N.J. Admin. Code § 10:56-3.7

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

Section 10:56-3.7 - D5000-D5899 PROSTHODONTICS (REMOVABLE)

(a) Complete dentures (including six months post delivery care):

				Maximum Fee
HCPCS	Allowance
IND	Code	Mod	Procedure Description	S	$	NS
*	D5110	Complete Denture--Maxillary	334.00	302.00

NOTE: Including denture I.D.

D5120

Complete Denture--Mandibular

342.00

311.00

NOTE: Including denture I.D.

(b) Immediate complete dentures (six months post delivery care and placement of ID is included in fee):

1. Reimbursement also includes necessary rebases and/or relines for the six months following insertion.

2. In order to qualify for immediate denture reimbursement, the denture must involve the immediate replacement of anterior teeth which may include first premolars (teeth numbers 5 through 12 and 21 through 28 only). Second premolars and molars must not be included among the qualifying teeth. The date of insertion of a denture and the extractions must carry an identical date of service. List tooth code(s) of teeth involved.

D5130

Immediate Denture--Maxillary

365.00

332.00

NOTE 1: Replacing 1 through 4 teeth

D5130

Immediate Denture--Maxillary

392.00

353.00

NOTE 1: Replacing 5 through 8 teeth

D5140

Immediate Denture--Mandibular

372.00

338.00

NOTE 1: Replacing 1 through 4 teeth

D5140

Immediate Denture--Mandibular

400.00

363.00

NOTE 1: Replacing 5 through 8 teeth

(c) Partial dentures (including six month post delivery care):

*	D5211	Maxillary Partial Denture--Resin	275.00	250.00
Base (Including any conventional
clasps, rests and teeth)
*	D5211	52	Maxillary Partial Denture--Resin	186.00	173.00
Base (Including teeth--no clasps)
*	D5212	Mandibular Partial Denture--Resin	275.00	250.00
Base (Including any conventional
clasps, rests and teeth)
*	D5212	52	Mandibular Partial Denture--Resin	186.00	173.00
Base (Including teeth--no clasps)
*	D5213	Maxillary Partial Denture--Cast	361.00	328.00
Metal Framework with Resin Denture
Bases (Including any conventional
clasps, rests and teeth)
*	D5214	Mandibular Partial Denture--Cast	342.00	311.00
Metal Framework with Resin Denture
Bases (Including any conventional
clasps, rests and teeth)

(d) Immediate replacement of anterior teeth in conjunction with partial dentures (codes D5211 through D5214 only) in addition to denture, maximum six teeth (Teeth numbers 6 through 11 and 22 through 27 only).

1. Immediate partial dentures--Reimbursement also includes necessary rebases and/or relines for the six months following insertion.

*	Y2505	Immediate Replacement of Anterior	11.00	10.00
Teeth--Per Tooth

NOTE: List tooth code(s) of tooth being replaced.

(e) Adjustments to dentures--other than dentist providing denture or after the required period of post delivery care.

D5410	Adjust Complete Denture--Maxillary	10.00	9.00
D5411	Adjust Complete Denture--Mandibular	10.00	9.00
D5421	Adjust Partial Denture--Maxillary	10.00	9.00
D5422	Adjust Partial Denture--Mandibular	10.00	9.00

(f) Repairs to complete dentures:

1. Repair Broken Complete Denture Base:

i. Includes replacing teeth on denture

D5510

Repair Broken Complete Denture Base

49.50

45.00

NOTE: Maxillary--Upper

D5510

Repair Broken Complete Denture Base

49.50

45.00

NOTE: Mandibular--Lower.

D5520	Replace Missing or Broken	15.00	15.00
Teeth--Complete Denture (Each
Tooth)

NOTE 1: Code may be used in addition to codes D5510 YU or YL above.

NOTE 2: List tooth codes of teeth being replaced.

(g) Repairs to partial denture:

D5610

Repair Resin Denture Base

49.50

45.00

NOTE: Maxillary.

D5610

Repair Resin Denture Base

49.50

45.00

NOTE: Mandibular.

D5620

Repair Cast Framework

33.00

30.00

NOTE 1: Welding in addition to repair procedure(s), limit two welds per denture.

NOTE 2: May be used in conjunction with other repair procedures or as a separate repair procedure.

D5630

Repair or Replace Broken Clasp

76.50

72.00

NOTE 1: Maxillary.

NOTE 2: Maximum two.

D5630

Repair or Replace Broken Clasp

76.50

72.00

NOTE 1: Mandibular.

NOTE 2: Maximum two.

D5640

Replace Broken Teeth--Per Tooth

15.00

NOTE 1: Code D5640 may be used in addition to partial denture repair procedure(s), D5610 YU or YL above.

D5650	Add Tooth to Existing Partial	66.00	60.00
Denture

NOTE 1: To replace extracted tooth. (List tooth code being replaced).

NOTE 2: For additional replacements beyond the first tooth, use code D5640. List tooth (teeth) being replaced.

D5660	YU	Add Clasp to Existing Partial	76.50	72.00
Denture

NOTE 1: Maxillary--First Clasp.

NOTE 2: List tooth code being clasped.

NOTE 3: Maximum two.

D5660	YL	Add Clasp to Existing Partial	76.50	72.00
Denture

NOTE 1: Mandibular--First Clasp.

NOTE 2: List tooth being clasped.

NOTE 3: Maximum two.

(h) Denture rebase procedures:

D5710	Rebase Complete Maxillary Denture	132.00	120.00
D5711	Rebase Complete Mandibular Denture	132.00	120.00
D5720	Rebase Maxillary Partial Denture	124.00	113.00
D5721	Rebase Mandibular Partial Denture	124.00	113.00

(i) Denture relining procedures:

D5730	Reline Complete Maxillary Denture	29.00	26.00
(Chairside)
D5731	Reline Complete Mandibular Denture	29.00	26.00
(Chairside)
D5740	Reline Maxillary Partial Denture	29.00	26.00
(Chairside)
D5741	Reline Mandibular Partial Denture	29.00	26.00
(Chairside)
D5750	Reline Complete Maxillary Denture	99.00	90.00
(Laboratory)
D5751	Reline Complete Mandibular Denture	99.00	90.00
(Laboratory)
D5760	Reline Maxillary Partial Denture	91.00	83.00
(Laboratory)
D5761	Reline Mandibular Partial Denture	91.00	83.00
(Laboratory)

(j) Other removable prosthetic services:

D5860	Overdenture--complete	342.00	311.00
D5862	Precision attachment	150.00	150.00
D5867	Replacement of replaceable part of	75.00	75.00
semi-precision or precision
attachment (male or female
component)
*	D5899	Unspecified Removable	BR	BR
Prosthodontic Procedure, By Report

N.J. Admin. Code § 10:56-3.7

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 allowances increased at (i), (j) and (k) effective 10/1/1988, January 1, 1989 and April 1, 1989.
See: 20 N.J.R. 2101(a).
Administrative Correction: In (k) 05212 effective 4/1/1989 corrected 140.00 to 165.00.
As amended by R.1989 d.135.
See: 20 N.J.R. 2558(a), 21 N.J.R. 760(a).
(k)1 deleted and NOTE changed to "a minimum of 2 cast chrome casts with rests".
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.2003 d.16, effective 1/6/2002.
See: 34 N.J.R. 2681(a), 35 N.J.R. 232(a).
Rewrote the section.