CSHCN 2008 > Dental > Benefits and Limitations

13.3.1.3 Reimbursement

Clinical Oral Evaluations

The following clinical oral evaluations procedure codes may be considered for reimbursement:

Procedure code D0140 is denied when billed on the same date of service, for the same provider as procedure code D0160, detailed and extensive oral evaluation problem focused, by report.

Procedure code D0170 will be denied when billed on the same date of service, for the same provider as D0140.

Procedure code D0170 will be denied when billed on the same day as procedure code D0160.

Radiographs or Diagnostic Imaging

The following radiographs or diagnostic imaging procedure codes may be considered for reimbursement:

Procedure codes D0220, D0240, D0250, and D0270 are limited to one per day by the same provider.

Procedure codes D0340, D0350, and D0470 are denied when billed with procedure code D8050 or D8080, which are considered inclusive procedures.

The number of radiograph films required for a complete intraoral series is dependent on the age of the client. An intraoral series requires at least eight films. Adults and children over 12 years of age require 12-20 films to be considered an intraoral series. A panoramic film (procedure code D0330) plus a minimum of four bitewing films (procedure code D0274) may be considered equivalent to a complete intraoral series including bitewings (procedure code D0210).

Tests and Oral Pathology Procedures

The following procedure codes may be considered for reimbursement and are limited to clients 1 year of age and older:

Procedure code D0460 includes multiple teeth and contralateral comparisons based on medical necessity. Procedure code D0460 is considered part of any endodontic procedure and is not separately reimbursed when billed on the same date of service as any endodontic procedure.

Refer to: Section 13.3.4, "Therapeutic Procedures," on page 13-12 for additional information about endodontic procedures.

When billing for diagnostic procedures not adequately described by other procedure codes, providers should use procedure code D0999. Only one emergency or trauma claim per client, per day may be submitted. Separate services may be submitted for the same client on the same date of service, one for emergency or trauma and one for nonemergency or routine care.

When billing electronically for emergency or trauma-related dental services, use the ET modifier indicating emergency.