N.J. Admin. Code § 10:56-3.10

Current through Register Vol. 56, No. 11, June 3, 2024

Section 10:56-3.10 - D7000-D7999 ORAL SURGERY

(a) Extractions--includes local anesthesia and routine post-operative care:

				Maximum Fee
HCPCS	Allowance
IND	Code	Mod	Procedure Description	S	$	NS
D7110	Single Tooth	32.00	30.00
D7120	Extraction--each additional tooth	32.00	30.00
D7130	Root Removal--Exposed Roots	19.50	18.00

NOTE 1: Per tooth.

(b) Surgical extractions--includes local anesthesia and routine post-operative care:

1. Prior authorization for the removal of impacted teeth is necessary for those beneficiaries up to and including 17 years of age as denoted by those codes with the "#" (cross-hatch) indicator.

#	D7210	Surgical Removal of Erupted Tooth	33.00	31.00
Requiring Elevation of
Mucoperiosteal Flap and Removal of
Bone and/or Section of Tooth
#	D7220	Removal of Impacted Tooth--Soft	43.00	40.00
Tissue
#	D7230	Removal of Impacted	114.00	106.00
Tooth--Partially Bony
#	D7240	Removal of Impacted	114.00	106.00
Tooth--Completely Bony
#	D7250	Surgical Removal of Residual Tooth	43.00	39.00
Roots (Cutting Procedure)

NOTE: Includes cutting of soft tissue and bone, removal of tooth structure and closure.

(c) Other surgical procedures:

D7260

Oroantral Fistula Closure

108.00

99.00

NOTE 1: Code may also be used for antral root recovery.

NOTE 2: Excision of fistulous tract between maxillary sinus and oral cavity and closure by advancement flap.

D7270	Tooth Re-implantation and/or	93.00	85.00
Stabilization of Accidentally
Avulsed or Displaced Tooth and/or
Alveolus
D7280	Surgical Exposure of Impacted or	101.00	94.00
Unerupted Tooth for Orthodontic
Reason (Including Orthodontic
Attachments)
D7281	Surgical Exposure of Impacted or	45.00	41.00
Unerupted Tooth to Aid Eruption
d	D7285	Biopsy of Oral Tissue--Hard	30.00	26.00

NOTE: Independent procedure (laboratory must bill separately).

d

D7286

Biopsy of Oral Tissue-Soft

18.00

16.00

NOTE: Independent procedure (laboratory must bill separately).

(d) Alveoloplasty surgical preparation of ridge for dentures:

1. Reimbursement will be based upon quadrants.

D7310	Alveoloplasty in Conjunction with	62.50	56.50
Extractions--Per Quadrant

NOTE 1: In conjunction with extractions of at least three teeth or the roots of at least three teeth in the same quadrant.

NOTE 2: Specify quadrant.

D7320	Alveoloplasty Not In Conjunction	62.50	56.50
with extraction--Per Quadrant

(e) Vestibuloplasty--including revision of soft tissues on ridges, muscle reattachment, tongue, palate, and other oral soft tissues (complete description including size and position must be submitted). Reimbursement will be based upon quadrants.

D7340	Vestibuloplasty--Ridge Extension	65.00	59.00
(Secondary Epithelialization)

NOTE: Including management of hypertrophied and hyperplastic tissue, per quadrant.

D7350	Vestibuloplasty--Ridge Extension	169.00	153.00
(Including Soft Tissue Grafts,
Muscle Re-attachments, Revision of
Soft Tissue Attachment, and
Management of Hypertrophied and
Hyperplastic Tissue)

NOTE: Per Quadrant.

(f) Surgical excision of reactive inflammatory lesions (scar tissue or localized congenital lesions):

NOTE: Biopsy report must be available upon request for review by the Division's dental consultants.

1. Includes lesions of skin, subcutaneous or mucous membranes, pyogenic granulomata and opercula.

D7410	Radical Excision--Lesion Diameter	30.00	26.00
Up to 1.25 cm.
D7420	Radical Excision--Lesion Diameter	42.00	37.00
Over 1.25 cm.

NOTE: Up to and including three cm.

D7420	22	Radical Excision--Lesion Diameter	100.00	86.00
Over 3 cm.

(g) Removal of tumors, cysts, and neoplasms:

1. In the excision and management of this type of lesion, a biopsy report must be available for review by the Medicaid/NJ FamilyCare dental consultants.

D7430	Excision of Benign Tumor--Lesion	30.00	26.00
Diameter Up to 1.25 cm.
D7431	Excision of Benign Tumor--Lesion	42.00	37.00
Diameter Over 1.25 cm.

D7431	22	Excision of Benign Tumor--Lesion	100.00	86.00
Diameter Over 3 cm.
D7440	Excision of Malignant	100.00	86.00
Tumor--Lesion Diameter Up to 1.25
cm.
D7441	Excision of Malignant	274.00	256.00
Tumor--Lesion Diameter Over 1.25
cm.

NOTE: Up to and including three cm.

D7441	22	Excision of Malignant	473.00	413.00
Tumor--Lesion Diameter Over 3 cm.
D7450	Removal of Odontogenic Cyst or	50.00	43.00
Tumor--Lesion Diameter Up to 1.25
cm.
D7451	Removal of Odontogenic Cyst or	100.00	87.00
Tumor--Lesion Diameter Over 1.25
cm.

NOTE: Up to and including three cm.

D7451	22	Removal of Odontogenic Cyst or	150.00	130.00
Tumor--Lesion Diameter Over 3 cm.
D7460	Removal of Non Odontogenic Cyst or	50.00	43.00
Tumor--Lesion Diameter Up to 1.25
cm.
D7461	Removal of Non Odontogenic Cyst or	100.00	87.00
Tumor--Lesion Diameter Over 1.25
cm.

NOTE: Up to and including three cm.

D7461	22	Removal of Non Odontogenic Cyst or	150.00	130.00
Tumor--Lesion Diameter Over 3 cm.
D7465	Destruction of Lesion(s) by	18.00	15.00
Physical Methods: Electrosurgery,
Chemotherapy, Cryotherapy or Laser

(h) Excision of bone tissue:

D7471

Removal of Exostosis--per site

62.50

56.50

1. Reimbursement will be based upon quadrants.

NOTE: Per quadrant.

D7471

22

Removal of Exostosis

109.00

98.00

NOTE: Torus palatinus.

D7480	Partial Ostectomy (Guttering or	211.00	184.00
Saucerization)
D7490	Radical Resection of Mandible with	807.00	807.00
Bone Graft

(i) Surgical incision:

D7510	Incision and Drainage of	28.00	26.00
Abscess--Intraoral Soft Tissue
D7520	Incision and Drainage of	42.00	37.00
Abscess--Extraoral Soft Tissue
D7530	Removal of Foreign Body, Skin, or	18.00	16.00
Subcutaneous Areolar Tissue
D7540	Removal of Reaction Producing	51.00	45.00
Foreign Bodies, Musculoskeletal
System
D7550	Sequestrectomy for Osteomyelitis	48.00	42.00

NOTE: Intraoral.

D7550

22

Sequestrectomy for Osteomyelitis

90.00

75.00

NOTE: Extraoral.

D7560	Maxillary Sinusotomy for Removal	242.00	210.00
of Tooth Fragment or Foreign Body

NOTE: Sinusotomy, maxillary (antrotomy, Caldwell Luc, unilateral).

(j) Treatment of fractures--simple:

1. Open reduction involves the dissection of tissues and/or the visual inspection of the fracture site.

D7610	Maxilla--Open Reduction (Teeth	273.00	249.00
Immobilized if Present)
D7620	Maxilla--Closed Reduction (Teeth	182.00	166.00
Immobilized if Present)
D7620	52	Maxilla--Closed Reduction	80.00	76.00

NOTE: No manipulation or fixation.

D7630	Mandible--Open Reduction (Teeth	363.00	331.00
Immobilized if Present)
D7630	22	Mandible--Open Reduction (Teeth	454.00	414.00
Immobilized if Present)

NOTE: Complicated--multiple surgical approaches (three or more) including internal fixation, interdental fixation, skeletal pinning with extraoral fixation.

D7640	Mandible--Closed Reduction (Teeth	182.00	166.00
Immobilized if Present)
D7640	52	Mandible--Closed Reduction	80.00	76.00

NOTE: No manipulation or fixation.

D7650	Malar and/or Zygomatic Arch--Open	182.00	166.00
Reduction
D7660	Malar and/or Zygomatic	63.00	58.00
Arch--Closed Reduction

NOTE: Including towel clip technique.

D7660	52	Malar and/or Zygomatic	56.00	52.00
Arch--Closed Reduction

NOTE: No manipulation or fixation.

D7670	Alveolus--Stabilization of Teeth,	138.00	126.00
Open Reduction Splinting

NOTE 1: Alveolar fracture.

NOTE 2: Reduction with wiring, application of arch bar or splint.

D7680	Facial Bones--Complicated	363.00	331.00
Reduction with Fixation and
Multiple Surgical Approaches

NOTE 1: Maxilla, malar and/or zygomatic arch.

NOTE 2: Multiple surgical approaches (three or more), fixation, traction, head frame, multiple internal and/or external fixation, and head cap.

(k) Treatment of fractures--compound:

1. Open reduction involves the dissection of tissues and/or the visual inspection of the fracture site.

D7710

Maxilla--Open Reduction

273.00

249.00

NOTE: Teeth immobilized if present.

D7720

Maxilla--Closed Reduction

182.00

166.00

NOTE: Teeth immobilized if present.

D7720

52

Maxilla--Closed Reduction

80.00

76.00

NOTE: No manipulation or fixation.

D7730

Mandible--Open Reduction

363.00

331.00

NOTE: Teeth immobilized if present.

D7730

22

Mandible--Open Reduction

454.00

414.00

NOTE: Complicated--multiple surgical approaches (three or more) including internal fixation, interdental fixation, and skeletal pinning with extraoral fixation.

D7740

Mandible--Closed Reduction

182.00

166.00

NOTE: Teeth immobilized if present.

D7740

52

Mandible--Closed Reduction

80.00

76.00

NOTE: No manipulation or fixation.

D7750	Malar and/or Zygomatic Arch--Open	182.00	166.00
Reduction
D7760	Malar and/or Zygomatic	63.00	58.00
Arch--Closed Reduction

NOTE: Including towel clip technique.

D7760	52	Malar and/or Zygomatic	56.00	52.00
Arch--Closed Reduction

NOTE: No manipulation or fixation.

D7770	Alveolus--Stabilization of Teeth,	138.00	126.00
Open Reduction Splinting

NOTE 1: Alveolar fracture.

NOTE 2: Reduction with wiring, application of arch bar or splint.

D7780	Facial Bones--Complicated	363.00	331.00
Reduction with Fixation and
Multiple Surgical Approaches

NOTE 1: Maxilla, malar and/or zygomatic arch.

NOTE 2: Multiple surgical approaches (three or more), fixation, traction, head frame, multiple internal and/or external fixation, and head cap.

(l) Reduction of dislocation and management of other temporo-mandibular joint dysfunctions:

D7810	Open Reduction of Dislocation	273.00	249.00
D7820	Closed Reduction of Dislocation	27.00	25.00
d	D7830	Manipulation under Anesthesia	27.00	25.00

NOTE: Anesthesia additional.

D7840	Condylectomy	362.00	315.00
D7850	Meniscectomy	362.00	315.00
D7852	Disc repair	362.00	308.00

NOTE: Unilateral.

D7854	Synovectomy	200.00	173.00
D7858	Joint reconstruction	623.00	623.00
D7860	Arthrotomy	182.00	155.00
D7865	Arthroplasty	362.00	308.00

NOTE: Unilateral.

d

D7870

Arthrocentesis

18.00

16.00

NOTE: Injection or aspiration (give complete details).

D7871	Non-arthroscopic lysis and lavage	190.00	190.00
D7872	Arthroscopy--diagnosis, with or	75.00	65.00
without biopsy
D7873	Arthroscopy--surgical: lavage and	200.00	200.00
lysis of adhesions
D7874	Arthroscopy--surgical: disc	500.00	425.00
repositioning and stabilization
D7875	Arthroscopy--surgical: synovectomy	264.00	224.00
D7877	Arthroscopy--surgical: debridement	160.00	136.00
*	D7880	Occlusal orthotic device, by report	BR	BR
D7899	Unspecified TMD therapy, by report	BR	BR

(m) Repair of traumatic wounds:

1. Describe completely, giving size, site, and all pertinent information.

2. Fee includes suture removal.

D7910	Suture of Recent Small Wounds up	35.00	32.00
to 5 cm.

NOTE: 2.5 cm. up to five cm.

(n) Complicated suturing (reconstruction requiring delicate handling of tissues and wide undermining for meticulous closure):

1. Also for irregularly shaped lacerations requiring extensive debridement.

D7911	Complicated suture--Up to 5 cm.	138.00	138.00
D7912	Complicated suture--greater than 5	242.00	242.00
cm.
D7920	Skin graft (identify defect	70.50	70.50
covered, location and type of
graft)

(o) Other repair procedures:

D7940	Osteoplasty--For Orthognathic	225.00	191.00
Deformities
D7941	Osteotomy--Mandibular rami	726.00	726.00

NOTE: Unilateral.

D7943	Osteotomy--Mandibular rami with	1,058	1,058
bone graft; includes obtaining the
graft

NOTE: Unilateral.

D7944	Osteotomy--Segmented or	332.00	289.00
subapical--per sextant or quadrant
D7945	Osteotomy--body of mandible	332.00	289.00
D7946	LeFort I (maxilla--total)	546.00	546.00
*	D7947	LeFort I (maxilla--segmented)	365.00	365.00
D7948	LeFort II or LeFort III	1,095	1,095
(Osteoplasty of facial bones for
midface Hypoplasia or
retrusion)--without bone graft
D7949	LeFort II or LeFort III--with bone	1,427	1,427
graft
D7950	Osseous, osteoperiosteal, or	575.00	489.00
cartilage graft of the mandible or
facial bones--autogenous or
nonautogenous, by report
D7955	Repair of Maxillofacial Soft and	203.00	176.00
Hard Tissue Defects
D7960	Frenulectomy (Frenectomy or	60.00	56.00
Frenotomy)--Separate Procedure
D7970	Excision of hyperplastic	45.00	39.00
tissue--per arch
D7971	Excision of pericoronal gingiva	42.00	37.00
D7980	Sialolithotomy	48.00	42.00
D7981	Excision of Salivary Gland, by	182.00	158.00
report
D7982	Sialodochoplasty	151.00	131.00
D7983	Closure of Salivary Fistula	151.00	131.00
D7990	Emergency Tracheotomy	121.00	105.00
D7991	Coronoidectomy	362.00	308.00
*	D7995	Synthetic graft--mandible or	BR	BR
facial bones, by report
D7996	Implant--mandible for augmentation	BR	BR
purposes (excluding alveolar
ridge), by report
D7997	Appliance removal (not by dentist	151.00	151.00
who placed appliance), includes
removal of archbar
**	D7999	Unspecified Oral Surgery	BR	BR
Procedure, By Report

NOTE: Complete description of procedure and the reason the procedure was performed.

N.J. Admin. Code § 10:56-3.10

Public notice: Pursuant to the provisions of N.J.S.A. 30:4D-2, 3, 5, 6 and 7 and the New Jersey Appropriations Act (P.L. 1988, c.47), maximum fee allowance increased for (c) single tooth and (d) surgical removal of erupted tooth effective 8/1/1988.
See: 20 N.J.R. 2101(a).
Amended by R.1989 d.135, effective 3/20/1989.
See: 20 N.J.R. 2558(a), 21 N.J.R. 760(a).
Qualifier added to 07130, in (c); prior authorization requirement removed from 07210, in (d).
Administrative Corrections to (c), ( l)1 and (q).
See: 22 N.J.R. 1375(a).
Amended by R.1990 d.456, effective 9/4/1990.
See: 22 N.J.R. 1660(b), 22 N.J.R. 2713(a).
In (d): revised (d)1 to specify conditions for extraction, by incorporating text from old (d)2. Recodified (d)3 as (d)2 and added new (d)3. Deleted asterisks in List. In (f)1: added new "07310".
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.2000 d.426, effective 10/16/2000.
See: 32 N.J.R. 2411(a), 32 N.J.R. 3836(a).
Changed Maximum Fee Allowances throughout.
Amended by R.2001 d.268, effective 8/6/2001.
See: 33 N.J.R. 1554(a), 33 N.J.R. 2666(b).
In (g)1, inserted a reference to NJ FamilyCare.
Amended by R.2003 d.16, effective 1/6/2002.
See: 34 N.J.R. 2681(a), 35 N.J.R. 232(a).
Rewrote the section.
Amended by R.2004 d.25, effective 1/20/2004.
See: 35 N.J.R. 4032(a), 36 N.J.R. 568(a).
In (g)1, inserted reference to NJ FamilyCare.