HSCSN Table Top Reference Guide

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1 Age Limitation Covered One per 6 months per dentist or dental group. Only one exam (D0120) every 6 months per dentist or dental D0120 iodic oral evaluation 0-20 No group. D0140 Limited oral evaluation 0-20 No Not reimbursable on the same day as D0120, D0150 or D0160 One comprehensive exam per patient per dentist or dental group per 12 months. Only one exam (D0120) every 6 months per dentist or D0150 Comprehensive oral evaluation 0-20 No dental group. Detailed and extensive oral One comprehensive exam per patient per dentist or dental group per 12 months. Only one exam (D0120) every 6 months per dentist or D0160 evaluation 0-20 No dental group. D0170 D0180 Re-evaluation- limited, problem focused 0-20 No Comprehensive periodontal evaluation 0-20 No One per 6 months per dentist or dental group. Only one exam every 6 months per dentist or dental group. One per 6 months per dentist or dental group. Only one exam every 6 months per dentist or dental group.

2 Age Limitation Covered One per 36 months, Either a D0210 Intraoral- complete series 0-20 No D0210 or D0330 D0220 Intraoral- periapical first film 0-20 No Intraoral- periapical each D0230 additional film 0-20 No D0240 Intraoral- occlusal 0-20 No D0270 Bitewing- single film 0-20 No D0272 Bitewing- two films 0-20 No D0274 Bitewing- four films 0-20 No Posterior- anterior or lateral D0290 skull and facial bone survey 0-20 No shall be maintained D0330 Panoramic film 0-20 No One per 36 months, Either a D0210 or D0330 D0340 Cephalometric film 0-20 No One per 36 months- non orthodontic cases. necessity. D0460 Pulp vitality tests 0-20 No One per visit. Includes multiple teeth and contra lateral comparison(s), as indicated. D0470 Diagnostic casts 0-20 No One per 6 months. Includes scaling and polishing procedures to remove coronal plaque, calculus and D1110 Prophylaxis- adult 0-20 No D1120 Prophylaxis- child 0-20 No One per 6 months. Topical application of fluoride D1203 w/o prophy- child 0-20 No One per 6 months.

3 Code D1204 Age Description Limitation Covered Topical application of fluoride w/o prophy- adult 0-20 No One per 6 months. D1351 Sealant- per tooth 0-14 Space maintainer- fixed- D1510 unilateral 0-20 No Space maintainer- fixed- D1515 bilateral 0-20 No Space maintainer- removable- D1520 unilateral 0-20 No 1 through Amalgam- one surface, 32, A D2140 primary or permanent 0-20 through T No D2150 D2160 D2161 Amalgam- two surfaces, primary or permanent 0-20 Amalgam- three surfaces, primary or permanent 0-20 Amalgam- four surfaces, primary or permanent through 32, A through T No 1 through 32, A through T No 1 through 32, A through T No 2,3,14,15,18,19, 30,31 Once per lifetime. Covered on permanent molars Indicate missing tooth numbers and arch/quadrant Indicate missing tooth numbers and arch/quadrant Indicate missing tooth numbers and arch/quadrant

4 Code Description Age Limitation Covered D2330 D2331 D2332 D2335 D2391 D2392 D2393 Resin- based composite- one surface, anterior 0-20 Resin- based composite- two surfaces, anterior 0-20 Resin- based composite- three surfaces, anterior 0-20 Resin-based composite crownanterior 0-20 Resin- based composite- one surface, posterior 0-20 Resin- based composite- two surface, posterior 0-20 Resin- based composite- three surface, posterior , 22-27, C-H, M-R No 6-11, 22-27, C-H, M-R No 6-11, 22-27, C-H, M-R No 6-11, 22-27, C-H, M-R No 4,5,12,13, 20,21,28, 29 No 4,5,12,13, 20,21,28, 29 No 4,5,12,13, 20,21,28, 29 No 1,2,3,14-19, 30-32/ A,B,I,J,L,K,S,T are not covered for composites. Amalgams are covered 1,2,3,14-19, 30-32/ A,B,I,J,L,K,S,T are not covered for composites. Amalgams are covered. 1,2,3,14-19, 30-32/ A,B,I,J,L,K,S,T are not for composites.amalgams are covered.

5 Age Limitation Covered Resin- based composite- four 4,5,12,13, 20,21,28, 1,2,3,14-19, 30-32/ A,B,I,J,L,K,S,T are not covered for composites. D2394 surface, posterior No Amalgams are covered. Crown- resin based composite D2710 (indirect) 0-20 Yes Pre-operative radiograph Crown- porcelain fused to high D2750 noble metal through Yes One per 60 months. Crown- full cast high noble D2790 metal through Yes One per 60 months. D2920 Recement crown through Yes One per 60 months. Prefabricated stainless steel D2930 crown- primary tooth 0-20 Yes. D2931 Prefabricated stainless steel crown- permanent tooth 0-20 Yes D2940 Sedative filling 0-20 No Post and core in addition to D2952 crown, indirectly fabricated 0-20 Yes Temporary crown (fractured D2970 tooth) 0-20 No Unspecified restorative D2999 procedure 0-20 Yes, by report Temporary restoration intended to relieve pain. Not to be used as a base or liner under a restoration...

6 Age Limitation Covered Pulp cap- direct (excluding D3110 final restoration) 0-20 Yes Pre-operative radiograph. D3220 Therapeutic pulpotomy 0-20 Yes Pre-operative radiograph. D3310 D3320 D3330 D3347 Anterior- one canal (excluding final restoration) 0-20 Yes Once per lifetime. Bicuspid- two canals (excluding final restoration) 0-20 No Once per lifetime. Molar- three canals (excluding final restoration) 0-20 Yes Once per lifetime. Retreatment of previous root canal therapy- anterior 0-20 Yes Once per lifetime. Apexification/recalcification- D3351 initial visit 0-20 Yes Once per lifetime. Apicoectomy/periradicular D3410 surgery- anterior 0-20 No Once per lifetime. Apicoectomy/periradicular D3426 surg (each additional root) 0-20 No Once per lifetime. with authorization. Fill radiograph with authorization. Fill radiograph with authorization. Fill radiograph with authorization. Fill radiograph with authorization. Fill radiograph..

7 Age Limitation Covered D3430 Retrograde filling- per root 0-20 No Once per lifetime.. Gingivectomy or gingivoplastyfour or more contiguous teeth or bounded teeth spaces per One per 24 months. A minimum of four (4) teeth in iodontal charting preoperative D4210 quadrant 0-20 Quadrant. Yes the affected quadrant. radiographs. D4211 D4249 D4263 Gingivectomy or gingivoplastyone to three contiguous teeth or bounded teeth spaces per quadrant 0-20 Clinical crown lengthening- hard tissue 0-20 Bone replacement graft- first site in quadrant 0-20 Quadrant. Yes Quadrant. Yes Quadrant Yes One per 24 months. One (1) to three (3) teeth in the affected quadrant. One per 24 months. Crown Lengthening requires reflection of a flap. iodontal charting preoperative radiographs. Pre-operative radiograph and narrative There must be evidence of restorability. iodontal charting preoperative radiographs. D4264 Bone replacement graft- each additional site in quadrant 0-20 Quadrant. Yes iodontal charting preoperative radiographs. D4341 iodontal scaling and root planning- Four or more teeth per quadrant 0-20 Quadrant. Yes One per 12 months. A minimum of four (4) teeth in the affected quadrant. iodontal charting preoperative radiographs. There must be radiographic evidence of root calculus or noticeable loss of bone support.

8 Code D4342 Description iodontal scaling and root planning- one to three teeth per quadrant 0-20 Age Limitation Covered Quadrant. Yes iodontal charting preoperative radiographs. There One per 12 months. A must be radiographic minimum of four (4) teeth in evidence of root calculus or the affected quadrant. noticeable loss of bone D4355 Full mouth debridement 0-20 No One per 12 months. Calculus must be abnormally heavy and visible on radiograph as well as diagnostic records shall be maintained in the patients records. D5110 Complete denture- maxillary 0-20 Yes One per 60 months.. D5120 Complete denture- mandibular 0-20 Yes One per 60 months.. Maxillary partial denture- resin D5211 base 0-20 Yes One per 60 months.. D5213 Maxillary partial denture- cast metal framework with resin denture bases 0-20 Yes One per 60 months. Mandibular partial denturecast metal framework with resin denture bases 0-20 Yes One per 60 months. D5214 Removable unilateral partial D5281 denture 0-20 Yes One per 60 months. D5610 Repair resin denture base 0-20 No One per 60 months. D5640 Replace broken teeth- per 0-20 No One per 60 months. Interim partial denture D5820 (maxillary) 0-20 Yes One per 60 months....

9 Age Limitation Covered Interim partial denture D5821 (mandibular) 0-20 Yes One per 60 months. D7140 Extraction 0-20 No D7210 D7220 D7230 D7240 D7241 D7250 Surgical removal of erupted tooth 0-20 No Removal of impacted toothsoft tissue 0-20 No Removal of impacted toothpartially bone 0-20 No Removal of impacted toothcompletely bony 0-20 No Removal of impacted toothcompletely bony w/con 0-20 No Surgical removal of residual tooth roots 0-20 No D7260 Oroantral fistula closure 0-20 No D7270 Replantation of tooth with splint 0-20 No Removal of asymptomatic tooth not covered. Removal of asymptomatic tooth not covered. Removal of asymptomatic tooth not covered. Removal of asymptomatic tooth not covered. Removal of asymptomatic tooth not covered. Includes splinting and/or stabilization Pre and post-operative radiographs and narrative of medical necessity.

10 Code Description Age Limitation Covered Surgical access of an D7280 unerupted tooth 0-20 No Mobilization of erupted or malpositioned tooth to aid D7282 eruption 0-20 No D7286 Biopsy of oral tissue- soft 0-20 No Alveolectomy in conjunction Minimum of three D7310 with extraction 0-20 No extractions in the affected Alveloplasty not in conjunction with extractionfour or more teeth or tooth No extractions performed in D7320 spaces, per quadrant 0-20 No an edentulous area. Vestibuloplasty- ridge D7340 extension (secondary 0-20 Yes Vestibuloplasty ridge- D7350 extension (including soft tissue 0-20 Yes Removal of benign odontogenic cyst or tumor- D7460 lesion diameter up to 1.25 cm 0-20 No Incision and drainage of D7510 abscess- intraoral soft tissue 0-20 No By request and report Incision and drainage of D7520 abscess- extraoral soft tissue 0-20 No By request and report D7610 Maxilla- open reduction 0-20 Yes By request and report and narrative. Copy of pathology report Copy of pathology report necessity. necessity.

11 Age Limitation Covered D7620 Maxilla- closed reduction 0-20 Yes By request and report D7630 Mandible- open reduction 0-20 Yes By request and report D7640 Mandible- closed reduction 0-20 Yes By request and report D7820 Closed reduction of dislocation 0-20 Yes By request and report Surgical discectomy, D7850 with/without implant 0-20 Yes By request and report D7860 Arthrotomy 0-20 Yes By request and report D7870 Arthrocentesis 0-20 Yes By request and report Complicated suture- up to 5 D7911 cm 0-20 Yes By request and report Osteotomy- for orthognathic D7940 deformities 0-20 Yes By request and report D7960 Frenulectomy 0-20 No By request and report D7980 Sialolithotomy 0-20 Yes By request and report D7995 Synthetic graft 0-20 Yes By request and report Unspecified oral surgery D7999 procedure 0-20 Yes By request and report necessity. Comprehensive orthodontic treatment of the transitional D8070 definition 0-20 Yes Once per lifetime. Study models. Panoramic or periapical radiographs and narrative/treatment plan.

12 Age Limitation Covered Comprehensive orthodontic treatment of the adolescent Study models. Panoramic or periapical radiographs and D8080 definition 0-20 Yes Once per lifetime. narrative/treatment plan. Removable appliance- habit D8210 breaker Yes D8220 Fixed appliance therapy 0-20 Yes palliative treatment of dental D9110 pain 0-20 No Not allowed with any other services other than radiographs. D9220 D9221 D9230 General anesthesia- first 30 minutes 0-20 No General anesthesia- each additional 15 minutes 0-20 No Analgesia- inhalation of nitrous oxide 0-20 No D9310 Consultation 0-20 No D9420 Hospital visit 0-20 No D9430 Consultant evaluation exam 0-20 No Maximum of 60 minutes (4 units) Diagnostic service provided by dentist other than practitioner providing treatment.

13 Code Description D9940 occlusal equlibration by report 0-20 Age Limitation Covered One per 24 months. Removable dental appliances which are designed to minimize the effects of bruxism (grinding) and other Yes occlusal factors. Fabrication of athletic D9941 mouthgaurd 0-20 Yes One per 12 months. Not covered with any restorative procedure on same date of service. Two D9951 occlusal adjustment ltd 0-20 No per 12 months. Not covered with any restorative procedure on same date of service. Two D9952 occlusal adjustment complete 0-20 Yes per 12 months.

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