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MEDICAL ASSISTANCE PROGRAM FEE SCHEDULE
DENTAL
Please Not&
Dental - General Payment Policies
All dental procedures are considered to be outpatient procedures. These procedures are not compensable on an inpatient basis
unless there is medical justification which is documented in the patient's medical record.
Provider types 03 - Dentist and 01 - Physician are the only provider types eligible to receive payment for dental services.
Provider type 01 (Physician) is eligible for payment only for procedure codes D7450 through 0 7 4 7 , D7960 and 07970. (This does
not exclude provider type 03 - Dentist.)
Provider type 03 (Dentist) who is a board certified or board eligible orthodontist is the only provider type eligible for payment of
orthodontic services.
Anesthesia
Provider type 01 (Physician) is the only provider type eligible for the anesthesia allowance when provided in a hospital short
procedure unit, ambulatory surgical center, emergency room or inpatient hospital.
Provider type 03 (Dentist) is eligible for payment only for procedure codes D9220 for General Anesthesia, 09230 for Nitrous Oxide,
D9241 for Intravenous Sedation, or 09248 for Conscious Sedation provided in a dentist's office or a dental clinic.
Crowns
Individuals age 21 and older are eligible for crowns under certain situations and criteria. Crown coverage is limited to one crown per
tooth for six years and is limited to four per calendar year with no more than two crowns per arch.
Procedure codes 02710 through 02791 are cornpensable only for fully developed permanent teeth and primary teeth with no
permanent successors. Payment is not made for prefabricated andlor self-curing dental materials.
Procedure codes D2930 - D2933, 02336 and D2337 are crowns for primary or developing permanent teeth only, and are not
compensable with construction of a permanent crown.
Effective Date-March
1, 200 1
DENTAL
DPW-OMA-MA MANUAL
MEDICAL ASSISTANCE PROGRAM FEE SCHEDULE
DENTAL (Continued)
Crowns (continued)
Procedure codes D2930 - 02933, D2336 and 02337 are payable for individuals under 21 years of age only.
Dentures
A partial denture that replaces only posterior permanent teeth must include three or more teeth on the dentures that are anatomically
correct (natural size, shape and color) to be compensable (excluding third molars).
Complete dentures for individuals 21 years of age and older are limited to one per arch, regardless of procedure code, every seven
years.
Partial dentures for individuals 21 years of age and older must include two or more anterior teeth or four or more posterior teeth
(excluding third molars) on the denture all of which must be anatomically correct (natural size, shape and color) to be compensable;
limited to one per arch, regardless of procedure code, every seven years.
The fees for dentures and partial dentures include all necessary adjustments andlor denture relines during the six month period
following insertion of the denture.
Denture Relines
Individuals age 21 years of age and dder - relining of dentures is limited to one per arch, regardless of procedure code, every two
years, for either full or partial dentures.
Chairside Reline - includes the use of light cured, self-curing andlor cold cure material in which the reline material is utilized as the
impression material.
-
Laboratory Reline includes the use of an impression material technique from which a model is poured, mounted and upon which
the reline material is cured. The reline material is not utitized as the impression material.
The use of tissue conditioners and temporary liners is not compensable.
-
-
Effective Date-March
1, 2001
DENTAL
DPW-OMA-MA MANUAL
MEDICAL ASSISTANCE PROGRAM FEE SCHEDULE
DENTAL (Continued)
Root Canals
Individuals age 21 years and older are eligible for root canals under certain situations and criteria including post-operative review
through the prior authorization program.
Restorations
Two or more restorations on the same surface of a tooth are considered as one restoration.
To bill for two or more restorations on one tooth, use the appropriate multiple procedure code.
The fees for restoration and filling include local anesthesia, polishing, bonding agents, cement bases, acid etch, light cured materiat
and the necessary medications where indicated.
Management Fee
Procedure code 09920 is limited to two per 365 days.
Payment for the management fee precludes payment for outpatient general anesthesia, intravenous sedation, conscious sedation, or
nitrous oxide on the same date of service.
Sealants
Payment for sealants, payable at the fee of $25.00, per permanent first molar (tooth numbers 3, 14, 19, 30) and permanent second
molars (tooth numbers 2, 15, 18, 31) is limited to individuals under 21 years of age. Payment is limited to one application per cariesfree and restoration-free permanent molar, per lifetime.
Radiographs
Maximum allowance for any combination of dental radiographs per patient per dentist per calendar year is $69.00.
Effective Date-March
1, 2001
DENTAL
DPW-OMA-MA MANUAL
MEDICAL ASSISTANCE PROGRAM FEE SCHEDULE
.
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DENTAL (Continued)
Prior Authorization
Prior authorization is required for orthodontics, complete and partial dentures, simple extraction of six or more teeth extracted during
one visit or period of hospitalization or when more than one tooth is extracted for insertion of a prosthetic device (excluding primary
teeth), all surgical extractions, crowns and periodontal services (except full mouth debridement which requires post operative review).
All dental procedures are considered to be outpatient procedures. These procedures are not cornpensable on an inpatient basis
unless there is medical justification which is documented in the patient's medical record.
Prior Authorization for Extractions
Simple Extractions
When more than one tooth is extracted for insertion of a prosthetic device; or
When six or more teeth'are extracted during one visit or period of hospitalization.
Prior authorization of simple extractions for primary teeth is not required.
Al t Surgical Extractions
w
=
Complete bony impactions;
Partial bony impactions;
Surgical extractions, erupted;
Soft tissue impactions; or
Root recoveries
Surgical Procedures
Surgical exposure for orthodontic purposes
Effective Date-March
1,2001
DENTAL
DPW-OMA-MA MANUAL
MEDICAL ASSISTANCE PROGRAM FEE SCHEDULE
DENTAL (Continued)
Prior Authorization for Periodontal Services
Gingivectomy or Gingivoplasty - per quadrant (Procedure Code D4210)
Prior authorization required.
Limited to no more than four different quadrant reimbursements within a 24-month period.
Periodontal Scaling and Root Planing
- per quadrant (Procedure Code 04341)
Prior authorization required.
Limited to no more than two quadrants on a single date of service with no more than four different quadrant reimbursements
within a 24-month period.
Reimbursement for periodontal scaling and root planing includes prophylaxis.
Full Mouth Debridement To Enable Comprehensive Periodontal Evaluation and Diagnosis (Procedure Code D4355)
=
Post-operative review required through the prior authorization program.
Limited to one treatment per 365 days.
Not compensable on same date as prophylaxis or other periodontal procedure.
Periodontal Maintenance Procedures Following Active Treatment (Procedure Code D4910)
Prior authorization required.
Active treatment excludes procedure code 04355.
Up to four procedures or any combination of routine prophylaxis and periodontal maintenance totaling four may be paid within a
12 consecutive month period.
Periodontal maintenance begins not less than 90 days following active periodontal therapy.
Types of Service
AS - Provider mileage
OA - Crowns only
OB - Prosthodontics
10 - Assistant Surgeon
20 - Surgery
21 -Oral Surgery
OC - Periodontal sewices
OD - Orthodontic
OE - Basic dental
40 - Anesthesia
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Effective D a t e M a r c h 1,2001
DENTAL
DPW-OMA-MA M ~ U A L
MEDICAL ASSISTANCE PROGRAM FEE SCHEDULE
CLEFT PALATE SERVICES
(Recipients 20 Years of Age and Under)
Surgical ServiceslDental Services
All current Medical Assistance regulations and payment policies are in effect for Cleft Palate Clinics and thejr associated providers for
procedures included in this fee schedule unless othetwise noted.
Orthodontics
Orthodontic services covered under this program must not be done solely for cosmetic purposes, but must be done in conjunction
with craniofacial reconstruction andlor the correction of a severe handicapping malocclusion. Orthodontic services will not be limited
to eight quarters of treatment andlor permanent dentition only for Cleft Palate Treatment.
Evaluations
After the initial evaluation has been completed by the Cleft Palate Clinic, please foward a copy to the address below. This must be
updated on a yearly basis as long as the recipient is covered by the Medical Assistance Cleft Palate Program.
Department of Public Welfare
Office of Medical Assistance Programs
Clefl Palate Service
P.O. Box 8044
Harrisburg, PA 17105-8044
For medically necessary services not included in the Medical Assistance Program Fee Schedule an 1150 Waiver (MA 97) may be submitted
for review.
Type of Sewice
CP - Cleft palate sewice
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Effective Date--March
1, 2001
DENTAL
DPW-OMA-MA MANUAL
MEDICAL ASSISTANCE PROGRAM FEE SCHEDULE
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Effective Date--March
1, 2001
DENTAL
DPW-OMA-MA MANUAL
MEDICAL ASSISTANCE PROGRAM FEE SCHEDULE
TY Pe
Service
Ptocedure
Code
MA
Fee
Limits
Tenninoloay
DENTAL PROCEDURES
OE
OE
OE
DO120
00120
DO150
DIAGNOSTIC
Clinical Oral Evaluations
periodic oral evaluation (under 21 years of age)
periodic oral evaluation (21 years of age and older)
comprehensive oral evaluation
RadiographslDiagnostic Imaging
intraoral complete series (including bitewings)
intraoral periapical first film
intraoral periapical each additional film
intraoral occlusal film
extraoral first film
extraoral - each additional film
bitewing single film
biewings - two films
bitewings four films
panoramic film
cephalometric film (not performed in conjunction with orthodontic
treatment)
-
D1110
Dl 110
D l 120
PREVENTIVE
Dental Prophylaxis
prophylaxis adult (13 years of age thru 20 years of age)
prophylaxis adult (21 years of age and older)
prophylaxis - child
-
Dl203
Topical Fluoride Treatment {OPfice Procedure)
topical application of fluoride (prophylaxis not included) - child (16
years of age and under)
Dl 351
Other Preventive Services
sealant - per tooth (under 21 years of age)
report tooth nurnber(s) when billing for sealants
Effective Date--March 1, 2001
9
DENTAL
1 per 180 days
1 per 365 days
1 per patientlper dentist
$20.00
$20.00
$20.00
1 per 5 years
1 per 5 years
1 per 180 days
1 per 365 days
1 per 180 days
1 per 180 days
1 application per indicated
permanent 1st and 2nd molar
per lifetime
$25.00
DPW-OMA-MA MANUAL
MEDICAL ASSISTANCE PROGRAM FEE SCHEDULE
TY Pe
Service
Procedure
OE
OE
OE
D1510
Dl 515
Dl 550
Code
MA
Terminoloqy
Space Maintenance (Passive Appliances)
space maintainer - fixed - unilateral
space maintainer fixed - bilateral
recementation of space maintainer
Limits
Fee
1 per quadrant
1 per arch
-
RESTORATIVE
Amalgam Restorations (Including Polishing)
amalgam - one surface, primary
amalgam - two surfaces, primary
amalgam three surfaces, primary
amalgam four or more surfaces, primary
amalgam - one surface, permanent
amalgam - two surfaces, permanent
amalgam -three surfaces, permanent
amalgam - four or more surfaces, permanent
-
Resin-Based Composite Restorations
resin-based composite one surface, anterior
resin-based composite two surfaces, anterior
resin-based composite - three surfaces, anterior
resin-based composite crown, anterior primary
resin-based composite crown, anterior permanent
resin-based composite one surface, posterior primary
resin-based composite - two surfaces, posterior - primary
resin-based composite - three or more surfaces, posterior
primary
resin-based composite - one surface, posterior - permanent
resin-based composite two surfaces, posterior - permanent
resin-based composite - three surfaces, posterior - permanent
-
-
-
-
-
-
-
Crowns Single Restorations Only Refer to page 2 for limits
for individuals 2.1 years of age and older
OA
D2710
crown - resin (laboratory)
OA
D2721
crown resin with predominantly base metal
OA
02751
crown porcelain fused to predominantly base metal
OA
D2791
crown - full cast predominantly base metal
(CROWNS ARE LIMITED TO ONE CROWN PER TOOTH PER
TIME LIMITATION REGARDLESS OF CODE)
10
Effective Date--March 1, 2001
DENTAL
-
1 per 3 years
Iper 5 years
1 per 5 years
I per 5 years
DPW-OMA-MA MANUAL
MEDICAL ASSISTANCE PROGRAM FEE SCHEDULE
T -v- ~ e
Service
OE
Procedure
Code
D3220
OE
D3230
OE
03240
OE
OE
OE
03310
D3320
D3330
20
20
D3410
03421
D3425
20
20
I33426
Terminoloqy
Other Restorative Services
recement inlay
recement crown
prefabricated stainless steel crown - primary tooth
prefabricated stainless steel crown - permanent tooth
prefabricated resin crown
prefabricated stainless steel crown with resin window
cast post and core in addition to crown
prefabricated post and core in addition to crown
crown repair
Limits
-
MA
Fee
-
ENDODONTICS
Pulpotomy
therapeutic pulpotomy (excluding final restoration) - removal of pulp
coronal to the dentinocementa1junction and application of
medicament
Endodontic Therapy (Including Treatment Plan, Clinical
Procedures (X-Rays), Necessary Medication and Follow-Up
Care. Refer to page 4 for limits for individuals 21 years of age
and older.
pulpal therapy (resorbable filling) anterior, primary tooth (excluding
final restoration)
pulpal therapy (resorbable filling) - posterior, primary tooth
(excluding final restoration)
anterior (excluding final restoration)
bicuspid (excluding final restoration)
molar (excluding final restoration)
-
ApicoectomylPeriradicular Services
apicoectomylperiradicular surgery - anterior
apicoedomylperiradicular surgery bicuspid (first root)
apicoectomylperiradicular surgery - molar (first root)
apicoectomylperiradicular surgery (each additional root)
-
PERIODONTICS (Refer to page 6 for Prior Authorization requirements)
Surgical Services (Including Usual Post-Operative Care)
21
04210
gifigivectomy or gingivoplasty per quadrant
4 quadrants per 24-months
$125.00 PA
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Effective Date--March 1, 2001
DENTAL
DPW-OMA-MA MANUAL
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MEDICAL ASSISTANCE PROGRAM FEE SCHEDULE
TYPe
Service
Procedure
Code
OC
04341
OC
04355
OC
D4910
OB
OB
OB
OB
D5110
D5120
D5130
D5140
MA
Terrninoloqy
NonSurgical Periodontal Sewices
periodontal scaling and root planing - per quadrant
futl mouth debridement to enable comprehensive periodontal
evaluation and diagnosis
Other Periodontal Services
periodontal maintenance procedures (following active therapy)
PROSTHODONTICS (REMOVABLE)
Complete Dentures (Including Routine Post-Delivery Care) Refer to page 3 for limits for individuals 21 years of age and
older
complete denture - maxillary
complete denture mandibular
immediate denture - maxillary
immediate denture - mandibular
(Complete Dentures are limited to one denture per arch per
time limitation regardless of code)
-
Partial Dentures (Including Routine Post-Delivery Care)
(Identify teeth replaced) Refer to page 3 for limits for
individuals 21 years of age and older)
maxillary partial denture - resin base (including any conventional
clasps, rests and teeth)
mandibular partial denture resin base (including any conventional
clasps, rests and teeth)
maxillary partial denture cast metal framework with resin denture
bases (including any conventional clasps, rests and teeth)
mandibular partial denture cast metal framework with resin denture
bases (including any conventional clasps, rests and teeth)
(Partial dentures are limited to one denture per arch per time
limitation regardless of code)
Limits
Fee
-
2 quadrants on same date of
service; 4 quadrants per 24months
1 per 365 days
$75.00 PA
any combination of routine
prophylaxis and periodontal
maintenance totaling 4 per 12
months
$44.00 PA
$60.00 Post-op review
Iper 5 years
1 per 5 years
1 per 5 years
1 per 5 years
-
OB
D5211
OB
D5212
OB
D5213
OB
D5214
Effective Date--March 1, 2001
-
-
-
12
DENTAL
1 per 5 years
1 per 5 years
1 per 5 years
1 per 5 years
DPW-OMA-MA MANUAL
MEDICAL ASSISTANCE PROGRAM FEE SCHEDULE
Type
Service
Procedure
Code
06
OB
DS410
0541 1
05421
OB
05422
Adjustments to Dentures
adjust complete denture maxillary
adjust complete denture mandibular
adjust partial denture - maxillary
adjust partial denture - mandibular
DS510
D5520
Repairs to Complete Dentures
repair broken complete denture base
replace missing or broken teeth - complete denture (each tooth)
7
OB
OB
06
08
08
OB
08
08
08
D5610
05620
05630
D5640
D5650
05660
Limits
-
MA
Fee
-
-
,
Repairs t o Partial Dentures
repair resin denture base
repair cast framework
repair or replace broken clasp
replace broken teeth per tooth
add tooth to existing partial denture
add clasp to existing partial denture
-
3 teeth
3 teeth
-
Denture Reline Procedures Refer to page 3 for limits for
individuals 21 years of age and older
reline complete maxillary denture (chairside)
reline complete mandibular denture (chairside)
reline rnaxilla~ypartial denture (chairside)
reline mandibular partial denture (chairside)
reline complete maxillary denture (laboratory)
reline complete mandibular denture (laboratory)
reline maxillary partial denture (laboratory)
reline mandibutar partial denture (laboratoty)
D6930
D6980
Effective Date-March 1. 2001
PROSTHODONTICS, FIXED (EACH RETAINER AND EACH
POMTlC CONSTITUTES A UNIT IN A FIXED PARTIAL
DENTURE)
Other Fixed Partial Oenture Services
recement fixed partial denture
fixed partial dentu~erepair
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DENTAL
DPW-OMA-MA MANUAL
MEDICAL ASSISTANCE PROGRAM FEE SCHEDULE
TY Pe
Service
Procedure
Code
Terminoloay
ORAL AND MAXILLOFACIAL SURGERY
Extractions (Includes Local Anesthesia, Suturing, if Needed,
and Routine Postoperative Care)
21
07110
extractions{includeslocalanesthesia,suturing,ifneeded,and
$45.00
07120
routine postoperative care) single tooth
each additional tooth
$45.00
21
MA
Fee
Limits
Surgical Extractions (Includes Local Anesthesia, Suturing, if
Needed, and Routine Postoperative Care)
surgical removal of erupted tooth requiring elevation of
mucoperitoseal flap and removal of bone andlor section of tooth
removal of impacted tooth soft tissue
removal of impacted tooth - partially bony
removal of impacted tooth completely bony
surgical removal of residual tooth roots (cutting procedure)
21
D7210
21
21
21
21
D7220
07230
07240
07250
21
21
D7260
D7270
21
07280
21
D73t0
Alveoloplasty Surgical Preparation of Ridge for Dentures
alveoloptasty in conjunction with extractions - per quadrant
21
07320
alveoloplasty not in conjunction with extractions per quadrant
-
Other Surgical Procedures
oroantral fistula closure
tooth reimplantation andlor stabilization of accidentally evulsed or
displaced tooth andlor alveolus
surgical exposure of impacted or unerupted tooth for orthodontic
reasons (including orthodontic attachments)
-
-
Surgical Excisions
removal of odontogenic cyst or tumor lesion diameter up to 1.25
cm
20
removal of odontogenic cyst or tumor - lesion diameter greater than
D7451
1.25 cm
20
removal of nonodontogenic cyst or tumor - lesion diameter up to
D7460
1.25 cm
14
Effective Date--March 1, 2001
DENTAL
20
D7450
bill per quadrant with one
quadrant equal to 5 8 teeth
-
bill per quadrant with one
quadrant equal to 5 8 teeth
-
$30.00 1st quadrant
$15.00each, 2nd - 4t h
quadrant
$30.00 1st quadrant
$15.00 each, 2nd 4th
quadrant
-
DPW-OMA-MA MANUAL
-
MEDICAL ASSISTANCE PROGRAM FEE SCHEDULE
TvPe
* Service
20
Procedure
Code
D7461
20
D7471
Removal of Tumors, Cysts and Neoplasms
removal of exostosis per site
20
20
D7871
07960
D7970
Other Repair Procedures
non-arthroscopic lysis and lavage
frenulectomy (frenectorny or frenotomy) - separate procedure
excision of hyperplastic tissue - per arch
OE
D9110
ADJUNCTIVE GENERAL SERVICES
Unclassified Treatment
palliative (emergency)treatment of dental pain - minor procedure
40
40
40
40
D9220
09230
09241
09248
Anesthesia
general anesthesia
analgesia, anxiolysis, inhalation of nitrous oxide
intravenous sedationlanalgesia
non-intravenous conscious sedation
09920
Miscellaneous Services
behavior management
20
OE
D9930
W0500
Terrninolosv
removal of nonodontogenic cyst or tumor - lesion diameter greater
than 1.25 cm
MA
Limits
Fee
$80.00
-
under 21 years of age only
for difficult to manage persons
with developmental disabilities;
2 per 365 days
(Developmental disability - a
substantial handicap having its
onset k f o r e the age of 18
years of indefinite duration and
attributable to neuropathy)
treatment of complications (post-surgical) - unusual circumstances
mileage additional allowance for home, skilled nursing facility and
ICF visits
Effective Date--March 7 , 2001
$210.00
$30.00
$150.00
$95.00
under 21 years of age only
-
15
DENTAL
$30.00
$15.00
$0.10 per mile
DPW-OMA-MA MANUAL
MEDICAL ASSISTANCE PROGRAM FEE SCHEDULE
TYPe
Service
Procedure
Code
OD
D8900
OD
28051
MA
-
Limits
Terrninoloqv
ORTHODONTICS
orthodontic exam and treatment plan (including the Salzmann
Evaluation Index)
diagnostic aids (radiographs, photographs, models, etc.) one time
payment
Fee
$20.00
$63.00
Comprehensive Orthodontic Treatment (includes Diagnostic
Procedures, Retention Limited t o Formal Full-banded
Treatment)
orthodontic treatment first quarter
orthodontic treatment second quarter
orthodontic treatment third quarter
orthodontic treatment fourth quarter
arthodontic treatment fifth quarter
orthodontic treatment sixth quarter
orthodontic treatment seventh quarter
orthodontic treatment eighth quarter
retention services following reduced active treatment, prior to the
end of seventh quarter of treatment plan
(Procedure codes D8900 and 28051 through 28310 are limited to 1
per patient per lifetime)
-
CLEFT PALATE SERVICES
Maxillofacial Prosthetics
impress & custom prep: interim OBT prosthesis
impress & custom prep: defin OBT prosthesis
impress & custom prep: mandib resct prosthesis
impress & custom prep: palatal AUM prosthesis
impress & custom prep: palatal lift prosthesis
impress & custom prep: speech aid prosthesis
impress & custom prep: oral surg splint
impress & custom prep: auricular prosthesis
impress & custom prep: nasal prosthesis
impress & custom prep: facial prosthesis
CP
D8900
Effective Date--March 1, 2001
Orthodontics
orthodontic exam and treatment plan
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DENTAL
DPW-OMA-MA MANUAL
MEDICAL ASSISTANCE PROGRAM FEE SCHEDULE
TY Pe
Sewice
CP
Procedure
CP
X7501
CP
X7502
Code
X7500
CP
08210
CP
D8220
Terrninoloqy
initial screening, all diagnostic aids, appliances and active
treatment, first quarter
subsequent continuing treatment, each quarter, to include
appliances and all necessary adjustments
retention year, when necessary, to include appliances
Limits
MA
Fee
-
$360.00
$160.00
$50.00
Minor Treatment To Control Harmful Habits (Includes All
Related Procedures and Necessary Adjustments)
removable appliance therapy
fixed appliance therapy
Ancillary Services
For Provider Type 01,03,
CP
41 and 50
X7503
CP
X7504
complete initial examination at Diaqnostic Clinic Only (cleft palate)
involving all licensed staff (limit 1 per patient)
(This procedure code can only be billed by one member of the Cleft
Palate Treatment Team and is inclusive of all providers.)
re-examination at Diaanostic Clinic Only (cleft palate) per clinician $75 max.(per recipientlper year)
Effective Date--March1, 2001
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DENTAL
DPW-OMA-MA MANUAL