N.J. Admin. Code § 10:56-2.11

Current through Register Vol. 56, No. 12, June 17, 2024

Section 10:56-2.11 - Endodontic services

(a) Reimbursement for root canal therapy for all teeth shall include pulpal extirpation, endodontic treatment to include complete filling of the root canal(s) with permanent material, all necessary radiographs during treatment, a radiograph demonstrating proper completion, and follow-up care.

1. Silver points shall not be reimbursed when used as the "permanent material" for filling the root canal.

2. Complete filling of the root canal is defined as filling of the canal to within 0.5 millimeters of the apex.

(b) Root canal treatment for beneficiaries with permanent teeth will not be reimbursed without prior authorization by a Division dental consultant. When the beneficiary is in pain, the dentist should institute emergency measures to extirpate the pulp and/or relieve the pain only until authorization is requested and received. The Dental Prior Authorization Form (MC-10A), and the Dental Claim Form (MC-10) shall be submitted with diagnostic periapical radiograph(s) of the involved teeth.

1. The pulpotomy code is also reimbursable as an emergency endodontic procedure.

(c) Root canal therapy for primary teeth (with permanent successors only) shall include pulpal extirpation, and endodontic treatment to include complete filling of the root canal(s) with resorbable filling material. A radiograph(s) demonstrating proper completion shall be available for review by Division staff.

(d) Pulp capping (direct) is defined as an obtundent or regenerative dressing over the directly exposed vital pulp. This is differentiated from the routine placement of a medicated base or lining under a restoration. Pulp capping is not a separate reimbursable procedure.

(e) Apicoectomy will be considered for prior authorization and/or reimbursement only if one or more of the following conditions exist:

1. Overfilled canal (previously treated tooth);

2. Canal cannot be filled properly because of excessive root curvature or calcification;

3. Fractured root tip that cannot be reached endodontically;

4. Broken instrument in canal;

5. Perforation of the apical third of canal;

6. Displaced root canal filling lying free in periapical tissues and acting as an irritant;

7. Periapical pathology not resolved by previous endodontic therapy;

8. Periapical pathology which in the practitioner's judgment will not be resolved by endodontic therapy alone;

9. A post, post and core, or post-crown which cannot be removed.

(f) Apicoectomy should not be performed for convenience. If endodontic treatment is necessary, but none of the above conditions exist, reimbursement for the apicoectomy will not be made.

(g) Retrograde filling(s) will be inserted when necessary in conjunction with appropriate endodontic treatment, to include apicoectomy, but not in lieu of a properly filled canal.

(h) Reimbursement includes those post-treatment radiographs determined necessary by the practitioner. Such radiographs shall be available to the Medicaid/NJ FamilyCare fee-for-service programs upon request.

N.J. Admin. Code § 10:56-2.11

Amended by R.1986 d.385, effective 9/22/1986.
See: 18 N.J.R. 1337(a), 18 N.J.R. 1958(a).
Note is renumbered to (a)5ii.
Recodified from 10:56-1.17 and amended by R.1996 d.428, effective 9/16/1996.
See: 28 N.J.R. 3069(a), 28 N.J.R. 4243(a).
Amended by R.2001 d.268, effective 8/6/2001.
See: 33 N.J.R. 1554(a), 33 N.J.R. 2666(b).
In (a), inserted "/NJ Family Care fee-for-service" preceding "dental" and substituted "beneficiary" for "recipient"; in (b)1, substituted references to beneficiaries for references to recipients; in (i), inserted "/NJ Family Care fee-for-service" preceding "programs".
Amended by R.2004 d.25, effective 1/20/2004.
See: 35 N.J.R. 4032(a), 36 N.J.R. 568(a).
Deleted former (a); recodified former (b) as (a), deleted former (b)1 and recodified former (b)2 and (b)3 as (a)1 and (a)2; recodified existing (c) through (i) as (b) through (h).
Amended by R.2007 d.36, effective 2/5/2007.
See: 38 N.J.R. 3419(a), 39 N.J.R. 479(a).
Section was "Endodontia". In (a)1, substituted "shall not be reimbursed when used" for "are not acceptable"; rewrote introductory paragraph of (b); in (c), substituted "shall" for "must; and in (h), substituted ". Such radiographs shall" for "and must".