New York Medicaid/CHI P 2 of (D0270-D0274) every 12 months D cephalometric radiographic image, measurement and analysis 1 (00340) every 36 months, limited to orthodontists or oral surgeons for the purpose or treatment of physically handicapping malocclusion D0350 2D oral/facial photographic image, intra-orally/extra-orally D0367 Cone beam CT capture & interpretation, view of both jaws; cranium D0470 Diagnostic casts 1 (00350) every 12 months, lim enrolled orthodontists or oral 1 (00367) every 60 months, limited to enrolled oral and maxillofacial su ons 1 (00470) every 12 months. Reimbursement is limited to orthodontists or oral surgeons for the purpose or treatment of 1 of (01110, 01120, 04910) every 6 months 1 (01206) every 3 months for ages 3 months up to 7. For individuals 7 years of age and older 01206 is only approvable for apical application of fluoride varnish those individuals identified with a recipient exception code of RE 81 rtbi Eligible") or RE 95 ("OMRDD/Managed Care Exemption"), or, in cases where salivary gland function has been compromised through surgery, radiation, or disease Reimbursable to physicians, nurse practitioners, and physician assistants under CPT code 99188 1 of (D2140-D2335, D2391-D2394) every 24 months, per tooth, per surface per surface COT-2018: Current Dental Terminology, 2017 American Dental Association. '!~II rights reserved. Making members shine, one smile at a time" '
1 of (02710-D2794) every 60 months, per tooth 1 of (03310-03330) per lifetime, per tooth 1 of (D3346-D3348) per lifetime, per tooth, unless medically necessary 1 of (0341O-D3425) per lifetime, per tooth 1 of (04210, 04211) every 12 months, per quad, by report 1 of (04341, 04342} every 24 months, per quad, age 13 and over 1 of (D5UO, D5120) every 96 months, per arch, age 18 and over 1 of (D5211-D5226) every 96 months, per arch, age 15 and over CDT-20IS: Current Denta l Terminology, 2017 American Dentill Association. All rights reserved. NYMC-2Q180403 Making members shine, one smile at a time" '
New York Medicaid/CHI P 1 of (D5211-D5226) every 96 months} per arch} age 15 and over 4 of (0541O-D5422) every 12 months} per arch. Not covered within 6 months of placement 1 of (05511,05512) every 12 months, per arch 1 of (05611,05612) every 12 months, per arch 1 of (05621,05622) every 12 months, per arch date rch, age 15 and over N Ie within 6 months seat date 1 of (D5820, 05821) every 12 months, per arch, age 6 up to 16. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~Nottobeused in lieu of space maintainers. Interim partial denture, mandibular ssue conditioning, maxillary Indkatem~~ngteeth numbers on claim. 1 of (D5250, D5851) every 60 months, per arch, age 15 and over. Once per denture prior to reline, rebase, or impression for new denture Payable within six (6) months prior to the delivery of a ssue conditioning, mandibular new prosthesis CDT-2018: Current Dental Terminology, 2017 American Dentilll\5sociation. ;'\11rights reserved. Making members shine, one smile at a time""
1 of (D6210-D6794) every 60 months, per tooth ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~F~edb~dgewo~~gene~l~con~deredbeyond~eKopeof~e NYS Medicaid program. The placement of a fixed prosthetic ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~appliancewillonlybecon~deredfortheanteriorsegmentofthe mouth in those exceptional cases where there is a documented ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ physicalorneurologicaldisorderthat~ouldprecludeplace~ent ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ofa removab~prosthes~,orinthosecasesrequiringdeftpalate sta bilization In cases other than for cleft palate stabilization, treatment would generally be limited to replacement of a single maxillarv anterior tooth or replacement of two adjacent ~andibular teeth. Y- if more than 4 extractions in 12 months CDT 2018: Current Dental Terminology, 2017 American Dent al Association. }\II rights reserved. NYMC-10180403 Making members shine, one smile at a time"
NewVork Medicaid/CHIP covered benefit. Payable only if orthodontic treatment has been authori2ed as a 1 of (D7310-D7321) per lifetime, per site/quad CDT-201S: Current Dental Terminology, 2017.-\merican Dentill A5~ociation. A ll rights reserved. Making members shine, one smile at a time" '
orthodontic clinics. D8060) per lifetime. If comprehensive treatment is required following a course of interceptive treatment, a period of ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 12monthsshouldbeallowedp~ortoreque~~gcomprehen~ve Interceptive orthodontic treatment of the transitional dentition Y treatment to ide for sta bilization of the result. 1 of (08070, D8080, D8090] per lifetime. Only allowed for enrolled Orthodontists and orthodontic clinics. 08210 Removable appliance therapy 5.",,,,,.-tina 1 (08220) 08220 Fixed appliance therapy 08660 Pre-orthodontic treatment examination to monitor growth and development must be submitted and over must be submitted 3 (D8660) every 12 months. May not be reimbursed in conjunction with other examination codes. Only allowed for enrolled Orthodontists and orthodontic clinics. Age 5 and over (DT 2018: Current Dental Terminology, 2017,o\merican Dental,l\s5ociation.,-\11 rights reserved. Making members shine, one smile at a time""
y 02670 Periodic orthodontic treatment visit D8680 IUlthIDd()ntlc retention (removal of appliances, construction and placement of y 12 (D8670) per lifetime. Maximum of 12 periodic orthodontic treatment visits per lifetime. Only 4 units are approved per authorization. During the 10th month of the first year an authorization will need to be submitted tor the 2nd year of treatment. During the 20th month oftreatment an authorization will need to be submitted for the 3rd year oftreatment. Only allowed for enrolled Orthodontists and orthodontic clinics, Age 5 and over 1 (D8680) per lifetime, Only allowed and orthodontic clinics. enrolled Orthodontists 5 and over 1 of (D8690) per lifetime, Services provided by an orthodontist 08690 Orthodontic treatment (alternative billing to a contract fee) y other than the original t reating orthodontist, This is limited to transfer care and removal of appliance. Only allowed for enrolled Orthodontists and orthodontic clinics. Age 5 and over D8692 Replacement of lost or broken retainer 1 (D8692) per 1 lifetime, per arch. By Report Documentation must be submitted detailing the circumstances of how the appliance was lost or broken. Appliances which do not fit will not be replaced. Must be within one year of D8680. Only allowed for enrolled Orthodontists and orthodontic clinics. 2 (09110) every 12 months. Not reimbursable in addition to other therapeutic services performed at the same visit or in conjunction with initial or periodic oral examinations. 09222 Deep sedation/general anesthesia, first 15 minute increment D9223 Deep sedation/general anesthesia, each subsequent 15 minute increment D9239 Intravenous moderate (conscious) sedation/analgesia, first 15 minute increment 09143 Intravenous moderate (conscious) sedation/analgesia, each subsequent 15 minute increment D9310 Consultation, other than requesting dentist Maximum 0 60 minutes 4 units. Wil ursab provided by a qualified dental provider who has the appropriate level of certification in Dental Anesthesia. Not to be combined with D9222, D9223 1 (09310) every 2 months, By Report. Will not be reimbursed within 90 days of oono, 00140, D0150, D0160, D9110 or D9430 to consulting dentist who assumes treatment 1 (09410) D9410 House/extended care facility call D9420 Hospital or ambulatory surgical center call visit, observation, regular hours, no other services ce visit, after regularly scheduled hours D9920 Behavior management, by report 1 day, By Repo rt. Reimbursement is per visit, re less of number of beneficiaries seen 3 (09420) per 1 week, By Report. Professional visits for erative care treatment codes or behavior management (09920) on the same date of service Limited to specialists for non-referred patients Used to monitor the status of a beneficiary following an authori2ed phase of surgical treatment that are required beyond the follow up period for that procedure listed in the fee schedule Not be used for orthodontic retention follow-u visits By Report, not payable in conjunction with an examination, observation, or consultation. By Report. Not billable as a "stand alone" procedure or in combination with deep sedation/general anesthesia Another billable clinical service must be provided on the same date of service For developmentally disabled population (OM ROD Clients) Narrative of medical necessity required with claim A copy of the completed OMRDD client identification letter must be attached to each claim. CDT-2018: Current Dental Terminology. 2017,1\merican Dental Association. :\ 11rights reserved. Making members sh ine, one smile at a time""