clinic patients referred for Special Dental Services or for the school dental clinic patients or adolescents who are not able to access their regular oral health provider in an emergency during normal practice hours




PST2

Preformed post (para, flexi, etc) and core




RAD1

Periapical radiograph

RAD2

Panoramic radiograph

CON4

Emergency consultation after hours (indicate time)




RAD3

Occlusal radiograph

CRN1

Preformed metal crown




RCT1

Root canal treatment and root fillings in permanent anterior teeth (per canal treated) including necessary radiographs performed during treatment and a mandatory post-operative radiograph for the patient’s records

CRN4

Gold crown (partial or full coverage)

CRN5

Complex reconstruction in composite resin

DEN3

Acrylic partial denture




RCT2

Pulp removal and root filling in a deciduous tooth (maximum fee per deciduous tooth treated)

DEN4

Acrylic partial denture – each extra tooth




RCT3

Pulpotomy in deciduous tooth

DEN5

Acrylic partial denture – each clasp




RCT4

Pulpotomy in permanent tooth

DEN6

Denture full upper or lower




RCT5

Root canal treatment and root fillings in permanent posterior teeth (per canal treated) including necessary radiographs performed during treatment and a mandatory post-operative radiograph for the patient’s records

DEN7

Dentures upper and lower

EMD1

Emergency dressing




RCM1

Re-cement inlay or crown

EXT1

Extraction of a single permanent tooth or deciduous quadrant (excluding extractions for orthodontic purposes)

with local anaesthetic






SPLT

Bite splints

VEN2

Labial composite veneers

EXT2

Subsequent extraction of a permanent tooth (maximum 4 teeth) or deciduous quadrant (excluding extractions for orthodontic purposes)










EXT3

Extraction of a single permanent tooth or deciduous quadrant (excluding extractions for orthodontic purposes)

with general anaesthetic












FIL1

One surface restoration in posterior teeth (including the anterior and posterior pit and all buccal, palatal and lingual fissure extensions of molars)










FIL2

Two surface (approximooccusal) restorations in posterior teeth










FIL3

Three surface amalgam (mesiooccusaldistal) restorations in posterior teeth










FIL4

Complex coronal reconstruction in amalgam (including restoration of one or more cusps)










FIL5

Simple non-metallic restorations in anterior teeth










FIL6

More than one surface non-metallic restorations in anterior teeth










MSO1

Minor surgical operation or other time based procedures – 1st half hour










MSO2

Minor surgical operation or other time based procedures – each additional quarter hour










PBW1

Bitewing radiograph










Ministry of Health, PO Box 1026, Wellington, New Zealand. Telephone 0800 458 448. HP 5959
July 2016


Special Dental Service Agreement
Individual Treatment Report

This form must be attached to a completed claim summary form (HP5957)





NHI number (mandatory)




Patient’s last name

 

 

 

 

 

 

 










     

Date of birth










Patient’s first name

 

 

 

 

 

 

 

 










     

Sex




Address of patient

Male  Female 




     

Name of school or dental clinic




Name of usual dentist

     




     

Town / city of school or dental clinic




Town / city of usual dentist

     




     




To be completed by agreement holder

The required treatment was (tick applicable box)

 1. As referred: Referral letter attached (if referral letter is not attached, write referral number).

 2. Emergency care for a child enrolled in the School Dental Service. Give name of patient’s school or dental clinic and town/city (mandatory).

 3. Treatment for a child enrolled in the school dental services who was presented to you without referral by a school dental therapist. Indicate school and town/city (mandatory).

 4. Emergency care for a child enrolled for Oral Health Services for Adolescent with another provider. Indicate the name of usual dentist and town/city (mandatory).



 5. Emergency care for a preschool, primary, intermediate or adolescent school child who is enrolled with neither the school dental service nor a private patient of a dentist.


Date of treatment

Code

Comments

Quantity

Teeth

Value
$


Ministry of Health only




Standard services not requiring prior approval

School dental referral number

 

 

 

 

 

 

 

 




     

     

     

     

     

     




     

     

     

     

     

     




     

     

     

     

     

     




     

     

     

     

     

     




     

     

     

     

     

     







Standard services requiring prior approval

Approval number

 

 

 

 

 

 

 

 




     

     

     

     

     

     




     

     

     

     

     

     




     

     

     

     

     

     




     

     

     

     

     

     




     

     

     

     

     

     







Total claimed (GST exclusive)

$     

$     

Please return to: Ministry of Health, PO Box 1026, Wellington 6140. Telephone 0800 458 448. HP 5959


July 2016



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