Current through Register Vol. 64, No. 1, January 1, 2025
Section 410-123-1620 - Pertaining to Coding(1) The Authority requires providers to use the standardized code sets adopted by the Health Insurance Portability and Accountability Act (HIPAA) and the Centers for Medicare and Medicaid Services (CMS).(2) Unless otherwise directed in rule, providers must accurately code claims according to the national standards in effect for the date the service(s) was provided.(3) Procedure codes: (a) For dental services, and procedures that are directly related to the teeth and the structures supporting the teeth, use Current Dental Terminology (CDT) codes as maintained and distributed by the American Dental Association (ADA). Contact the ADA to obtain a current copy of the CDT reference manual;(b) For physician provided oral health services performed due to an underlying medical condition (i.e., procedures on or in preparation for treatment of the jaw, tongue, cheek, roof of mouth), use Health Care Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes; and(c) Such procedures are covered under the Authority's medical surgical program (refer to Chapter 410, Division 130).(4) Diagnosis codes:(a) International Classification of Diseases 10th Clinical Modification (ICD-10-CM) diagnosis codes are not required for dental services submitted on an ADA claim form; and(b) When OAR 410-123-1260 requires services to be billed on a professional claim form, ICD-10-CM diagnosis codes are required (refer to Chapter 410, Division 130).(5) Ancillary codes: (a) Medication and deep sedation are provided for hospitalization, for conditions appearing above the funding line of the Prioritized List, and subject to the Prioritized List's ancillary guideline notes.(b) Must be medically necessary and dentally appropriate. Some ancillary codes are not eligible for separate payment (Refer to OAR 410-123-1260 for more detail on codes not to be billed separately).(c) Approved ancillary codes (subject to OAR 410-123-1260) for all members are as follows: (A) D7990- Emergency Tracheotomy;(B) D9211 - Regional block anesthesia;(C) D9212 - Trigeminal division block anesthesia;(D) D9220 - Deep sedation/general anesthesia, first 30 minutes;(E) D9221 - Deep sedation/general anesthesia, each additional 15 minutes;(F) D9222 - Deep sedation/general anesthesia, first 15 minutes;(G) D9239 - Intravenous moderate (conscious) sedation/analgesia, first 15 minutes;(H) D9310 - Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician; and(I) D9997 - Dental case management, patients with special health care needs.(d) D9248 - (non-intravenous conscious sedation) is covered for EPSDT beneficiaries as follows: (A) Limited to four (4) times per year for members age 13 and younger;(B) Includes payment for monitoring and Nitrous Oxide; and(C) Requires use of multiple agents to receive payment.(e) D9410 - (House/extended care facility call) is covered only for urgent or emergent dental visits that occur outside of a dental office. This code is not reimbursable for provision of preventive services or for services provided outside of the office for the provider or facilities' convenience.Or. Admin. Code § 410-123-1620
OMAP 23-1999, f. & cert. ef. 4-30-99; OMAP 17-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 48-2002, f. & cert. ef. 10-1-02; OMAP 65-2003, f. 9-10-03 cert. ef. 10-1-03; DMAP 25-2007, f. 12-11-07, cert, ef. 1-1-08; DMAP 38-2008, f. 12-11-08, cert. ef. 1-1-09; DMAP 16-2009 f. 6-12-09, cert. ef. 7-1-09; DMAP 13-2013, f. 3-27-13, cert. ef. 4-1-13; DMAP 51-2015, f. 9-22-15, cert. ef. 10/1/2015; DMAP 50-2021, amend filed 12/24/2021, effective 1/1/2022; DMAP 70-2024, minor correction filed 02/22/2024, effective 2/22/2024; DMAP 139-2024, amend filed 12/06/2024, effective 1/1/2025Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065