April 2012

Provider Bulletin Number 12039

Dental Providers Anterior Crowns for Children Effective with dates of service on or after May 1, 2012, D2934 will be considered covered for Title 19 and Title 21 eligible children when placed on anterior primary teeth. Refer to the updated Dental Provider Manual for benefit limitations. Clinic criteria must be met (page 28). D2934: Prefabricated esthetic coated stainless steel crown – primary tooth. Stainless steel primary crown with exterior esthetic coating. Maximum allowable: $140.

Updated Fee Schedule Effective with dates of service on or after May 1, 2012, refer to the updated Medical Assistance Dental Fee Schedule included with this bulletin. Also, refer to the exhibits at the end of the current Dental Provider Manual for benefit plan coverage.

Dental Reminders Primary insurance claims • A copy of the explanation of medical benefits (EOMB) from the primary insurance company is not required by KMAP. To submit claims with other insurance payment on the KMAP website, click the blue bar labeled TPL. Complete the required information from the EOMB and the remainder of the claim form. Click Submit. You must retain the EOMB in your file. • If you choose to submit primary insurance claims on paper, you must enter the actual amount paid by the commercial dental insurance in Field 32, Other Fees. Do not just attach the EOMB or write the third-party liability (TPL) paid amount in the Remarks section. The amount must be written in Field 32. A note can be made in the Remarks section, such as EOB attached. • The KMAP dental program does not require providers to submit medical review narrative, radiographs, or documentation when other insurance is primary and makes payment on the services provided. Payment from the primary insurance must be reported on the claim. Quadrants The following numeric values should be used in Field 25, Area of Oral Cavity, when an arch or quadrant designation is required per the current CDT® Manual, such as D1510, D4211, or D4341. 00 – (EOC) Entire Oral Cavity 10 – (UR) Upper Right Quadrant 01 – (UA) Maxillary Arch 20 – (UL) Upper Left Quadrant 02 – (LA) Mandibular Arch 30 – (LL) Lower Left Quadrant 40 – (LR) Lower Right Quadrant Information about the Kansas Medical Assistance Program (KMAP) as well as provider manuals and other publications is available at https://www.kmap-state-ks.us. For the changes resulting from this provider bulletin, view the updated Dental Provider Manual, Exhibit A, pages EA-1 and EA-10; Exhibit B, page EB-1; Exhibit C, page EC-1; Exhibit D, page ED-2; and Exhibit E, page EE-1. If you have any questions, please contact Customer Service at 1-800-933-6593 (in-state providers) or 785-274-5990 from 8:00 a.m. until 5:00 p.m., Monday through Friday. HP Enterprise Services is the fiscal agent and administrator of KMAP. Page 1 of 6

Kansas Medical Assistance Program Medical Assistance Dental Fee Schedule Title 19 and Title 21 May 1, 2012 Please refer to the exhibits at the end of the Dental Provider Manual for current benefit plan coverage. All codes listed below are not covered under every benefit plan. Code D0120 D0140 D0145 D0150 D0170 D0210 D0220 D0230 D0240 D0250 D0260 D0270 D0272 D0273 D0274 D0277 D0290 D0321 D0322 D0330 D0460 D1110 D1120 D1203 D1351 D1510 D1515 D1525 D1550 D2140 D2150 D2160 D2161 D2330 D2331 D2332 D2335 D2390 D2391 D2392 D2393 D2394 D2710 D2740 D2751 D2752 D2783 D2791 D2792 04/30/2012

Procedure periodic oral evaluation - established patient limited oral evaluation oral eval for patient under 3 years of age comprehensive oral evaluation re-evaluation intraoral - complete series intraoral - periapical 1st film intraoral - periapical each additional intraoral - occlusal film extraoral - 1st film extraoral - each additional bitewing - single film bitewing - two films bitewing - three films bitewing - four films vertical bitewings - 7 to 8 films posterior-anterior or lateral skull film other tmj films - by report tomographic survey panoramic film pulp vitality tests prophylaxis - adult prophylaxis - child topical application of fluoride-child sealant - per tooth space maintainer - fixed - unilateral space maintainer - fixed - bilateral space maintainer - removable - bilateral re-cementation space maintainer amalgam - 1 surface amalgam - 2 surface amalgam - 3 surface amalgam - 4+ surface composite - 1 surface anterior composite - 2 surface anterior composite - 3 surface anterior composite - 4+ surface anterior composite crown - anterior composite - 1 surface posterior composite - 2 surface posterior composite - 3 surface posterior composite - 4+ surface posterior crown - resin crown - porc/ceramic crown - porc/metal base crown - porc/metal noble crown - 3/4 porc/ceramic crown - full metal base crown - full metal noble 1

Maximum Allowance $21.00 $29.35 $29.00 $29.00 $25.00 $60.00 $12.00 $10.00 $18.00 $20.00 $12.50 $14.00 $20.00 $25.00 $29.00 $25.00 $60.00 $60.00 $55.00 $57.00 $15.00 $41.00 $30.00 $17.00 $24.92 $150.00 $210.00 $200.00 $30.00 $53.50 $64.00 $76.00 $91.50 $66.00 $80.00 $95.00 $110.00 $150.00 $70.00 $75.00 $80.00 $95.00 $400.00 $300.00 $450.00 $470.00 $270.00 $216.00 $259.20

Kansas Medical Assistance Program Medical Assistance Dental Fee Schedule Title 19 and Title 21 May 1, 2012 Please refer to the exhibits at the end of the Dental Provider Manual for current benefit plan coverage. All codes listed below are not covered under every benefit plan. Code D2910 D2920 D2930 D2931 D2934 D2940 D2951 D2954 D2957 D3110 D3220 D3221 D3222 D3310 D3320 D3330 D3331 D3351 D3352 D3353 D3410 D3421 D3425 D3426 D3430 D4210 D4211 D4230 D4231 D4268 D4341 D4342 D4355 D5110 D5120 D5211 D5212 D5213 D5214 D5225 D5226 D5281 D5410 D5411 D5421 D5422 D5510 D5520 D5610 04/30/2012

Procedure recement inlay recement crown crown - prefab stainless steel - primary crown - prefab stainless steel - permanent crown - prefab esthetic coated stainless steel – primary sedative filling pin retention - per tooth prefab post & core each additional prefab post pulp cap - direct pulpotomy pulpal debridement - primary and permanent partial pulpotomy for apexogenesis - permanent endodontic therapy - anterior endodontic therapy - bicuspid endodontic therapy - molar treatment of root canal obstruction apexification/recalcification - initial apexification/recalcification - interim apexification/recalcification - final apicoectomy - anterior apicoectomy - bicuspid - first root apicoectomy - molar - first root apicoectomy - each additonnal root retrograde filling - per root gingivectomy/gingivoplasty - 4+ teeth per quad gingivectomy/gingivoplasty - 1 to 3 teeth per quad anatomical crown exposure - 4+ contiguous teeth per quad anatomical crown exposure - one to 3 teeth per quad surgical revision - per tooth scaling and root planing - 4+ teeth per quad scaling and root planing - 1 to 3 teeth per quad full mouth debridement complete denture - max complete denture - mand partial denture - resin base - max partial denture - resin base - mand partial denture - metal base - max partial denture - metal base - mand partial denture - flexible base - max partial denture - flexible base - mand removable unilateral partial denture adjustment - complete denture - max adjustment - complete denture - mand adjustment - partial denture - max adjustment - partial denture - mand repair - complete denture base replace - missing/broken teeth - complete denture repair - partial denture base 2

Maximum Allowance $10.80 $31.00 $120.00 $131.00 $140.00 $30.00 $28.00 $120.00 $110.00 $28.00 $60.00 $60.00 $60.00 $250.00 $275.00 $350.00 $250.00 $60.00 $100.00 $100.00 $90.00 $90.00 $90.00 $90.00 $40.00 $118.80 $30.00 $118.80 $60.00 $30.00 $53.00 $53.00 $58.00 $1,106.14 $1,107.92 $830.35 $843.91 $1,177.06 $1,176.75 $801.90 $801.90 $184.29 $89.10 $89.10 $59.40 $48.17 $132.05 $113.28 $131.25

Kansas Medical Assistance Program Medical Assistance Dental Fee Schedule Title 19 and Title 21 May 1, 2012 Please refer to the exhibits at the end of the Dental Provider Manual for current benefit plan coverage. All codes listed below are not covered under every benefit plan. Code D5620 D5630 D5640 D5650 D5660 D5670 D5671 D5730 D5731 D5750 D5751 D5760 D5761 D5850 D5851 D6100 D6930 D7140 D7210 D7220 D7230 D7240 D7241 D7250 D7260 D7270 D7280 D7285 D7286 D7310 D7320 D7350 D7410 D7411 D7412 D7413 D7414 D7415 D7440 D7441 D7450 D7451 D7460 D7461 D7471 D7472 D7473 D7490 04/30/2012

Procedure repair - cast framework partial denture repair - broken clasp partial denture replace - missing/broken teeth - partial denture add tooth - partial denture add clasp - partial denture replace all teeth - partial denture - max replace all teeth - partial denture - mand reline- complete denture - max - chairside reline- complete denture - mand - chairside reline- complete denture - max - lab reline - complete denture - mand - lab reline - partial denture - max - lab reline - partial denture - mand - lab tissue conditioning - max tissue conditioning - mand implant removal recement bridge extraction - erupted tooth or exposed root extraction - surgical impaction - soft tissue impaction - partially bony impaction - completely bony impaction - completely bony - surgical complications surgical removal of residual roots oroantral fistula closure tooth reimplantation surgical access of unerupted tooth biopsy of oral tissue - hard biopsy of oral tissue - soft alveloplasty in conjunctino with extractions per quad 4+ teeth/spaces alveloplasty w/o extractions per quad - 4+ teeth/spaces vestibuloplasty w/ soft tissue grafts excision benign lesion - 1.25 cm excision benign lesion - >1.25 cm excision benign lesion - complicated excision malignant lesion - 1.25 cm excision malignant lesion - >1.25 cm excision malignant lesion - complicated excision malignant tumor - 1.25 cm excision malignant tumor - >1.25 cm removal odontogenic cyst/tumor - 1.25 cm removal odontogenic cyst/tumor - >1.25 cm removal nonodontogenic cyst/tumor - 1.25 cm removal nonodontogenic cyst/tumor - >1.25 cm removal of lateral exostosis - max or mand removal of torus palatinus removal of torus mandibularis radical resection of mand w/ graft 3

Maximum Allowance $133.65 $59.40 $111.83 $138.87 $170.67 $103.95 $103.95 $242.35 $243.05 $312.61 $314.29 $297.00 $297.00 $96.23 $96.23 By Report $89.10 $60.00 $129.67 $110.00 $150.00 $175.00 $205.00 $110.00 $648.00 $176.00 $200.00 $75.00 $58.00 $167.32 $80.00 $800.00 $75.00 $50.00 $82.08 $125.00 $50.00 $82.08 $42.00 $160.00 $85.00 $242.00 $125.00 $486.00 $100.00 $100.00 $100.00 $750.00

Kansas Medical Assistance Program Medical Assistance Dental Fee Schedule Title 19 and Title 21 May 1, 2012 Please refer to the exhibits at the end of the Dental Provider Manual for current benefit plan coverage. All codes listed below are not covered under every benefit plan. Code D7510 D7511 D7520 D7521 D7530 D7540 D7550 D7560 D7610 D7620 D7630 D7640 D7650 D7660 D7670 D7680 D7710 D7720 D7730 D7740 D7750 D7760 D7770 D7780 D7820 D7860 D7865 D7910 D7911 D7912 D7920 D7955 D7960 D7963 D7971 D7980 D7981 D7982 D7983 D7990 D8010 D8020 D8050 D8060 D8070 D8080 D8210 D8220 D8999 04/30/2012

Procedure incision & drainage - intraoral incision & drainage - intraoral - complicated incision & drainage - extraoral incision & drainage - extraoral - complicated removal of foreign body removal of reaction producing foreign bodies partial ostectomy/sequestrectomy maxillary sinusotomy max - open reduction - teeth immobilized max - closed reduction - teeth immobilized mand - open reduction - teeth immobilized mand - closed reduction - teeth immobilized malar/zygo arch - open reduction malar/zygo arch - closed reduction alveolus - closed reduction - stabilization facial bones - complicated reduction max - open reduction - compound max - closed reduction - compound mand - open reduction - compound mand - closed reduction - compound malar/zygo - open reduction - compound malar/zygo - closed reduction - compound alveolus - open reduction - stabilization - compound facial bones - complicated reduction with fixation closed reduction - dislocation arthrotomy arthroplasty suture of small wounds - 5.0 cm complicated suture - 5.0 cm complicated suture - >5.0 cm skin graft repair soft/hard tissue defect frenulectomy frenuloplasty excision of periocoronal gingiva sialolithotomy excision of salivary gland - by report sialodochoplasty closure of salivary fistula emergency tracheotomy limited ortho - primary limited ortho - transitional interceptive - primary interceptive - transitional comprehensive - transitional comprehensive - adolescent removable appliance therapy fixed appliance therapy unspecified procedure - by report 4

Maximum Allowance $45.00 $45.00 $81.00 $81.00 $60.00 $17.28 $360.00 By Report $340.20 $540.00 $335.00 $201.00 $486.00 $113.40 $216.00 By Report $810.00 $267.57 $335.00 $335.00 $435.50 $335.00 $60.00 $1,000.00 $150.00 $250.00 By Report $60.00 $91.00 $175.00 By Report By Report $145.00 $145.00 $56.00 $20.10 $33.50 $21.60 By Report $270.00 $300.00 $375.00 $1,728.00 $1,728.00 $1,728.00 $1,728.00 $216.00 $305.00 By Report

Kansas Medical Assistance Program Medical Assistance Dental Fee Schedule Title 19 and Title 21 May 1, 2012 Please refer to the exhibits at the end of the Dental Provider Manual for current benefit plan coverage. All codes listed below are not covered under every benefit plan. Code D9212 D9220 D9221 D9230 D9241 D9242 D9310 D9410 D9420 D9610 D9920 D9999

04/30/2012

Procedure trigeminal division block anesthesia deep sedation/general anesthesia - 1st 30 min deep sedation/general anesthesia - each 15 min analgesia/anxiolysis/inhalation of nitrous oxide iv conscious sedation/analgesia - 1st 30 min iv conscious sedation/analgesia - each 15 min consultation - diagnostic service provided by dentist or physician other then requesting dentist or physician house/extended care facility call hospital call therapeutic drug injection - by report behavior management unspecified procedure - by report

5

Maximum Allowance $28.00 $190.00 $85.00 $20.00 $95.00 $35.00 $30.00 $16.20 $75.00 $20.00 By Report By Report