016-06-13 Ark. Code R. § 8

Current through Register Vol. 49, No. 6, June, 2024

Rule 016.06.13-008 - Provider Manual Update Transmittal DENTAL-2-13

Section II Dental

215.000Child Health Services (EPSDT) Dental Screening

The Child Health Services (EPSDT) periodic and interperiodic dental screening exams consist of an inspection of the oral cavity by a licensed dentist. The purpose of the dental screening exams is to check for obvious dental abnormalities and to assure access to needed dental care. Regular screening exams should be performed in accordance with the recommendations of the Child Health Service (EPSDT) periodicity schedule.

The Child Health Services (EPSDT) periodic dental screening exam is limited to two screening exams every six (6) months plus one (1) day for individuals under age 21. These benefits may be extended if documentation is provided that verifies medical necessity. See Section 262.100 to view the procedure code for periodic dental screening exams.

Individuals under age 21 enrolled in the EPSDT Program may receive an interperiodic dental screening exam twice per SFY. Extension of benefits is available in cases of medical necessity. .View or print form ADA-J400. See Section 262.100 for the interperiodic dental screening examprocedure code.

NOTE: ARKids First-B beneficiaries may also receive an interperiodic dental

screening exam twice per SFY. There is no extension of benefits for ARKids First-B beneficiaries.

Extension of benefits requests, in addition to a narrative and any supporting documentation, should be submitted to the Division of Medical Services Dental Care Unit - ATTN Dental

Extension of Benefits. .View or print the Division of Medical Services Dental Care Unit_______

contact information.

Infant oral health care examinations must be based on the recommendations of the American Academy of Pediatric Dentistry. Essential elements of an infant oral health care visit are a thorough medical and dental history, oral examination, parental counseling, preventive health education and determination of appropriate periodic re-evaluation. See Section 201.500 for information regarding the dentist's role in the EPSDT Program.

216.200Bitewing Radiographs

Bitewing radiographs are covered for beneficiaries of all ages. There are different limitations of coverage for beneficiaries under age 21 and for those beneficiaries age 21 and older.

The EPSDT periodic screening exam may include only two bitewings and is allowed every six (6) months plus one (1) day for beneficiaries under age 21. See Section 262.100 for the appropriate procedure code.

Two bitewing films are allowed once per state fiscal year (July 1 through June 30) for beneficiaries age 21 and over. See Section 262.200 for appropriate procedure codes.

221.100Endodontia

A. Guidelines

Root canal treatment should attempt to achieve the following:

1. Achieve and maintain access to apical anatomy during chemo-mechanical debridement.

2. Obturate the canal with densely compacted material within 2 mm of the apical terminus.

3. Prevent re-infection with a coronal restoration. If unable to conform in the above guidelines, the dentist must provide a narrative as to why it does not conform and the plan for monitoring the patient. Radiographic evidence (pre-operative and postoperative) must demonstrate completion of treatment and be maintained in the patient file. The following procedures may not be billed when performed on the same tooth and same day as root canal therapy: pulpotomy, pulpectomy, temporary restorations, palliative treatment or sedative fillings.

4. Root canal therapy is not allowed on the 2n^d and 3^rd molars with the exception of when the 1^st molar is absent. Also, root canal therapy is not allowed on maxillary 1^st molar if the 2n^d molar is unerupted.

B. Reimbursement

Pulpotomy for deciduous teeth may be performed without prior authorization for beneficiaries under age 21. Pulpotomies are not covered for beneficiaries age 21 and over.

Current indications require carious exposure of the pulp. Payment for pulp caps is included in the fee for restorations and is not payable separately.

Endodontic therapy is not covered for beneficiaries age 21 and over.

The fee for endodontic therapy does not include restoration to close a root canal access, but does include films for measurement control and post-op.

Medicaid does not cover endodontic retreatment, apexification, retrograde fillings or root amputation. See Section 262.100 for applicable procedure codes.

225.500Deep Sedation and General Anesthesia

Providers administering general anesthesia services must possess the appropriate permit as required by Arkansas law. Services performed in the dental office must be documented in the patient's record to include specific information on intubation, pharmacologic agents and amounts used, monitoring of vital signs and total anesthesia time. Prior authorization is required for deep sedation and general anesthesia procedures. General anesthesia and intravenous sedation will not be reimbursed for periods of time in excess of two (2) hours. D9220 and D9248 are not allowed on the same day. These codes are subject to post payment review; therefore, providers should be prepared to justify utilization of these procedures and the amount of time patients were kept under deep sedation and general anesthesia.

228.000Hospital Services

All inpatient and outpatient hospitalization for dental treatment requires prior authorization. The dental consultant may request a second opinion when reviewing requests for dental prior authorization.

To request prior authorization, the dental treatment plan must be submitted on the ADA claim form with the appropriate X-rays. A copy of the Additional Information form (DMS-32-A) should be attached indicating the reason(s) hospitalization is necessary and the name of the hospital. .View or print form DMS-32-A ._________________________________________________________

In unusual cases, for beneficiaries under age 21, when it is impossible to determine the treatment plan before the patient is anesthetized, indicate the information on the DMS-32-A. Beneficiaries age 21 and over are not covered for general anesthesia, nitrous oxide and non-intravenous conscious sedation.

The provider must complete the first portion of the ADA claim form (the ID of the patient and doctor) and submit both forms together. After the treatment is performed, any procedure(s) requiring prior authorization must be submitted to the dental consultant for authorization.

228.100Inpatient Hospital Services

Hospitalization for dental treatment may be approved when the patient's age, medical or mental problems and/or the extensiveness of treatment necessitates hospitalization. Consideration is given in cases of traumatic accidents and extenuating circumstances.

Because of the cost of a hospital stay, providers are encouraged to use outpatient hospital care whenever feasible. The length of hospitalization should be kept to a minimum.

Request for hospitalization should be made only when other methods such as premedication, delay of treatment, limited in office treatment, sedation, etc., have been evaluated.

228.200Outpatient Hospital Services

When a primary procedure to be performed in outpatient surgery is medical in nature, Arkansas Medicaid will not cover a dental procedure that is incidental to the primary procedure (e.g., the removal of a wisdom tooth when a tonsillectomy is being performed). When the primary procedure is medical, and it is cancelled, the provider may request a prior authorization for the dental procedure to be performed as outpatient surgery.

Information that should be included in the request for prior authorization for outpatient surgery includes the following.

A. An explanation for the reason the dental procedure cannot be performed in the provider's office.

B. An explanation for the reason a dental procedure cannot be postponed. (e.g., a procedure that cannot be postponed until a child matures and becomes receptive to a dental office environment and treatment.)

C. The provider should also state whether sedation or general anesthesia will be used during the procedure for beneficiaries under age 21. Note: General anesthesia, nitrous oxide and non-intravenous conscious sedation are not covered for beneficiaries age 21 and over.

D. A copy of the dental treatment plan must be included with the prior authorization request. For outpatient hospitalization, all procedures involved must be indicated on the treatment plan.

262.100ADA Procedure Codes Payable to Beneficiaries Under Age 21

The following ADA procedure codes are covered by the Arkansas Medicaid Program. These codes are payable for beneficiaries under the age of 21.

Beside each code is a reference chart that indicates whether X-rays are required and when prior authorization (PA) is required for the covered procedure code. If a concise report is required, this information is included in the PA column.

* Revenue code

*** (...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the covered service.

** Prior authorization is required for panoramic X-rays performed on children under six years of age (See Section 216.100 ).

ADA Code	Description	PA Yes/No	Submit X-Ray with Treatment Plan Yes/No
Child Health Services (EPSDT) Dental Screening (See Section 215.000 )
D0120	***(CHS/EPSDT Dental Screening Exam)	No	No
D0140	***(CHS/EPSDT Interperiodic Dental Screening Exam)	No, but limited to two (2) per SFY	No
Radiographs (See Sections 216.000 - 216.300)
D0210	Intraoral - complete series (including bitewings)	No	No
D0220	Intraoral - periapical - first film	No, but limited to five (5) per SFY	No
D0230	Intraoral - periapical - each additional film	No, but limited to five (5) per SFY	No
D0240	Intraoral - occlusal film	No, but limited to five (5) per SFY	No
D0250	Extraoral - first film	No	No
D0260	Extraoral - each additional film	No, but limited to five (5) per SFY	No
D0272	Bitewings - two films	No	No
D0330	Panoramic film	No**	No
D0340	Cephalometric film	Yes	No
Tests and Laboratory
D0350	Oral/facial photographic images	Yes	No
D0470	Diagnostic casts	Yes	No
Preventive
Dental Prophylaxis (See Section 217.100 )
D1120	Prophylaxis - child ***(ages 0-9)	No	No
D1110	Prophylaxis - adult ***(ages 10-20)	No	No
Topical Fluoride Treatment (Office Procedure) (See Section 217.100 )
D1203	Topical application of fluoride (prophylaxis not included) - child ***(ages 0-20)	No	No
Dental Sealants (See Section 217.200 )
D1351	Sealant per tooth ***(1st and 2nd permanent molars only)	No	No
Space Maintainers (See Section 218.000 )
D1510	Space maintainer - fixed - unilateral	Yes	Yes
D1515	Space maintainer - fixed - bilateral	Yes	Yes
D1525	Space maintainer - removable-bilateral	Yes	Yes
Restorations (See Sections 219.000 - 219.200)
Amalgam Restorations (including polishing) (See Section 219.100 )
D2140	Amalgam - one surface	No	No
D2150	Amalgam - two surfaces	No	No
D2160	Amalgam - three surfaces	No	No
D2161	Amalgam - four or more surfaces	No	No
Composite Resin Restorations (See Section 219.200 )
D2330	Resin - one surface, anterior, permanent	No	No
D2331	Resin - two surfaces, anterior, permanent	No	No
D2332	Resin - three surfaces, anterior, permanent	No	No
D2335	Resin - four or more surfaces or involving incisal angle, permanent	Yes	Yes
Crowns - Single Restoration Only (See Section 220.000 )
D2710	Crown - resin (laboratory)	Yes	Yes
D2752	Crown - porcelain -ceramic substrate	Yes	Yes
D2920	Re-cement crown	No	Yes
D2930	Prefabricated stainless steel crown - primary	No	No
D2931	Prefabricated stainless steel crown - permanent	Yes, but no PA required when billed for tooth numbers 3, 14, 19 and 30.	Yes
Endodontia (See Section 221.000 )
Pulpotomy
D3220	Therapeutic pulpotomy (excluding final restoration)	No	No
D3221	Gross pulpal debridement, primary and permanent teeth	Yes	No
Endodontic (Root Canal) therapy (including treatment plan, clinical procedures and follow-up care)
D3310	Anterior tooth (excluding final restoration)	No	No
D3320	Bicuspid tooth (excluding final restoration)	No	No
D3330	Molar (excluding final restoration)	No	No
Periapical Services
D3410	Apicoectomy (per tooth) - first root	Yes	Yes
Periodontal Procedures (See Section 222.000 )
Surgical Services (including usual postoperative services)
D4341	Periodontal scaling and root planing	Yes	Yes
D4910	Periodontal maintenance procedures (following active therapy)	Yes	Yes
Complete dentures (Removable Prosthetics Services) (See Section 223.000 )
D5110	Complete denture - maxillary	Yes	Yes
D5120	Complete denture - mandibular	Yes	Yes
Partial Dentures (Removable Prosthetic Services) (See Section 223.000 )
D5211	Upper partial - acrylic base (including any conventional clasps and rests)	Yes	Yes
D5212	Lower partial - acrylic base (including any conventional clasps and rests)	Yes	Yes
Repairs to Partial Denture (See Section 223.000 )
D5610	Repair acrylic saddle or base	Yes	No
D5620	Repair cast framework	Yes	No
D5640	Replace broken teeth - per tooth	Yes	No
D5650	Add tooth to existing partial denture	Yes	No
Fixed Prosthodontic Services (See Section 224.000 )
D6930	Re-cement bridge	Yes	No
Oral Surgery (See Section 225.000 )
Simple Extractions (includes local anesthesia and routine postoperative care) (See Section 225.100 )
D7111	Extraction, coronal remnants-deciduous tooth	No	No
D7140	Extraction, erupted tooth or exposed root (elevation and/or forceps removal)	No	No
Surgical Extractions (includes local anesthesia and routine postoperative care) (See Section 225.200 )
D7210	Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth	Yes	Yes
D7220	Removal of impacted tooth - soft tissue	Yes	Yes
D7230	Removal of impacted tooth - partially bony	Yes	Yes
D7240	Removal of impacted tooth - completely bony	Yes	Yes
D7241	Removal of impacted tooth - completely bony, with unusual surgical complications	Yes	Yes
D7250	Surgical removal of residual tooth roots (cutting procedure)	Yes	Yes
Other Surgical Procedures
D7270	Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth and/or alveolus	Yes	Yes
D7280	Surgical exposure of impacted or un-erupted tooth for orthodontic reasons (including orthodontic attachments)	Yes	Yes
D7285	Biopsy of oral tissue - hard	Yes	Yes
D7286	Biopsy of oral tissue - soft	Yes	Yes
Osteoplasty for Prognathism, Micrognathism or Apertognathism
D7510	Incision and drainage of abscess, intraoral soft tissue	Yes	No
Frenulectomy
D7960	Frenulectomy (Frenectomy or Frenotomy) Separate procedure	Yes	Yes
Orthodontics (See Section 226.000 )
Minor Treatment of Control Harmful Habits
D8210	Removable appliance therapy	Yes	Yes
D8220	Fixed appliance therapy	Yes	Yes
Comprehensive Orthodontic Treatment - Permanent Dentition
D8070	Class I Malocclusion	Yes	Yes
D8080	Class II Malocclusion	Yes	Yes
D8090	Class III Malocclusion	Yes	Yes
Other Orthodontic Devices
D8999	Unspecified orthodontic procedure, by report	Yes	Yes
Anesthesia
D9220	General Anesthesia - first 30 minutes	Yes	Yes
D9221	General Anesthesia - each 15 minutes	Yes	No
D9230	Analgesia N20	No, but requires report for request for more than 1 unit per day	No
D9248	Non-I.V. Conscious Sedation	Yes and requires report	No
Consultations (See Section 214.000 )
D9310	*(Second opinion examination) Consultation, diagnostic service provided by dentist or physician other than practitioner providing treatment	Yes	No
Smoking Cessation
D1320	Tobacco counseling for the control and prevention of oral disease - Counseling and referral by a provider to a tobacco cessation program	No	No
D9920	Behavior Management by Report - Tobacco counseling received from the provider for the control and prevention of oral disease	No	No
Unclassified Treatment
D9110	Palliative treatment with dental pain	Yes	No

262.200ADA Procedure Codes Payable to Medically Eligible Beneficiaries

Age 21 and Older

The following list shows the procedure code, procedure code description, whether or not prior authorization is required, whether an X-ray should be submitted with a treatment plan and if there is a benefit limit on a procedure.

The column titled Benefit Limit indicates the benefit limit, if any, and how the limit is to be applied. When the column indicates "Yes, $500.00", then that item, when used in combination with other items listed, cannot exceed the $500.00 Medicaid maximum allowable reimbursement limit for the state fiscal year (July 1 through June 30). Other limitations are also shown in the column (i.e.: 1 per lifetime ). If "No" is shown, the item is not benefit limited.

NOTE: The use of the symbol, #*, along with text in parentheses, indicates the Arkansas Medicaid description of the product.

ADA Code	Description	PA Yes/No	Submit X-Ray with Treatment Plan Yes/No	Benefit Limit Yes/No
Dental Screening (See Section 215.000 )
D0120	Periodic oral evaluation	No	No	Yes-$500 Yes-1 per year
D0140	Limited oral evaluation-problem focused	No	No	Yes-$500 Yes-12 per year
Radiographs (See Sections 216.000 - 216.300)
D0210	Intraoral - complete series (including bitewings)	No	No	Yes-$500 Yes-1 per 5 years
D0220	Intraoral - periapical - first film	No	No	Yes-$500 Yes-5 per year
D0230	Intraoral - periapical - each additional film	No	No	Yes-$500 Yes-5 per year
D0272	Bitewings - two films	No	No	Yes-$500 Yes-1 per year
D0330	Panoramic film	No	No	Yes-$500 Yes-1 per 5 years
Tests and Laboratory
D0470	Diagnostic Casts (full denture) Diagnostic Casts (partial denture)	No Yes	No Yes	Yes-$500 Yes-4 per lifetime
Dental Prophylaxis (See Section 217.100 )
D1110	Prophylaxis - adult	No	No	Yes-$500 Yes-1 per year
Topical Fluoride Treatment (Office Procedure) (See Section 217.100 )
D1204	Topical application of fluoride (prophylaxis not included) - adult	No	No	Yes-$500 Yes-1 per year
Restorations (See Sections 219.000 - 219.200)
Amalgam Restorations (including polishing) (See Section 219.100 )
D2140	Amalgam - one surface, primary or permanent	No	No	Yes-$500
D2150	Amalgam - two surfaces, primary or permanent	No	No	Yes-$500
D2160	Amalgam - three surfaces, primary or permanent	No	No	Yes-$500
D2161	Amalgam - four or more surfaces, primary or permanent	No	No	Yes-$500
Composite Resin Restorations (See Section 219.200 )
D2330	Resin - one surface, anterior, permanent	No	No	Yes-$500
D2331	Resin - two surfaces, anterior, permanent	No	No	Yes-$500
D2332	Resin - three surfaces, anterior, permanent	No	No	Yes-$500
D2335	Resin - four or more surfaces or involving incisal angle, permanent	Yes	Yes	Yes-$500
Crowns - Single Restoration Only (See Section 220.000 )
D2920 D2931	Re-cement crown Prefabricated stainless steel crown - permanent	No Yes, but no PA required when billed for tooth numbers 3, 14, 19 and 30.	Yes Yes	Yes-$500 Yes-$500
Surgical Services (including usual postoperative services)
D4341	Periodontal scaling and root planing-four or more contiguous	Yes	Yes	Yes-$500
D4355	Full mouth debridement to enable comprehensive evaluation and diagnosis	Yes	Yes	Yes-$500
D4910	Periodontal maintenance procedures (following active therapy)	Yes	Yes	Yes-$500
Repairs to Complete and Partial Dentures (See Section 223.000 )
D5410	Adjust complete denture-maxillary	No	No	Yes-$500 Yes-3 per lifetime
D5411	Adjust complete denture-mandibular	No	No	Yes-$500 Yes-3 per lifetime
D5610 D5640 D5650 D5730	Repair acrylic saddle or base Replace broken teeth - per tooth Add tooth to existing partial denture Reline complete maxillary denture (chairside)	Yes Yes Yes No	No No No No	Yes-$500 Yes-$500 Yes-$500 Yes-$500 Yes-1 every 3 years
D5731	Reline lower complete mandibular denture (chairside)	No	No	Yes-$500 Yes-1 every 3 years
Fixed Prosthodontic Services (See Section 224.000 )
D6930	Re-cement bridge	Yes	No	Yes-$500
Oral Surgery (See Section 225.000 )
Simple Extractions (includes local anesthesia and routine postoperative care) (See Section 225.100 )
D7140	Single tooth	No	No	No
Surgical Extractions (includes local anesthesia and routine postoperative care) (See Section 225.200 )
D7210	Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth	Yes	Yes	No
D7220	Removal of impacted tooth - soft tissue	Yes	Yes	No
D7230	Removal of impacted tooth - partially bony	Yes	Yes	No
D7240	Removal of impacted tooth - completely bony	Yes	Yes	No
D7241	Removal of impacted tooth - completely bony, with unusual surgical complications	Yes	Yes	No
D7250	Surgical removal of residual tooth roots (cutting procedure)	Yes	Yes	Yes-$500
Other Surgical Procedures
D7285	Biopsy of oral tissue - hard	Yes	Yes	Yes-$500
D7286	Biopsy of oral tissue - soft	Yes	Yes	Yes-$500
D7310	Alveoplasty in conjunction with extractions-four or more teeth	Yes	No	Yes-$500
D7472	Removal of torus palatinus	Yes	No	Yes-$500 1 per lifetime
D7473	Removal of torus mandibularis	Yes	No	Yes-$500 1 per lifetime
Osteoplasty for Prognathism, Micrognathism or Apertognathism
D7510	Incision and drainage of abscess, intraoral soft tissue	Yes	No	Yes-$500
Unclassified Treatment
D9110	Palliative treatment with dental pain	Yes	No	Yes-$500
Smoking Cessation
D1320	Tobacco counseling for the control and prevention of oral disease - Counseling and referral by a provider to a tobacco cessation program	No	No	Yes-$500 2 counseling sessions per SFY
D9920	Behavior Management by Report - Tobacco counseling received from the provider for the control and prevention of oral disease	No	No	Yes-$500 2 counseling sessions per SFY

016.06.13 Ark. Code R. § 008

7/16/2013