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Delta Dental of New Jersey Required Documentation Chart If there is an extenuating circumstance not evident from the documentation listed below, a narrative and any available corroborating diagnostics must be submitted. As part of the re-review process Delta Dental may require documentation (e.g., photographs) in addition to that listed in this chart. All radiographic images are pretreatment unless otherwise indicated. Any radiographic image submitted must be of diagnostic quality and substantiate the need and appropriateness of the service submitted for predetermination or payment. In order to do so, the dentist may need to submit radiographic images in addition to those listed in this chart. Submission Requirements - Radiographic Images Whenever a participating dentist submits a claim that includes any combination of intraoral radiographic images whose combined fee equals or is greater than a complete series (D0210), the fee allowed will be limited to that of a complete series. Also, a panoramic radiographic image submitted together with supplemental radiographic images will be handled in the same manner. If a participating or non-participating dentist submits eight or more intraoral radiographic images and/or a panoramic radiographic image with supplemental bitewings or periapical radiographic images, the dentist must submit a brief narrative as to the reason for taking the radiographic images and also identify the tooth numbers of the periapical radiographic images if the radiographic images are not part of a complete series or are not intended to function as a complete series. Delta Dental will consider that supplemental information in determining whether the radiographic images will be subject to the limitations for individual radiographic images rather than for a complete series. All procedures listed on this chart are not necessarily covered benefits, and all benefits are not necessarily listed. Unless otherwise noted: Yes = Documentation Required Blank = Documentation Not Required PA = Periapical Radiographic Image (may require more than one for diagnostic purposes) FMX = Full Mouth Series Pano = Panorex DDNJ = Delta Dental of New Jersey Medical EOB Requirements Medical plans may cover some dental procedures, such as oral surgery. This chart indicates if a procedure requires a medical EOB for processing. If a Medical EOB is required for an oral surgery procedure on a claim, a medical EOB is also required for related exams, x-rays and anesthesia. Some groups have elected Delta Dental as the primary plan for oral surgery. A list of these groups is available on the Delta Dental of New Jersey website and is updated on a regular basis. A medical EOB is not required for the groups on the list. ICD-10 codes: The documentation requirements specified in the following table remain in force even if an ICD-10 code is submitted with a claim or a prior authorization. Required Documentation Chart 2016 PS 11/15 Page 1 of 11 ADA CDT-2015 D0140 Description Radiographic Image(s) Limited oral evaluation-problem focused Perio Chart Medical EOB Other Yes, if in conjunction with another procedure that requires a Med EOB Yes, if in conjunction with another procedure that requires a Med EOB Yes, if in conjunction with another procedure that requires a Med EOB Yes, if in conjunction with another procedure that requires a Med EOB Narrative if within 21 days of surgical procedure and Office records (on appeal) D0160 Detailed and extensive oral evaluation - problem focused, by report D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit) D0220D0277 Intraoral radiographic images-8 or more PAs with or without any other intraoral radiographic image of any type D0330 + D0220D0277 Panoramic radiographic images + intraoral radiographic images of any type Yes, if in conjunction with another procedure that requires a Med EOB D0364D0395 Cone beam CT capture and image interpretations and post processing Yes, if in conjunction with another procedure that requires a Med EOB D0415D0431 D0472D0502 D0999 Tests and examinations Yes Oral pathology laboratory Yes D1999 D2140D2799, D6200D6999 D2335 D2390 D2510D2794 D2799 D2931D2933 Unspecified diagnostic procedure, by report Unspecified preventive procedure, by report Restorative procedures Narrative if within 21 days of surgical procedure and Office records (on appeal) If not part of or intended to function as a complete series, submit with tooth numbers for each image and diagnostic purpose for taking the various images If not part of or intended to function as a complete series, submit with tooth numbers for each image and diagnostic purpose for taking the various images If not part of or intended to function as a complete series, submit with tooth numbers for each image and diagnostic purpose for taking the various images Lab report of test performed Pathology report Narrative Narrative Narrative and radiographs if the procedure is performed due to attrition, erosion, abrasion (wear), abfraction, corrosion, or for periodontal, orthodontic, or other splinting. Fixed prosthodontics Resin-based composite - four or more surfaces or involving incisal angle (anterior) Resin-based composite crown, anterior Inlays, onlays and crowns PA Provisional crown - further treatment or completion of diagnosis necessary prior to final impression Stainless steel crowns Prefabricated resin crown PA Required Documentation Chart 2016 PS 11/15 Narrative if within 21 days of surgical procedure and Office records (on appeal) PA PA Photographs (optional) Narrative (optional) Models (optional) Narrative PA If permanent tooth Page 2 of 11 ADA CDT-2015 D2950 D2952D2953 D2954 & D2957 D2960D2962 D2970 D2971 D2975 D2980 D2981 D2982 D2983 D2999 D3110 D3220 D3222 D3230 D3240 D3331 D3332 D3333 D3346 D3347 Description Core buildup, including any pins when required Cast post and core in addition to crown and each additional cast post - same tooth Prefabricated post and core in addition to crown and each additional prefabricated post same tooth Labial veneers Temporary crown (fractured tooth) Additional procedures to construct new crown under existing partial denture framework Coping Crown repair necessitated by restorative material failure Inlay repair necessitated by restorative material failure Only repair necessitated by restorative material failure Veneer repair necessitated by restorative material failure Unspecified restorative procedure, by report Pulp cap - direct (excluding final restoration) 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) Treatment of root canal obstruction; non-surgical access Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth Internal root repair of perforation defects Retreatment of previous root canal therapy - anterior Retreatment of previous root canal therapy - bicuspid Required Documentation Chart 2016 PS 11/15 Radiographic Image(s) PA Perio Chart Medical EOB Other PA PA PA PA DDNJ Requirement Pre-operative photos as necessary Narrative Narrative PA Narrative Narrative Narrative Narrative Narrative PA Operative notes (on appeal) Narrative (if permanent tooth) PA PA PA PA Narrative Narrative PA Narrative PA both preand postoperative xrays PA both preand postoperative xrays Page 3 of 11 ADA CDT-2015 D3348 D3999 D4210 Description Retreatment of previous root canal therapy - molar Unspecified endodontic procedure, by report Gingivectomy or gingivoplasty four or more contiguous teeth or tooth bounded spaces per quadrant D4211 Gingivectomy or gingivoplasty one to three contiguous teeth or tooth bounded spaces per quadrant D4212 Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth Anatomical crown exposure - four or more contiguous teeth per quadrant Anatomical crown exposure - one to three teeth per quadrant Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant D4230 D4231 D4240 Radiographic Image(s) PA both preand postoperative xrays Perio Chart Other Narrative Yes Yes Bitewings Yes, for the following groups ONLY: Toms River BOE (#07166) Yes, for the following groups ONLY: Toms River BOE (#07166) Yes Narrative if more than two quadrants performed on same day. Indicate if it is or is not being used for implant Narrative if more than two quadrants performed on same day. Indicate if it is or is not being used for implant Narrative PA Narrative PA Narrative Yes D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant Yes D4245 Apically positioned flap Yes D4249 Clinical crown lengthening - hard tissue Osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant Osseous surgery (including flap entry and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant Bone replacement grafts PA D4265 D4260 Medical EOB Narrative if more than two quadrants performed on same day. Indicate if it is or is not being used for implant Narrative if more than two quadrants performed on same day. Indicate if it is or is not being used for implant Narrative if implants are being performed PA and/or FMX and/or Pano Yes Narrative if more than 2 quadrants performed on same day PA and/or FMX and/or Pano Yes Narrative if more than 2 quadrants performed on same day PA Yes Biologic materials to aid in soft and osseous tissue regeneration PA Yes Narrative which must indicate if it is or is not being used for implants Narrative which must indicate if it is or is not being used for implants and include type of material used D4266D4267 Guided tissue regeneration - per site PA Yes D4268 Surgical revision procedure, per tooth PA Yes D4261 D4263D4264 Required Documentation Chart 2016 PS 11/15 Yes, if in conjunction with D7955 Narrative which must indicate if it is or is not being used for implants Narrative which must indicate if it is or is not being used for implants Page 4 of 11 ADA CDT-2015 D4270 Description Radiographic Image(s) Perio Chart Soft tissue graft procedures Yes D4273 Autogenous connective tissue graft procedures (including donor and recipient surgical sites) first tooth, implant or edentulous tooth position in graft Yes D4274 Distal or proximal wedge procedure Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant or edentulous tooth position in graft Yes D4276 Combined connective tissue and double pedicle graft, per tooth Yes D4277 Free soft tissue graft procedure (including recipient and donor surgical site), first tooth, implant, or edentulous tooth position in graft Yes D4278 Free soft tissue graft procedure (including recipient and donor surgical site), each additional contiguous tooth, implant, or edentulous tooth position in same graft site Yes D4283 Autogenous connective tissue graft procedures (including donor and recipient surgical sites) each additional contiguous tooth, implant, or edentulous tooth position in same graft site Non-autogenous connective tissue graft (including recipient surgical site and donor material) each additional contiguous tooth, implant, or edentulous tooth position in same graft site Yes D4275 D4285 D4320D4321 Provisional splinting Required Documentation Chart 2016 PS 11/15 Yes Yes PA Medical EOB Other Narrative description of condition; specify amount of attached gingiva, and indicate if it is or is not being used for implants Narrative description of condition; specify amount of attached gingiva, and indicate if it is or is not being used for implants Narrative description of condition; specify amount of attached gingiva, and indicate if it is or is not being used for implants Narrative description of condition; specify amount of attached gingiva, and indicate if it is or is not being used for implants Narrative description of condition; specify amount of attached gingiva, and indicate if it is or is not being used for implants Narrative description of condition; specify amount of attached gingiva, and indicate if it is or is not being used for implants Narrative description of condition; specify amount of attached gingiva, and indicate if it is or is not being used for implants Narrative description of condition; specify amount of attached gingiva, and indicate if it is or is not being used for implants Yes Page 5 of 11 ADA CDT-2015 D4341 Description Periodontal scaling and root planing - four or more teeth per quadrant D4342 Periodontal scaling and root planing - one to three teeth, per quadrant D4381 Localized delivery of chemotherapeutic agents via a controlled release vehicle into diseased crevicular tissue, per tooth D4910 Periodontal maintenance procedures Unspecified periodontal procedure, by report Interim partial dentures D4999 D5810D5821 D5863 Radiographic Image(s) Appropriate radiographs of the affected area taken within 36 months Appropriate radiographs of the affected area taken within 36 months PA DDNJ Requirement Perio Chart Yes Yes Medical EOB Other No more than two quadrants of scaling and root planing (D4341) will be paid on the same date of service. Additional quadrants performed on the same date of service will be disallowed. Disallowed quadrants may be appealed and must include a narrative that explains how much time the patient was (or will be) scheduled for and the reason more than two quadrants of D4341 were performed on the same day of service. Narrative if more than two quadrants performed on same day Yes Post-scaling and root planing and prior to D4381 placement Yes, if third prophy Narrative Narrative Overdenture - complete maxillary Narrative D5864 Overdenture - partial maxillary Narrative D5865 Narrative D5866 Overdenture - complete mandibular Overdenture - partial mandibular D5862 Precision attachment, by report Narrative D5899 Unspecified removable prosthodontic procedure, by report Unspecified maxillofacial prosthesis by report Implant Services Narrative D5999 D6010D6050 D6013 Surgical placement of mini implant D6051 Interim abutment D6110D6117, D6094, D6194 Implant Supported Prosthetics Required Documentation Chart 2016 PS 11/15 Narrative Narrative PA, and/or FMX, and/or Pano PA, and/or FMX, and/or Pano PA 6010 PA 6040 Pano 6050 Pano PA, and/or FMX, and/or Pano PAs must show adjacent teeth Narrative Page 6 of 11 ADA CDT-2015 D6101 D6102 D6103 D6104 D6080, D6090D6095, D6100, D6190, D6199 D6205D6252 D6253 D6545D6792, D6794 D6793 D6980 D6999 D7210 Description Debridement of a periimplant defect and surface cleaning of exposed implant surfaces, including flap entry and closure Debridement and osseous contouring of a periimplant defect; includes surface cleaning of exposed implant surfaces and flap entry and closure Bone graft for repair of periimplant defect - not including flap entry and closure or, when indicated, placement of a barrier membrane or biologic materials to aid in osseous regeneration Bone graft at time of implant placement Other Implant Services Radiographic Image(s) PA and/or FMX and/or Pano Yes PA Yes PA Medical EOB Other Yes PA and/or FMX and/or Pano Yes Narrative Fixed partial denture pontics PA, and/or FMX, and/or Pano Provisional pontic - further treatment or completion of diagnosis necessary prior to final impression Fixed partial denture retainers inlays/onlays and crowns PA, and/or FMX, and/or Pano Provisional retainer crown further treatment or completion of diagnosis necessary prior to final impression Fixed partial denture repair necessitated by restorative material failure Unspecified, fixed prosthodontic procedure, by report Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated PA, and/or FMX, and/or Pano Required Documentation Chart 2016 PS 11/15 Perio Chart Identify all missing teeth in both arches. Use tooth chart if available on claim form Identify all missing teeth in both arches. Use tooth chart if available on claim form and narrative Identify all missing teeth in both arches. Use tooth chart if available on claim form PA, and/or FMX, and/or Pano Identify all missing teeth in both arches. Use tooth chart if available on claim form and narrative Narrative Narrative PA and/or Pano Yes, for the following groups ONLY: Hartford Hospital (#04590) A narrative must be provided that supports the need for surgical removal if the radiograph(s) provided for the tooth/teeth in question do not demonstrate radiographic gross decay, fracture, endodontic treatment, large existing restoration, or anatomic variation. Page 7 of 11 ADA CDT-2015 D7220 D7230 D7240 D7241 D7250 D7251 D7260 D7261 D7270 D7272 D7280 D7282 D7283 D7285D7286 D7287 D7288 D7290 D7291 D7295 D7340 D7350 D7410D7461 Description Removal of impacted tooth - soft tissue Radiographic Image(s) PA and/or Pano Perio Chart Medical EOB Yes, for the following groups ONLY: Capital Health (#03121) Hartford Hospital (#04590) Yes Removal of impacted tooth partially bony Removal of impacted tooth completely bony Removal of impacted tooth completely bony, with unusual surgical complications Surgical removal of residual tooth roots (cutting procedure) PA and/or Pano PA and/or Pano PA and/or Pano Coronectomy - intentional partial tooth removal Oroantral fistula closure PA and/or Pano Primary closure of a sinus perforation Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization) Surgical access of an unerupted tooth Mobilization of erupted or malpositioned tooth to aid eruption Placement of a device to facilitate the eruption of impacted tooth Biopsy of oral tissue PA Yes PA and/or Pano Yes PA and/or Pano Transseptal fiberotomy/supra crestal fiberotomy, by report Harvest of bone for use in autogenous grafting procedures Vestibuloplasty - ridge extension (secondary epithelialization) Vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) Surgical excision of soft tissue and intra-osseous lesions Required Documentation Chart 2016 PS 11/15 Yes Yes Narrative Yes, for the following groups ONLY: Hartford Hospital (#04590) Narrative Yes Narrative and Operative Report Narrative PA and/or Pano PA PA PA Cytology sample collection Brush biopsy - transepithelial sample collection Surgical repositioning of teeth Other Yes Pathology Report Yes Narrative and Pathology Report Narrative and Pathology Report PA Narrative PA and/or Pano Narrative and Operative Report Narrative Yes Operative Report and Narrative (if PTE) Yes Pathology Report Page 8 of 11 ADA CDT-2015 D7465 D7490 D7510D7511 D7520D7521 D7530 D7540 D7550 D7560 D7610D7680 D7710D7780 D7810D7877 Description Radiographic Image(s) Destruction of lesion(s) by physical or chemical method, by report Radical resection of mandible with bone graft Incision and drainage of abscess Intraoral - soft tissue Incision and drainage of abscess Extraoral - soft tissue Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue Removal of reaction-producing foreign bodies, musculoskeletal system Partial ostectomy/sequestrectomy for removal of non-vital bone Maxillary sinusotomy for removal of tooth fragment or foreign body Treatment of fractures - simple Perio Chart Medical EOB Other Yes Narrative Yes Operative Report including Pathology Report and Narrative (if PTE) Narrative Yes Narrative Yes Operative Report and Narrative (if PTE) Operative Report and Narrative (if PTE) Yes Yes Yes Operative Report and Narrative (if PTE) Operative Report and Narrative (if PTE) Operative Report and Narrative (if PTE) Operative Report and Narrative (if PTE) Operative Report and Narrative (if PTE) Yes D7880 Treatment of fractures compound Reduction of dislocation and management of other TMD dysfunctions Occlusal orthotic device D7899 Unspecified TMD therapy Yes, if a surgical procedure Narrative D7910 Suture of recent small wounds up to 5 cm Complicated suturing Yes Narrative Yes Narrative Other repair procedures Yes Narrative Yes Narrative indicating if the procedure is or is not being done in conjunction with implants Narrative indicating if the procedure is or is not being done in conjunction with implants Narrative indicating if the procedure is or is not being done in conjunction with implants Narrative indicating if the procedure is or is not being done in conjunction with implants Narrative indicating if the procedure is or is not being done in conjunction with implants D7911D7912 D7920D7949 D7950 Yes Narrative Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla - autogenous or nonautogenous Sinus augmentation with bone or bone substitutes via a lateral approach PA D7952 Sinus augmentation via a vertical approach PA D7953 Bone replacement graft for ridge preservation PA D7955 Repair of maxillofacial soft and/or hard tissue defect PA D7951 Required Documentation Chart 2016 PS 11/15 PA Yes Page 9 of 11 ADA CDT-2015 D7960 Description Radiographic Image(s) Perio Chart Medical EOB Frenulectomy-also known as frenectomy or frenotomy-separate procedure not incidental to another procedure Other Effective 3/1/2016 (only required for patients that are under two years of age on the date of service): Narrative Photographs (optional) D7970 Excision of hyperplastic tissue per arch D7971 Excision of pericoronal gingiva D7980D7999 D8010D8040 D8050D8060 D8070D8090 D8210D8220 D8660 Other repair procedures D8670 D8680 D8690 D8691 D8692 D8693 D8694 D8999 D9110 D9120 Yes, if natural teeth and/or implants are involved in surgery Narrative Narrative Yes Limited orthodontic treatment Narrative Interceptive orthodontic treatment The following information must be provided on the claim form or via narrative: Comprehensive orthodontic treatment Minor treatment to control harmful habits Pre-orthodontic treatment visit Treatment time, total case fee, initial fee, retention fee. Use narrative to notify DDNJ if treatment is longer or shorter than anticipated. Periodic orthodontic treatment visit (as part of contract) Orthodontic retention (removal of appliances, construction and placement of retainer(s)) Orthodontic treatment (alternative billing to a contract fee) Repair of orthodontic appliance Narrative Replacement of lost or broken retainer Rebonding or recementing of fixed retainers Repair of fixed retainers, includes reattachment Unspecified orthodontic procedure, by report Palliative (emergency) treatment of dental pain - minor procedure Fixed partial denture sectioning D9223 Deep sedation/general anesthesiaeach 15 minute increment D9243 Intravenous moderate conscious sedation/analgesia-each 15 minute increment D9310 Consultation Required Documentation Chart 2016 PS 11/15 Narrative Narrative Narrative Narrative Narrative PA Narrative Yes, if in conjunction with another procedure that requires a Med EOB Yes, if in conjunction with another procedure that requires a Med EOB Yes, if in conjunction with another procedure that requires a Med EOB Narrative and Anesthesia Record if > 1 hr start time/stop time Narrative and Anesthesia Record if > 1 hr start time/stop time Page 10 of 11 ADA CDT-2015 D9450 D9610 D9612 D9630 D9920 Description Radiographic Image(s) Perio Chart Medical EOB Case presentation, detailed and extensive treatment planning Therapeutic parenteral drug, single administration Therapeutic parenteral drugs, two or more administrations, different medications Other drugs and/or medicaments, by report Behavior management, by report Other Narrative Narrative Narrative Narrative Narrative D9930 Treatment of complications (postsurgical) - unusual circumstances, by report D9940 Occlusal guard, by report Narrative D9952 Occlusal adjustment - complete Narrative D9999 Unspecified adjunctive procedure, by report Narrative Required Documentation Chart 2016 PS 11/15 Yes, if in conjunction with another procedure that requires a Med EOB Narrative Page 11 of 11
