COVERED SERVICES
This section provides information on Medicaid covered services and is divided into the following subsections that correspond to the categories of services in Current Dental Terminology (CDT) as published by the American Dental Association.
* Diagnostic Services
* Preventive Services
* Restorative Treatment
* Endodontics
* Periodontics
* Prosthodontics (Removable)
* Oral Surgery
* Adjunctive General Services
Providers must use the current CDT procedure codes published by the American Dental Association (ADA) when completing both the claim and PA form. Refer to the Additional Code/Coverage Resource Materials subsection of the General Information for Providers Chapter for additional information regarding coverage parameters.
DIAGNOSTIC SERVICES
CLINICAL ORAL EVALUATION (EXAMINATIONS)
A periodic, comprehensive or problem-focused evaluation is considered a benefit for all beneficiaries only if detailed written documentation of medical and dental findings (both negative and positive) and tests are included in the beneficiary’s dental record. (Refer to the General Information for Providers Chapter of this manual for additional information.) Typically, it should include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, periodontal conditions, occlusal relationships, hard and soft tissue anomalies, oral cancer screening, prosthesis condition and usage, etc. Examinations without this documentation are not a covered benefit.
COMPREHENSIVE ORAL EVALUATION
A comprehensive oral evaluation is performed on a new patient or an established patient with significant health changes or absence from treatment for three or more years. The evaluation must include a documented medical and dental history, a thorough evaluation and recording of the condition of extraoral and intraoral hard and soft tissues, including a complete charting of the condition of each tooth and supporting tissues, occlusal relationships, periodontal conditions, including periodontal charting, oral cancer screening and appropriate radiographic studies (radiographs are separately reimbursable). The comprehensive oral evaluation is a covered benefit for all beneficiaries. In addition, a complete treatment plan must be included that addresses the beneficiary’s needs.
PERIODIC ORAL EVALUATION
A periodic oral evaluation is an examination of a patient of record to determine any changes in a beneficiary’s dental and medical health status since a previous comprehensive or periodic examination. The periodic oral evaluation must include a written update of the beneficiary’s dental and medical history, clinically appropriate charting necessary to update and supplement the comprehensive oral examination data, including periodontal screening and appropriate radiographs as necessary to update previous radiograph surveys (radiographs are separately reimbursable). A periodic oral evaluation is a covered benefit once every six months for all beneficiaries, but may not be billed within six months of a Comprehensive Oral Evaluation. In addition, a complete treatment plan must be included that addresses the beneficiary’s needs.
LIMITED ORAL EVALUATION – PROBLEM FOCUSED EXAM
A limited oral evaluation-problem focused exam consists of an examination for diagnosis and observation of a specific oral health problem or complaint, such as injuries to teeth and supporting structures. A limited oral evaluation must include appropriate recording of the beneficiary’s dental and medical history, and charting that is clinically appropriate for the particular problem. In addition, the findings, diagnosis, and treatment plan for the diagnosis must be included in the beneficiary’s chart.
A limited oral evaluation can be billed in conjunction with radiographs and/or extractions(simple or surgical) and considered as a covered benefit. Routine restorative procedures, root canal therapy, elective surgery, and denture services are not considered emergency procedures and cannot be billed in conjunction with a limited oral evaluation. Limited oral evaluation-problem focused exam is a covered benefit for all ages.
PRE-DIAGNOSTIC SERVICES
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ASSESSMENT OF A PATIENT
An assessment of a patient is a clinical evaluation performed by a dental hygienist operating in a public health setting or an approved Public Act 161 of 2005 (PA 161) program. Assessment services performed within the scope of dental hygiene practice can be provided to identify signs of disease, malformation or injury and the need for referral for examination, diagnosis and treatment. An assessment of a patient is a benefit for all ages. The assessment must include written documentation of the beneficiary’s dental and medical history. Written documentation of significant clinical findings and the appropriate referral is required. The assessment code cannot be used when a dentist is on site to perform the examination. An oral examination by the dentist always supersedes the assessment of a patient in place of service settings where the dentist is present. It can be billed in conjunction with other dental hygiene services, but may not be billed on the same date of service as other oral evaluation services.
CONSULTATION
A consultation provided by another dentist or a physician (MD, DO) is a benefit for all beneficiaries. Medicaid defines a consultation as a service rendered by a physician/dental specialist whose opinion or advice is formally requested by another appropriate practitioner (e.g., physician, certified nurse-midwife [CNM], dentist) for the further evaluation and/or management of the beneficiary. The consultant does not render patient care or treatment. If a consultant assumes responsibility for any patient management or treatment, then all services subsequent to the consultation must be billed under the appropriate procedure code (e.g., exams, procedures). If a dentist provides a consultation, the only separately reimbursable services that may be provided in addition to the consultation are radiographs.
A consultation service includes examination and evaluation of the beneficiary, documentation of history and physical examination findings, recommendations, and submission of a written formal consultation report to the requesting practitioner. The dentist requesting the consultation cannot bill the consultation procedure code.
A consultation related to routine dental treatment (e.g., caries) is not a covered benefit.
RADIOGRAPHS
The policy applies to all radiographs and radiographic procedures, both digital and traditional film, unless otherwise stated. (Refer to the Directory Appendix for website information.)
Radiographs are benefits for all beneficiaries and are limited to the number medically necessary to make a diagnosis (other limitations apply to radiographs – see below). The provider must maintain documentation in the beneficiary’s file stating the reason the radiographs were necessary, the diagnosis/radiographic findings, treatment plan, and referral if appropriate.
TECHNICAL CONSIDERATIONS AND ADDITIONAL REQUIREMENTS
All radiographs submitted must be diagnostically acceptable and meet the following technical considerations and additional requirements.
Technical Considerations
* All teeth or areas of concern must be visible on the radiographs.
* Density and clarity of the radiograph must be such that radiographic interpretation can be made without difficulty.
* On a periapical view, the apex of the tooth must be demonstrated clearly, as well as a minimum of one-eighth of an inch of surrounding bone.
* Where pathologic change is in question, healthy bone must be seen surrounding the questionable area.
* Interproximal bone must be visible without the overlapping of interproximal surfaces of teeth under consideration.
* Posterior teeth areas (e.g., demonstrated impactions, developing third molars) must be completely visible.
Additional Requirements
* All film radiographs submitted must be mounted in an x-ray mount, with the exception of a single film which may be submitted in an envelope. Only actual films or diagnostically acceptable duplicates will be accepted.
* Digital radiographs submitted must be regulation film size and printed on diagnostic quality paper.
* All radiographs must be identified with the beneficiary’s name and Medicaid ID number.
* All radiographs must have the date the radiograph was taken.
* All full-mouth radiographs and panoramic radiographs must have “right” and “left” identification.
* All radiographs must include the dentist’s name and address.
BITEWINGS
Bitewing radiographs are a covered benefit only once in a 12-month period for all beneficiaries.
OCCLUSAL RADIOGRAPHS
An occlusal radiograph is a covered benefit for beneficiaries under age 21 once every three years per arch. All occlusal radiographs, regardless of film size or method of exposure, will be reimbursed at the established fee for a periapical, first film.
PANORAMIC RADIOGRAPHS
A panoramic radiograph is a covered benefit once every five years for all beneficiaries ages five years and older.
FULL MOUTH OR COMPLETE SERIES
A full mouth or complete series is a covered benefit once every five years for all beneficiaries ages five years and older.
A full mouth or complete series consists of:
* A minimum of 10 periapical radiographs in conjunction with a minimum of two bitewing radiographs; or
* An intraoral/extraoral combination of a panoramic radiograph in conjunction with a minimum of two bitewing radiographs.
The maximum reimbursement for any combination of radiographs will not exceed the established fee for a full mouth or complete series. Any combination of 10 or more intraoral radiographs will be considered a full mouth series.
Radiographs submitted for prior authorization and audit purposes will be returned to the provider.
COPIES OF FULL MOUTH SERIES
When a beneficiary changes dental providers and has had a full mouth series of radiographs taken within the previous 12 months, the expectation is that the dental provider provides a copy of the radiographs to the new dental provider.
RADIOGRAPH SUBMISSION REQUIREMENTS FOR PRIOR AUTHORIZATION
In some cases, pre-op radiographs are necessary to document the presence and/or absence of teeth, related tooth structure, or related chronic pathology within the alveolar process(es).
A full mouth radiograph series must be submitted with PA requests for complete dentures in cases where beneficiaries are receiving their first denture. A full mouth radiograph series is optional for PA requests for replacement of existing complete dentures (i.e., the beneficiary is edentulous, has worn dentures for years, and needs replacement dentures). In this case, the dentist may submit radiographs if they deem them necessary in the evaluation of the beneficiary’s oral condition.
A full mouth radiograph series must be submitted with all PA requests for partial dentures.
A periapical radiograph is required when submitting PA requests for crown coverage. When requesting PA for procedures, the dentist may be required to send radiographs along with the request. (Information regarding the completion of the PA request and the submission of radiographs is contained in the Billing & Reimbursement for Dental Providers Chapter of this manual.)
NONCOVERED SERVICES
The following dental services are excluded from Medicaid coverage:
* Orthodontics
* Gold Crowns, Gold Foil Restorations, Inlay/Onlay restorations
* Fixed Bridges
* Bite Splints, Mouthguards, sports appliances
* TMJ Services
* Services or Surgeries that are experimental in nature
* Dental Devices not approved by the FDA
* Analgesia, Inhalation of Nitrous Oxide