SECTION 2. Oral Maxillofacial Surgeon Services. Table of Contents

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1 SECTION 2 Table of Contents Table of Contents 1. GENERAL POLICY (Updated 4/1/12) Credentials Clients Enrolled in a Managed Care Plan Clients NOT Enrolled in a Managed Care Plan Billing Definitions Diagnostic Services Radiographic Services Restorative Endodontics Periodontics Prosthodontics Denture Adjustments Oral Surgery Orthodontia Emergency Services Hospitalization I.V. Sedation General Anesthesia Oral Sedation After Hours Office Visit Billing for Supernumerary Teeth NON-COVERED SERVICES (Updated 4/1/12) DENTAL INCENTIVE PROGRAM (Updated 4/1/12) DENTAL PROCEDURE CODES, LIMITS AND CRITERIA (Updated 4/1/12)... 6 SECTION 2 Page 1 of 15

2 4-1 Table Headings Defined... 6 ORAL SURGERY SERVICES DENTAL CODES... 8 CPT CODES OPEN TO ORAL MAXILLOFACIAL SURGEONS (Updated 4/1/12) INDEX SECTION 2 Page 2 of 15

3 1. GENERAL POLICY (Updated 4/1/12) Oral maxillofacial surgeon services are optional services. However, oral maxillofacial surgeon services are mandatory for individuals eligible for Early Periodic Screening, Diagnosis, and Treatment (EPSDT) also known in Utah as Child Health Evaluation and Care (CHEC). References: 42 C.F.R , , , , , ; Utah Department of Health Rule R455-20B. Non-pregnant Adults Age 21 and Older Non-pregnant adults age 21 and older with Traditional Medicaid coverage receive the oral maxillofacial surgeon services described in SECTION 2,, that are physician services, medical or surgical services if performed by an oral surgeon. Effective July 1, 2009, non-pregnant adults are no longer eligible for dental services. Children, ages 0 through 20 and Pregnant Women Children from birth through age 20 and pregnant women continue to be covered for the services described in SECTION 2,, and SECTION 2, Dental Services. 1-1 Credentials Oral Maxillofacial Surgeons licensed in the state where the services are provided may be reimbursed for services. 1-2 Clients Enrolled in a Managed Care Plan (MCP) A Medicaid client enrolled in a managed health care plan must receive all health care services, including medical supplies, through that plan. Refer to SECTION 1 of this manual, Chapter 5, Verifying Eligibility, for information about how to verify a client s enrollment in a plan. For more information about managed health care plans, refer to SECTION 1, Chapter 4, Managed Care Plans. Each plan may offer more benefits and/or fewer restrictions than the Medicaid scope of benefits explained in this section of the provider manual. Each plan specifies services which are covered, those which require prior authorization, the process to request authorization and the conditions for authorization. All questions concerning services covered by or payment from a managed care plan must be directed to the appropriate plan. Medicaid does NOT process prior authorization requests for services to be provided to a Medicaid client who is enrolled in a capitated managed care plan when the services are included in the contract with the plan. Providers requesting prior authorization for services for a client enrolled in a managed care plan will be referred to that plan. A list of MCPs with which Medicaid has a contract to provide health care services is included as an attachment to the provider manual. Please note that Medicaid staff make every effort to provide complete and accurate information on all inquiries as to a client s enrollment in a managed care plan. Because eligibility information as to what plan the patient must use is available to providers, a fee for service claim will not be paid even when information is given in error by Medicaid staff. SECTION 2 Page 3 of 15

4 1-3 Clients NOT Enrolled in a Managed Care Plan (Fee-for-Service Clients) Medicaid clients who are not enrolled in a managed care plan may receive services from any provider who accepts Medicaid. This provider manual explains the conditions of coverage for Medicaid fee-forservice clients. 1-4 Billing Use ADA codes for all dental procedures and CPT codes only when there is not an applicable dental code. Dental services using ADA codes are billed using the ADA 2006 paper claim form. The CMS 1500 (08/05) form must be used to bill when using CPT codes. 1-5 Definitions Refer to SECTION 2, Dental Services, Chapter 1-3, Definitions. 1-6 Diagnostic Services Refer to SECTION 2, Dental Services, Chapter 1-5, Diagnostic Services. 1-7 Radiographic Services Refer to SECTION 2, Dental Services, Chapter 1-6, Radiographic Services. 1-8 Restorative Services Refer to SECTION 2, Dental Services, Chapter 1-8, Restorative Services. 1-9 Endodontics Refer to SECTION 2, Dental Services, Chapter 1-9, Endodontics Periodontics Refer to SECTION 2, Dental Services, Chapter 1-10, Periodontics Prosthodontics Refer to SECTION 2, Dental Services, Chapter 1-11, Prosthodontics Denture Adjustments, Repairs, Rebases, Relines Refer to SECTION 2, Dental Services, Chapter 1-12, Denture Adjustments, Repairs, Rebases, Relines Oral Surgery Refer to SECTION 2, Dental Services, Chapter 1-13, Oral Surgery. In addition to the policy cited in that chapter, tooth reimplantation and/or stabilization of accidentally avulsed or displaced tooth and/or alveolus are covered for children only. SECTION 2 Page 4 of 15

5 1-14 Orthodontia Refer to SECTION 2, Dental Services, Chapter 1-14, Orthodontia 1-15 Emergency Services Refer to SECTION 2, Dental Services, Chapter 1-15, Emergency Services. In addition to the policy cited in that chapter, an oral surgeon shall note the following instructions: 1. If a Medicaid client is assigned to a MCP, the MCP must be billed when the oral surgery procedure is the result of an accident or is an emergency. These procedures most likely will occur in an emergency room or hospital. Typically, these procedures can be billed using the CPT codes recently opened to oral surgeons. If the procedure is truly dental and not medical in nature and not the result of an accident, the procedure shall be billed to Medicaid directly and not the MCP. For more information on clients assigned to a MCP, refer to Chapter 1-2, Clients Enrolled in a Managed Care Plan, and Chapter 1-3, Clients NOT Enrolled in a Managed Care Plan (Fee-for- Service Clients). 2. Remember, when billing Medicaid using CPT codes, use the CMS 1500 (08/05) form. If using dental codes, use the ADA form Hospitalization for Dental Services Refer to SECTION 2, Dental Services, Chapter 1-16, Hospitalization for Dental Services I.V. Sedation Refer to SECTION 2, Dental Services, Chapter 1-17, I.V. Sedation General Anesthesia Refer to SECTION 2, Dental Services, Chapter 1-18, General Anesthesia Oral Sedation Refer to SECTION 2, Dental Services, Chapter 1-19, Oral Sedation After Hours Office Visit Refer to SECTION 2, Dental Services, Chapter 1-20, After Hours Office Visit Billing for Supernumerary Teeth Medicaid supports the nomenclature approved by the ADA for identifying supernumerary teeth. Please bill using the following tooth identifiers for supernumerary teeth: SECTION 2 Page 5 of 15

6 Upper Right Deciduous Teeth Upper Left Upper Right Deciduous Teeth Upper Left Tooth # A B C D E F G H I J Supernumerary # AS BS CS DC ES FS GS HS IS JS Lower Right Deciduous Teeth Lower Left Tooth # T S R O P Q N M L L Supernumerary # TS SS RS OS PS QS NS MS LS KS Upper Right Permanent Teeth Upper Left Tooth # Super # Upper Right Permanent Teeth Upper Left Tooth # Super # Lower Right Permanent Teeth Upper Left Tooth # Super # NON-COVERED SERVICES (Updated 4/1/12) Refer to SECTION 2, Dental Services, Chapter 2, NON-COVERED SERVICES. 3. DENTAL INCENTIVE PROGRAM (Updated 4/1/12) Refer to SECTION 2, Dental Services, Chapter 4, DENTAL INCENTIVE PROGRAM. The Medicaid Agreement Letter is included with Dental Services. 4. DENTAL PROCEDURE CODES, LIMITS AND CRITERIA (Updated 4/1/12) Oral surgeons may use any of the covered codes for dental services, subject to any limits and criteria stated for the procedure code. Dental codes are listed in SECTION 2, Dental Services, Chapter 5, DENTAL PROCEDURE CODES, LIMITS AND CRITERIA. In addition to dental codes, oral surgeons may use the codes listed in this section of the manual. 4-1 Table Headings Defined Code: The code is the Health Common Procedure Code System (HCPCS) code used by Medicaid to identify the item. The procedure codes listed are the only ones accepted by Medicaid. SECTION 2 Page 6 of 15

7 Criteria The criteria listed are required by Medicaid before the item will be reimbursed and include criteria used by Medicaid staff to review a request for prior authorization. Limits Any limits applicable to a procedure code. Coding Notes Codes newly added to the list are in bold print. An asterisk (*) marks where a code is newly removed. Current Dental Terminology (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright 2008 American Dental Association. All rights reserved. Applicable FARS/DFARS Apply. SECTION 2 Page 7 of 15

8 ORAL SURGERY SERVICES DENTAL CODES Note: Effective July 1, 2009, non-pregnant adults on Traditional Medicaid are no longer eligible to receive the dental codes (CDT codes) described in this section. Code Description Criteria Limits D7260 Oroantral fistula closure D7285 D7450 D7451 D7460 D7461 D7465 D7520 D7530 D7540 D7550 D7560 D7610 D7620 D7630 D7640 D7670 D7710 D7720 D7730 D7740 D7910 D7911 D7912 D7920 D7950 Biopsy of oral tissue - hard (bone, tooth) Removal of benign odontogenic cyst or tumor-lesion diameter up to 1.25 cm Removal of benign odontogenic cyst or tumor-lesion diameter > than 1.25 cm Removal of benign nonodontogenic cyst or tumorlesion diameter up to 1.25 cm Destruction, lesion Incision and drainage, abscess, extraoral soft tissue Incision and drainage, abscess, extraoral soft tissue Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue Removal, reaction producing foreign bodies, musculoskeletal system Sequestrectomy for osteomyelitis Maxillary sinusostomy, removal, tooth fragment or foreign body Open reduction maxillary fracture, teeth immobilized Closed reduction maxillary fracture, teeth immobilized Open reduction mandibular fracture, teeth immobilized Closed reduction mandibular fracture, teeth immobilized Alveolus - closed reduction, may include stabilization of teeth Open reduction maxillary compound fracture Closed reduction maxillary compound fracture Open reduction mandibular compound fracture Closed reduction mandibular compound fracture Suture recent small wound, up to 5 cm Suture up to 5 cm, complicated Suture over 5 cm, complicated Skin graft, all information included Osseous graft, mandible Only open to services provided by PCMC Cleft Palate clinic dentist SECTION 2 Page 8 of 15

9 D7955 D7980 D7981 D7982 D7983 D9930 Repair, maxillofacial soft/hard tissue defects, palatoplasty, for cleft palate Sialolithotomy Salivary gland excision, by report Sialodochaplasty Closure fistula salivary Treatment, complication, hospital, post surgical, unusual SECTION 2 Page 9 of 15

10 The following CPT codes are not ONLY to provider type 95 (oral surgeon). Note: All Traditional Medicaid recipients, regardless of age, remain eligible for the following services. CPT CODES OPEN TO ORAL MAXILLOFACIAL SURGEONS (Updated 4/1/12) CPT Code Description Incision and drainage abscess; complicated/multiple Puncture aspiration of abscess, hematoma, bulla or cyst Complex drainage wound and S/post Biopsy of facial tissue Simple repair of superficial wounds of scalp, neck, cm or less to over 30 cm Simple repair of superficial wounds of face, ears, eyelids, nose lips and mucous membranes; 2.5 cm or less to over 30 cm Repair Intermediate, layer closure of wound of scalp, cm or less to over 30 cm Repair Intermediate, layer closure of wound of neck, cm or less to over 30 cm Repair Intermediate, layer closure of wound of face, ears, eyelids, nose lips and mucous membranes; cm or less to over 30 cm Repair Complex, full thickness repair of scalp, neck, face, lips and mouth Removal implant superficial; e.g. buried wire, screw, plate Removal of implant; deep (e.g. buried wire, pin, screw, metal band, nail, rod or plate Removal of contouring of benign tumor of facial bone Excision of benign tumor or cyst of maxilla or zygoma by enucleation and curettage Excision of torus mandibularis Excision of maxillary torus plantines Excision of malignant tumor of maxilla or zygoma Excision of benign cyst or tumor of mandible; by enucleation and curettage Excision of malignant tumor of mandible Excision of benign cyst or tumor of mandible; by enucleation and curettage Close treatment of nasal bone fracture without manipulation Closed treatment of nasal bone fracture; without stabilization with stabilization Open treatment of nasal fracture; uncomplicated complicated, with internal and /or external skeletal fixation With concomitant open treatment of fractured septum Open treatment of nasal septal fracture, with or without stabilization Closed treatment of nasal septal fracture, with or without stabilization Open treatment of nasoethmoid fracture; without external fixation with external fixation Percutaneous treatment of nasoethmoid complex fracture, with splint, wire or headcap fixation, including repair of cathal ligaments and/or nasolacrimal apparatus Open treatment of depressed frontal sinus fracture Open treatment of complicated fontal sinus fracture, via coronal or multiple approach Closed treatment of nasomaxillary complex fracture (LeFort II), with interdental wire fixation or splint Open treatment of nasomaxillary complex fracture (LeFort II), with wiring, local fixation Percutaneous treatment of fracture of malar area, including zygomatic arch and malar tripond, with manipulation Open treatment of depressed zygomatic arch fracture Open treatment of depressed malar fracture, including zygomatic arch and malar tripod Open treatment of complicated fracture(s) of malar area, with fix, multiple approach Open treatment of orbital floor blowout fracture; transantral approach Open treatment of orbital floor blowout fracture; periorbital approach Open treatment of orbital floor blowout fracture; combined approach Closed treatment of fracture of orbit, except blowout ; without manipulation Closed treatment of fracture of orbit, except blowout ; with manipulation Open treatment of fracture of orbit, except blowout ; with our implant SECTION 2 Page 10 of 15

11 21421 Closed treatment of palatal or maxillary fracture (LeFort I type) w interdental wire fixat Open treatment of palatal or maxillary fracture (LeFort I type) Closed treatment of craniofacial separation (LeFort III type) use interdental wire fixation Open treatment of craniofacial separation (LeFort III type) with wire, internal fixation Closed treatment of mandibular or maxillary alveolar ridge fracture, separate proc Open treatment of mandibular or maxillary alveolar ridge fracture, separate proc Closed treatment of mandibular fracture; without manipulation Closed treatment of mandibular fracture; with manipulation Percutaneous treatment of mandibular fracture, with external fixation Open treatment of mandibular fracture with external fixation Open treatment of mandibular fracture, without interdental fixation Open treatment of mandibular fracture, with interdental fixation Open treatment of mandibular condylar fracture Open treatment of complicated mandibular fracture by multiple surgical approaches including internal fixation, interdental fixation, and. or wiring of denture or splint Incision and drainage, deep abscess or hematoma, soft tissues of neck Repair of oromaxillary fistula Sinusotomy, maxillary/radical with removal of antrochoanal polyps Biopsy of lip Excision of lip; transverse wedge excision with primary closure V-excision with primary direct linear closure full thickness, reconstruction with local flap full thickness, reconstruction with cross lip flap Resection of lip, more than one-fourth, with reconstruction Repair lip, full thickness; vermilion only up to half vertical height over one-half vertical height, or complex Drainage of abscess, cyst, hematoma, vestibule of mouth; simple complicated Excision of lesion of mucosa and submucosa, vestible of mouth; without repair with simple repair with complex repair complex, with excision of underlying muscle Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; lingual sublingual, superficial sublingual, deep, supramylohyoid submental space submandibular space masticator space Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; sublingual submental submandibular masticator space Excision of lesion of tongue with closure; anterior two-thirds Excision, lesion of floor of mouth Excision of lesion or tumor, dentoalveolar structures, without repair with simple repair with complex repair Drainage, abscess of plate/uvula Drainage abscess, parotid, simple Drainage abscess, parotid, complicated Drainage abscess, submaxillary/sublingual, intraoral Drainage abscess, submaxillary, external SECTION 2 Page 11 of 15

12 42700 Drainage, peritonsillar abscess Drainage retro/parapharyngeal abscess, intraoral Incision and drainage abscess; retro/parapharyngeal, external Office or other outpatient visit for the evaluation and management of a new patient Office or other outpatient visit for the evaluation and management of an established patient SECTION 2 Page 12 of 15

13 INDEX Alphabetical ADA codes... 4 Agreement Letter... 6 alveolar ridge fracture Anesthesia... 5 benign tumor billing... 5 Billing... 4 Biopsy... 8, 10, 11 CHEC... 3 children... 4 Children... 3 claim forms... 4 Closed reduction mandibular fracture... 4, 8 Closure fistula salivary... 9 complex intermediate complex repair covered services... 9 COVERED SERVICES... 6 CPT codes... 4, 5, 10 CPT Codes... 9 CPT CODES craniofacial separation Credentials... 3 Definitions... 4 dental codes... 5 Dental codes... 6 DENTAL CODES... 8 DENTAL PROCEDURE CODES... 6 dental services... 3, 6 Dental services... 4 Dental Services... 4 dentist... 8 Denture Adjustments... 4 Destruction, lesion... 8 Diagnostic Services... 4 Drainage of abscess, cyst, hematoma, vestibule of mouth Emergency Services... 5 EPSDT... 3 Extraoral incision General Anesthesia... 5 Hospitalization... 5 I.V. Sedation... 5 incision and drainage Incision and drainage... 8, 11 Intraoral incision Limits... 7, 8 LIMITS... 6 managed care plan... 3 Managed Care Plan... 3, 4, 5 mandibular fracture... 8, 11 Maxillary sinusostomy... 8 Medicaid Agreement Letter... 6 nasal bone fracture nasal fracture NON-COVERED SERVICES... 6 non-pregnant adults... 8 Non-pregnant Adults... 3 Numberic by Code numeric by code Numeric by Code SECTION 2 Page 13 of 15

14 D D D D D D D D D D D D D D D D D D D D D D SECTION 2 Page 14 of 15

15 D D D D D D odontogenic cyst or tumor... 8 Office Visit... 5 Open reduction maxillary fracture... 8 Oral Surgery... 4 ORAL SURGERY... 8 ORAL SURGERY SERVICES... 8 Oroantral fistula closure... 8 palatal or maxillary fracture pregnant women... 3 Pregnant Women... 3 prior authorization... 3, 7 procedure codes... 6, 7 PROCEDURE CODES... 6 Radiographic Services... 4 Repair lip Restorative... 4 Restorative Services... 4 Salivary gland excision... 9 septum Sialodochaplasty... 9 Sialolithotomy... 9 simple repair Simple repair sinus fracture Skin graft... 8 Supernumerary Teeth... 5 Suture... 8 Table Headings Defined... 6 tooth reimplantation... 4 SECTION 2 Page 15 of 15