INDIANA HEALTH COVERAGE PROGRAMS

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1 INDIANA HEALTH COVERAGE PROGRAMS PROVIDER CODE TABLES Note: Due to possible changes in Indiana Health Coverage Programs (IHCP) policy or national coding updates, inclusion of a code on the code tables does not necessarily indicate current coverage. See IHCP Banner Pages and Bulletins and the IHCP Fee Schedule for updates to coding, coverage, and benefit information. Previous versions of code tables are archived for purposes of historical reference. For information about using these code tables, see the Dental Services provider reference module. Table 1 Dental s Allowed for Package E Members Table 3 Dental Codes with Age Restrictions Table 1 Dental s Allowed for Package E Members D0140 D0210 D0220 D0230 D0240 D0251 D0270 D0272 D0273 D0274 D0277 D0330 D7111 D7140 D7210 Limited oral evaluation problem focused Intraoral complete series of radiographic images Intraoral periapical first radiographic image Intraoral periapical each additional radiographic image Intraoral occlusal radiographic image Extra-oral posterior dental radiographic image Bitewing single radiographic image Bitewings two radiographic images Bitewings three radiographic images Bitewings four radiographic images Vertical bitewings 7 to 8 radiographic images Panoramic radiographic image Extraction, coronal remnants deciduous tooth Extraction, erupted tooth or exposed root (elevation and/or forceps removal) Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated Published: September 12,

2 Table 1 Dental s Allowed for Package E Members D7220 D7230 D7240 D7241 D7250 D7251 D7260 D7261 D7270 D7280 D7282 D7285 D7286 D7288 D7510 D7511 D7520 D7521 D7560 D7610 D7620 D7630 D7640 D7650 D7660 D7670 D7671 D7680 D7710 D7720 D7730 D7740 D7750 D7760 D7770 Removal of impacted tooth soft tissue Removal of impacted tooth partially bony Removal of impacted tooth completely bony Removal of impacted tooth completely bony, with unusual surgical complications Removal of residual tooth roots (cutting procedure) Coronectomy intentional partial tooth removal Oroantral fistula closure Primary closure of a sinus perforation Tooth re-implantation and/or stabilization of accidentally evulsed or displaced tooth Exposure of unerupted tooth Mobilization of erupted or malpositioned tooth to aid eruption Incisional biopsy of oral tissue hard (bone, tooth) Incisional biopsy of oral tissue soft Brush biopsy transepithelial sample collection Incision and drainage of abscess intraoral soft tissue Incision and drainage of abscess intraoral soft tissue complicated (includes drainage of multiple fascial spaces) Incision and drainage of abscess extraoral soft tissue Incision and drainage of abscess extraoral soft tissue complicated (includes drainage of multiple fascial spaces) Maxillary sinusotomy for removal of tooth fragment or foreign body Treatment of closed fractures; maxilla open reduction (teeth immobilized, if present) Treatment of closed fractures; maxilla closed reduction (teeth immobilized, if present) Treatment of closed fractures; mandible open reduction (teeth immobilized, if present) Treatment of closed fractures; mandible closed reduction (teeth immobilized, if present) Treatment of closed fractures; malar and/or zygomatic arch open reduction Treatment of closed fractures; malar and/or zygomatic arch closed reduction Treatment of closed fractures; alveolus closed reduction, may include stabilization of teeth Treatment of closed fractures; alveolus open reduction, may include stabilization of teeth Treatment of closed fractures; facial bones complicated reduction with fixation and multiple surgical approaches Treatment of open fractures; maxilla open reduction Treatment of open fractures; maxilla closed reduction Treatment of open fractures; mandible open reduction Treatment of open fractures; mandible closed reduction Treatment of open fractures; malar and/or zygomatic arch open reduction Treatment of open fractures; malar and/or zygomatic arch closed reduction Treatment of open fractures; alveolus open reduction stabilization of teeth Published: September 12,

3 Table 1 Dental s Allowed for Package E Members D7771 D7780 D7910 D7911 D7912 D7999 D9223 * D9230 ** D9243 *** D9248 D9920 Treatment of open fractures; alveolus closed reduction stabilization of teeth Treatment of open fractures; facial bones complicated reduction with fixation and multiple surgical approaches Suture of recent small wound up to 5 cm Complicated suture up to 5 cm Complicated suture greater than 5 cm Unspecified oral surgery procedure, by report Deep sedation/general anesthesia each 15 minute increment Inhalation of nitrous oxide/analgesia, anxiolysis Intravenous moderate (conscious) sedation/analgesia each 15 minute increment Non-intravenous conscious sedation Behavior management, by report * Covered only if medically necessary. Only covered in the office setting for members less than 21 years of age. Only covered for members 21 years of age and older in the hospital (inpatient or outpatient) or ASC setting. When performed in a hospital or ASC setting, providers may not bill the CDT procedure code. Instead the appropriate CPT/HCPCS code must be billed on the CMS-1500 claim form. ** Covered only for members 20 years of age and younger and limited to 1 unit per visit. *** Covered for oral surgical procedures only. Reviewed/Updated: September 8, 2017 D0220 D0230 D1351 D1352 D1354 D1510 D1550 D1555 D1575 D2140 D2150 D2160 D2161 D2330 Intraoral periapical first radiographic image Intraoral periapical each additional radiographic image Sealant per tooth Preventive resin restoration in a moderate to high caries risk patient - permanent tooth Interim caries arresting medicament application Space maintainer fixed, unilateral Re-cement or re-bond space maintainer Removal of fixed space maintainer Distal shoe space maintainer fixed unilateral Amalgam one surface, primary or permanent Amalgam two surfaces, primary or permanent Amalgam three surfaces, primary or permanent Amalgam four or more surfaces, primary or permanent Resin one surface anterior Published: September 12,

4 Reviewed/Updated: September 8, 2017 D2331 D2332 D2335 D2390 D2391 D2392 D2393 D2394 D2910 D2920 D2921 D2930 D2931 D2932 D2933 D2934 D2980 D3220 D3222 D3230 D3240 D3310 D3320 D3330 D3346 D3347 D3348 D3351 D3352 D3353 D3410 D3421 D3425 D3426 Resin two surfaces anterior Resin three surfaces anterior Resin-four or more surfaces or involving incisal angle (anterior) Resin-based composite crown, anterior Resin-based composite one surface, posterior Resin-based composite two surfaces, posterior Resin-based composite three surfaces, posterior Resin-based composite four or more surfaces, posterior Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration Re-cement or re-bond crown Reattachment of tooth fragment, incisal edge or cusp Prefabricated stainless steel crown primary tooth Prefabricated stainless steel crown permanent tooth Prefabricated resin crown Prefabricated stainless steel crown with resin window Prefabricated esthetic coated stainless steel crown primary tooth Crown repair necessitated by restorative material failure Therapeutic pulpotomy (excluding final restoration) removal of pulp coronal to the dentinocemental junction and application of medicament Partial pulpotomy for apexogenesis permanent tooth with incomplete root development Pulpal therapy (resorbable filling) anterior, primary tooth (excluding final restoration) Pulpal therapy (resorbable filling) posterior, primary tooth (excluding final restoration) Endodontic therapy, anterior tooth (excluding final restoration) Endodontic therapy, bicuspid tooth (excluding final restoration) Endodontic therapy, molar (excluding final restoration) Retreatment of previous root canal therapy anterior Retreatment of previous root canal therapy bicuspid Retreatment of previous root canal therapy molar Apexification/recalcification initial visit (apical closure/calcific repair of perforations, root resorption, etc.) Apexification/recalcification interim medication replacement (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) Apexification-recalcification final visit (includes completed root canal therapy-apical closure/calcific repair of perforations, root resorption, etc.) Apicoectomy anterior Apicoectomy bicuspid (first root) Apicoectomy molar (first root) Apicoectomy (each additional root) Published: September 12,

5 D3427 D3430 D4212 D5520 D5640 D5650 D5660 D6081 D7111 D7140 D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7270 D7280 D7282 D7510 Reviewed/Updated: September 8, 2017 Periradicular surgery without apicoectomy Retrograde filling per root Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth Replace missing or broken teeth complete denture (each tooth) Replace broken teeth per tooth Add tooth to existing partial denture Add clasp to existing partial denture per tooth Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure Extraction, coronal remnants deciduous tooth Extraction, erupted tooth or exposed root (elevation and/or forceps removal) Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated Removal of impacted tooth-soft tissue Removal of impacted tooth partially bony Removal of impacted tooth completely bony Removal of impacted tooth completely bony, with unusual surgical complications Removal of residual tooth roots (cutting procedure) Coronectomy intentional partial tooth removal Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth Exposure of an unerupted tooth Mobilize of erupted or malpositioned tooth to aid eruption Incision and drainage of abscess intraoral soft tissue Table Revision History September 8, 2017, update: Removed (effective July 20, 2017): D1515, D7285, D7286 Added (effective September 8, 2017): D1575 Published: September 12,

6 Procedure Code D0145 Table 3 Dental Codes with Age Restrictions Oral evaluation for a patient under three years of age and counseling with primary caregiver Age Restriction (Years) D1110 Prophylaxis adult 12 and older D1120 Prophylaxis child 1 11 D1206 Topical application of fluoride varnish 1 20 D1208 Topical application of fluoride excluding varnish 0 20 D1351 Sealant per tooth 0 20 D1352 Preventive resin restoration in a moderate to high caries risk patient permanent tooth D1354 Interim caries arresting medicament application 0 20 D1510 Space maintainer fixed, unilateral 1 20 D1515 Space maintainer fixed, bilateral 1 20 D1520 Space maintainer removable, unilateral 1 20 D1525 Space maintainer removable, bilateral 1 20 D1550 Re-cement or re-bond space maintainer 1 20 D1575 Distal shoe space maintainer fixed, unilateral 0-20 D2932 Prefabricated resin crown 1 20 D2933 Prefabricated stainless steel crown with resin window 1 20 D3310 Endodontic therapy, anterior tooth (excluding final restoration) 1 20 D3320 Endodontic therapy, bicuspid tooth (excluding final restoration) 1 20 D3330 Endodontic therapy, molar (excluding final restoration) 1 20 D3346 Retreatment of previous root canal therapy - anterior 1 20 D3347 Retreatment of previous root canal therapy bicuspid 1 20 D3348 Retreatment of previous root canal therapy-molar 1 20 D3351 Apexification/recalcification initial visit (apical closure/calcific repair of perforations, root resorption, etc.) D3352 Apexification/recalcification interim medication replacement (apical 1 20 closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) D3353 Apexification/recalcification final visit (includes completed root canal 1 20 therapy - apical closure/calcific repair of perforations, root resorption, etc.) D3410 Apicoectomy anterior 1 20 D3421 Apicoectomy bicuspid (first root) 1 20 D3425 Apicoectomy molar (first root) 1 20 D3426 Apicoectomy (each additional root) 1 20 D3427 Periradicular surgery without apicoectomy 1 20 D3430 Retrograde filling per root 1 20 D4910 Periodontal maintenance 3 and older Published: September 12,

7 Procedure Code Table 3 Dental Codes with Age Restrictions Age Restriction (Years) D5130 Immediate denture maxillary 21 and older D5140 Immediate denture mandibular 21 and older D5730 Reline complete maxillary denture (chairside) 1 and older D5731 Reline complete mandibular denture (chairside) 1 and older D5740 Reline maxillary partial denture (chairside) 1 and older D5741 Reline mandibular partial denture (chairside) 1 and older D5951 Feeding aid 0 20 D5952 Speech aid prosthesis, pediatric 0 18 D5993 Maintenance and cleaning of a maxillofacial prosthesis (extra- or intra-oral) other than required adjustments, by report D6930 Re-cement or re-bond fixed partial denture 1 20 D6980 Fixed partial denture repair necessitated by restorative material failure 1 20 D8010 Limited orthodontic treatment of the primary dentition 1 20 D8020 Limited orthodontic treatment of the transitional dentition 1 20 D8030 Limited orthodontic treatment of the adolescent dentition 1 20 D8040 Limited orthodontic treatment of the adult dentition 1 20 D8050 Interceptive orthodontic treatment of the primary dentition 1 20 D8060 Interceptive orthodontic treatment of the transitional dentition 1 20 D8070 Comprehensive orthodontic treatment of the transitional dentition 1 20 D8080 Comprehensive orthodontic treatment of the adolescent dentition 1 20 D8090 Comprehensive orthodontic treatment of the adult dentition 1 20 D8210 Removable appliance therapy 1 20 D9223 Deep sedation/general anesthesia each 15 minute increment 0 20 D9230 Inhalation of nitrous oxide/analgesia, anxiolysis 0 20 D9248 Non-intravenous conscious sedation 0 20 D9920 Behavior management, by report 1 20 April 1, 2017, update: Added (effective January 1, 2017): D1575 September 16, 2016, update: Removed (effective September 16, 2016): D5281 Table Revision History 0 20 Published: September 12,

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