N.J. Admin. Code § 10:56-3.12
| Maximum Fee | ||||||
| HCPCS | Allowance | |||||
| IND | Code | Mod | Procedure Description | S | $ | NS |
| d | D9110 | Palliative (Emergency) Treatment | 10.00 | 9.00 | ||
| of Dental Pain--Minor Procedures | ||||||
NOTE: Emergency treatment of dental pain or infection, palliative (flat fee for all services performed, when not covered by separately listed procedure). Diagnosis and description of treatment is required. Per tooth or per site.
| D9210 | Local Anesthesia Not in | 13.00 | 11.00 |
| Conjunction with Operative or | |||
| Surgical Procedures |
NOTE 1: Infiltration and/or nerve block for diagnostic purposes or purposes other than anesthesia.
NOTE 2: Complete report must be available in patient records.
| D9211 | Regional block anesthesia | 13.00 | 11.00 | |
| D9212 | Trigeminal division block | 18.00 | 16.00 | |
| anesthesia | ||||
| D9220 | 22 | General Anesthesia | 125.00 | 125.00 |
NOTE: This code applies when the dentist performing the services (attending dentist) also administers the general anesthesia or in conjunction with oral surgery services only.
| D9220 | General anesthesia--first 30 | 22.00 | 22.00 |
| minutes | |||
| D9221 | General anesthesia--each | 11.00 | 11.00 |
| additional 15 minutes |
NOTE 1: Time units are for each additional 15 minute period or major portion thereof limited to "table" or "chair" time only. Maximum reimbursable is two hours.
NOTE 2: The general anesthesia codes above are limited to use in restorative dentistry alone or restorative dentistry in conjunction with other dental services requiring anesthetic management. These codes are reimbursable only to the dentist whose sole function is to administer general anesthesia.
NOTE 3: An anesthesia record must be available which shows elapsed anesthesia time, and pinpoints time and amounts of drugs administered, pulse rate and character, blood pressure, respiration, and so forth.
| D9230 | Analgesia, anxiolysis, inhalation | 15.00 | 14.00 |
| of nitrous oxide | |||
| D9241 | Intravenous sedation/ | 50.00 | 49.00 |
| analgesia--first 30 minutes |
NOTE: Parenteral Conscious Sedation.
| D9242 | Intravenous sedation/ | 11.00 | 11.00 |
| analgesia--each additional 15 | |||
| minutes |
NOTE: Maximum reimbursable is eight units.
| D9248 | Non-intravenous conscious sedation | 40.00 | 40.00 |
| d | D9310 | Consultation (diagnostic service | 22.00 | 17.00 |
| provided by dentist or physician | ||||
| other than practitioner providing | ||||
| treatment) |
| D9410 | House/extended care facility call | 20.50 | 19.00 |
| D9420 | Hospital Call | 32.00 | 27.00 |
NOTE: Code to be used for Hospital Day--Initial--Inpatient or Same Day Surgery.
| D9420 | Hospital Call | 19.00 | 17.00 |
NOTE 1: Code to be used for Hospital Day--Subsequent.
NOTE 2: Consisting of care and treatment by the Practitioner subsequent to date of "Hospital Day--Initial" and including those procedures ordinarily performed during a hospital visit dependent upon the practitioner's discipline.
NOTE 3: Not reimbursable for those services that include follow-up days.
| D9430 | Office Visit for Observation | 9.00 | 7.00 |
| (During Regularly Scheduled | |||
| Hours)--No Other Services Performed |
NOTE: Code may also be used when post-operative services are necessary following a major surgical procedure (for example, bony impactions, fractures, etc.)
| D9610 | Therapeutic Drug Injection | 2.50 | 2.50 | |
| D9610 | 22 | Therapeutic Drug Injection | 13.00 | 11.00 |
NOTE: Injection of one or more muscles of mastication in conjunction with treatment of T.M.J. dysfunction.
| d* | D9630 | Other Drugs and/or Medicaments, By | BR | BR |
| Report |
| D9910 | Application of Desensitizing | 6.00 | 5.00 |
| Medicaments |
NOTE 1: Application to tooth/teeth for cervical sensitivity, erosions, etc.
NOTE 2: This code is not to be used for bases, liners or adhesives under restorations.
NOTE 3: Per visit.
| D9911 | Application of desensitizing resin | 35.50 | 33.00 |
| for cervical and/or root surface, | |||
| per tooth |
NOTE 1: This code is not to be used for bases, liners or adhesives under restorations.
NOTE 2: Specify tooth code(s).
| D9920 | Behavior Management | 15.00 | 13.00 |
NOTE 1: Code to be used for those beneficiaries with developmental and other disabilities whose disorders necessitated an excessive amount of time to accomplish treatment (for example, mental retardation, neurological disorders, etc.). For use of this code, the dentist shall specify the beneficiary's disability which necessitates the use of this code on the MC-10A, Request for Prior Authorization, under Section 20, Remarks where services exceed the thresholds listed in note 2 below.
NOTE 2: Payment will be based on place of service and utilization thresholds in units (one unit equals 15 minutes) as follows:
| Place of Service | Utilization Threshold |
| Office or Clinic | 2 |
| Inpatient/Outpatient Hospital | 4 |
| Skilled Nursing Facility | 2 |
NOTE 3: The type of disorder and the number of time units requested must be entered on the Dental Services Claim form (MC-10).
NOTE 4: Prior authorization is required for all occurrences of this code that exceed the thresholds.
NOTE 5: Code to be used in addition to other procedures performed.
| D9930 | Treatment of Complications (Post | 9.00 | 8.00 |
| Surgical)--Unusual Circumstances |
NOTE: This code may also be used for post-operative treatment beyond that normally provided as part of the basic procedure or when provided by practitioner other than one who provided the original service or in excess of "follow-up days." (California Relative Value Study--1964), per visit.
| D9940 | Occlusal Guards | 50.00 | 45.00 |
NOTE 1: Special periodontal appliance (including occlusal guards and athletic mouth guards).
NOTE 2: Office procedure.
| D9940 | 22 | Occlusal Guards | 65.00 | 58.00 |
NOTE 1: Special periodontal appliance (including occlusal guards and athletic mouth guards).
NOTE 2: Laboratory procedure.
| D9951 | Occlusal Adjustment--Limited | 6.00 | 5.00 |
NOTE: One to three teeth.
| D9952 | 22 | Occlusal Adjustment--Complete | 68.00 | 60.00 |
| D9971 | Odontoplasty 1-2 teeth; includes | 6.00 | 5.00 | |
| removal of enamel projections | ||||
| D9974 | Internal bleaching--per tooth | 33.00 | 33.00 | |
| d** | D9999 | Unspecified Adjunctive Procedure, | BR | BR |
| By Report |
NOTE: To be used only when no code number exists or existing code is not precisely applicable. Complete description of condition and proposed treatment must be submitted to the Medicaid dental consultant.
N.J. Admin. Code § 10:56-3.12
See: 13 N.J.R. 413(a), 13 N.J.R. 575(a).
Delete text of (e)22 and substitute new text therefor.
As amended, R.1983 d.584, effective 1/1/1984.
See: 15 N.J.R. 1160(a), 15 N.J.R. 2170(a).
Further requirements for reimbursement added.
Amended by R.1986 d.385, effective 9/22/1986.
See: 18 N.J.R. 1337(a), 18 N.J.R. 1958(a).
Substantially amended.
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 at (b) Adjunctive general services effective 8/1/1988.
See: 20 N.J.R. 2101(a).
Administrative Correction to (c).
See: 20 N.J.R. 1375(a).
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.1998 d.353, effective 7/20/1998.
See: 30 N.J.R. 514(a), 30 N.J.R. 2654(a).
In (g), rewrote NOTE 1 and NOTE 4.
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.10, effective 1/2/2001.
See: 32 N.J.R. 3377(a), 33 N.J.R. 65(a).
In (c)1, substituted "Society" for "College" following "American", and substituted "2000" for "1967" following "Guide--".
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.2003 d.132, effective 3/17/2003.
See: 34 N.J.R. 3921(a), 35 N.J.R. 1424(a).
Rewrote (g).