N.J. Admin. Code § 10:56-3.2

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

Section 10:56-3.2 - D0100-D0999 DIAGNOSTIC

(a) Clinical Oral Examination:

				Maximum Fee
HCPCS	Allowance
IND	Code	Mod	Procedure Description	S	$	NS
D0150	Comprehensive oral evaluation	15.00	14.00

NOTE 1: This code is to be used for comprehensive clinical oral evaluation of a Medicaid/NJ FamilyCare fee-for-service beneficiary.

NOTE 2: This code requires a thorough observation of all conditions present in the oral cavity and contiguous structures to include:

a. An oral cancer screening;

b. Charting of all abnormalities;

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

NOTE 3: For reimbursement of the comprehensive oral evaluation with code D0150:

a. The examination is limited to once every six months for patients under 21 years of age and every 12 months for patients over 21 years of age, except as authorized by a dental consultant of the New Jersey Medicaid/NJ FamilyCare program;

b. All items on the Dental Services Claim form (MC-10) should be completed;

c. If no other treatment is necessary, this fact must be noted on the Dental Services Claim form (MC-10) in the diagnosis box (20). The abbreviation "NOTN" may be used to indicate no other treatment needed.

D0150

Comprehensive oral evaluation

14.00

13.00

NOTE 1: This code is to be used only if a beneficiary is developmentally disabled or neurologically impaired (see 10:56-2.9(a)1 ii), in which case an examination may be provided as often as every three months and may be submitted directly to the fiscal agent for payment without prior authorization. The nature of the beneficiary's disability must be recorded under "Remarks" on the Dental Services Claim form (MC-10).

D0150

Comprehensive oral evaluation

25.00

21.00

NOTE 1:

a.This code is to be used for comprehensive oral evaluation of a Medicaid/NJ FamilyCare fee-for-service beneficiary through and including the age of 20.

b. This code is to be used for comprehensive oral evaluation referred from EPSDT screenings.

NOTE 2: This code requires a thorough observation of all conditions present in the oral cavity and contiguous structures to include:

a. An oral cancer screening;

b. Assessment of dental development;

c. Charting of all abnormalities;

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

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

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

g. Assessment of systemic or topical fluoride needs.

NOTE 3: For reimbursement of the comprehensive oral evaluation with code D0150 EP:

a. The examination is limited to once every six months for patients under 21 years of age, except as authorized by a dental consultant of the New Jersey Medicaid/NJ FamilyCare program;

b. All items on the Dental Services Claim form (MC-10) should be completed;

D0120

Periodic Oral Evaluation

15.00

14.00

NOTE: An evaluation performed on a patient of record to determine any changes in the patient's oral health status since a previous initial or periodic examination.

D0120

Periodic Oral Evaluation

15.00

14.00

NOTE: This code is to be used with an EPSDT referral on a patient of record to determine any changes in the patient's oral health status since a previous initial or periodic examination.

D0140

Limited oral evaluation

4.00

3.00

NOTE: Make note of diagnosis and/or observation(s) on the Dental Services Claim form (MC-10).

D0160	Detailed and extensive oral	14.00	13.00
evaluation problem focused by
report.
D0170	Re-evaluation--limited, problem	14.00	13.00
focused (Established patient; not
post-operative visit)

(b) Radiographs:

1. Intraoral Radiographs: (Periapicals/Bitewing/Occlusal)

i. Indicate number of films in item 13 of the Dental Services Claim form (MC-10);

ii. For a complete series of radiographs, limitations pertaining to age are found in the first note below each code, and the maximum number of radiographs reimbursable as a single radiographic study every three years without prior authorization is found in the second note below each code.

				Maximum Fee
HCPCS	Allowance
IND	Code	Mod	Procedure Description	S	$	NS
D0210	52	Intraoral-Complete Series	18.00	18.00

NOTE 1: Limited to patients up to and including age six.

NOTE 2: Eight films.

D0210	Intraoral--Complete Series	22.00	22.00
(including bitewings)

NOTE 1: Limited to patients age seven up to and including age 14.

NOTE 2: Twelve films.

D0210	22	Intraoral--Complete Series	26.00	26.00
(including bitewings)

NOTE 1: Limited to patients age 15 or older.

NOTE 2: Minimum of 16 films.

D0220	Intraoral--Periapical--First Film	3.75	3.75
D0230	Intraoral--Periapical--Each	2.75	2.75
Additional Film

NOTE 1: Indicate complete number of films (D0220 Plus D0230) in item 13.

D0240

Intraoral--Occlusal Film

5.00

NOTE 1: Per film (maximum--two films).

NOTE 2: Indicate number of films in item 13.

2. Extraoral Radiographs

D0250

Extraoral, First Film

10.00

NOTE: Code to be used for lateral, anteroposterior, temporo-mandibular radiographs, etc. (one view).

D0260	Extraoral--	5.00	5.00
Each Additi
onal Film

NOTE 1: Indicate number of views in item 13.

NOTE 2: Maximum reimbursable--two additional views.

D0270	Bitewing--Single film	3.00	3.00
D0272	Bitewings--Two films	5.00	5.00
D0274	Bitewings--Four films	9.00	9.00
D0290	Posterior--anterior or lateral	10.00	10.00
skull and facial bone survey film
D0310	Sialography	15.00	15.00
D0310	22	Sialography	30.00	30.00

NOTE: Includes injection of contrast material (filling and/or emptying phases).

D0320	Temporomandibular joint	30.00	30.00
anthrogram, including injection
D0321	Other temporomandibular joint	BR	BR
films, by report
D0322	Tomographic survey	125.00	90.00
D0330	Panoramic Film	15.75	15.75
D0340	Cephalometric Film	15.00	15.00
D0340	22	Cephalometric Film	22.50	22.50

NOTE: Includes tracing.

(c) Test and laboratory examinations:

D0470

Diagnostic Casts

11.50

10.00

NOTE 1: Casts must have bases and be trimmed to permit articulation, per cast.

NOTE 2: Code not to be used in conjunction with denture construction.

D0472	Accession of tissue, gross	9.35	9.35
examination, preparation and
transmission of written report
D0473	Accession of tissue, gross and	20.85	20.85
microscopic examination,
preparation and transmission of
written report
D0474	Accession of tissue, gross and	40.00	40.00
microscopic examination, including
assessment of surgical margins for
presence of disease, preparation
and transmission of written report
D0480	Processing and interpretation of	12.00	12.00
cytologic smears, including the
preparation and transmission of
written report
D0350	Oral/facial images (includes intra	1.00	1.00
and extraoral images)

NOTE: Or slides, per view.

D0501

Histopathologic Examination

10.00

NOTE 1: The gross and microscopic examination of oral tissues, both hard and soft.

NOTE 2: Limited to specialists in oral pathology, and Oral Diagnosis (Pathology) Departments of dental schools.

D0502	Other oral pathology procedures,	BR	BR
by report
d*	D0999	Unspecified Diagnostic Procedure,	BR	BR
By Report

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

N.J. Admin. Code § 10:56-3.2

Administrative Correction to (f)1iv.
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): added new (d)1iv.
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).
In (g), deleted references to Denture Identification, Identification and Scaling (Additional to Prophy).
Amended by R.2001 d.268, effective 8/6/2001.
See: 33 N.J.R. 1554(a), 33 N.J.R. 2666(b).
Rewrote (d)4 and (d)6; in (f), rewrote the introductory paragraph, inserted a reference to NJ FamilyCare in 2, and inserted a reference to NJ FamilyCare fee-for-service in 6.
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 (a), inserted a reference to NJ FamilyCare and substituted "Centers for Medicare and Medicaid Services (CMS) Healthcare" for "Health Care Financing Administration's (HCFA)" in the first sentence; in (f), inserted a reference to NJ FamilyCare and substituted "N.J.A.C. 10:56-1 and/or 2" for "subchapter 1 and/or 2" 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).
Rewrote (a).