N.J. Admin. Code § 10:56-2.16

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

Section 10:56-2.16 - Pediatric dental services

(a) In recognition of the unique needs of providing dental care for children, and in conformance with the Federally mandated Early and Periodic Screening, Diagnosis and Treatment program for providing services for children, a special HCPCS code has been defined, "D0150 EP," to be used by dental providers when billing for comprehensive clinical oral evaluations of children.

(b) A dental provider shall bill using the HCPCS code for a comprehensive clinical oral evaluation provided to a child.

1. This evaluation may be either an initial or a periodic evaluation.

2. For determining when this HCPCS code may be used, a child is defined as a person under the age of 21 years.

(c) The HCPCS code D0150 EP is reimbursed at an enhanced rate of $ 26.00 for a specialist and $ 22.00 for a non-specialist. Reimbursement for a comprehensive clinical oral evaluation of a child, through age 20 years, shall be limited to once every six months, except as authorized by a Division dental consultant. At a minimum, the evaluation shall include:

1. Thorough observation of all conditions present in the oral cavity and contiguous structures including an oral cancer screening;

2. Assessment of dental development;

3. Charting of all abnormalities;

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

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

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

7. Assessment of systemic or topical fluoride needs.

N.J. Admin. Code § 10:56-2.16

New Rule, R.1996 d.428, effective 9/16/1996.
See: 28 N.J.R. 3069(a), 28 N.J.R. 4243(a).
Amended by R.2000 d.426, effective 10/16/2000.
See: 32 N.J.R. 2411(a), 32 N.J.R. 3836(a).
In (c), increased the dollar amounts for specialist and nonspecialist reimbursement.
Amended by R.2003 d.16, effective 1/6/2003.
See: 34 N.J.R. 2681(a), 35 N.J.R. 232(a).
Substituted "D0150 EP" for "00110 WT" (a) and (c).
Amended by R.2004 d.25, effective 1/20/2004.
See: 35 N.J.R. 4032(a), 36 N.J.R. 568(a).
In (c), inserted a reference to NJ FamilyCare in the introductory paragraph.
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 "Pedodontia: pediatric dentistry". In (a), substituted "evaluations" for "examinations"; in the introductory paragraph of (b), substituted "A" for "On or after January 15, 1995, a", "shall" for "may" and "evaluation" for "examination"; rewrote (b)1; and rewrote the introductory paragraph of (c).