Or. Admin. Code § 410-123-1620

Current through Register Vol. 63, No. 11, November 1, 2024

Section 410-123-1620 - Procedure and Diagnosis Codes

(1) The Division 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). Unless otherwise directed in rule, providers shall accurately code claims according to the national standards in effect for the date the service(s) was provided.

(2) 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. Contact the American Dental Association (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. Such procedures are covered under the Division's medical surgical program found in Oregon Administrative Rule (OAR) 410-130-0000.

(3) 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;

(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 the Medical-Surgical administrative rules for additional information, OAR 410 division 130.

(4) Ancillary codes:

(a) Ancillary codes for hospitalization, medication and deep sedation are provided for conditions appearing above the funding line of the Prioritized List of Health Services, and subject to The List's ancillary guideline notes when applicable. Ancillary codes must be dentally or medically appropriate and part of the care for a funded condition on The List. Some ancillary codes are not eligible for separate payment. See OAR 410-123-1200 for more detail on codes not to be billed separately.

(b) Approved ancillary codes for all members include D7990, D9211, D9212, D9220, D9221, D9222, D9239, D9310, and D9997.

(c) D9248 is covered for members under age 21 and limited to four times per year for members under 13 years of age. Includes payment for monitoring and Nitrous Oxide. Requires use of multiple agents to receive payment.

(d) D9410 is covered for all members and shall be only used 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

Statutory/Other Authority: ORS 413.042 & 414.065

Statutes/Other Implemented: ORS 414.065