Chart - Delta Dental of New Jersey

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.
Required Documentation Chart 2015
PS 11/14
Page 1 of 10
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
Narrative if within 21 days
of surgical procedure and
Office records (on appeal)
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
Unspecified diagnostic procedure,
by report
Unspecified preventive procedure,
by report
Restorative procedures
Narrative
Fixed prosthodontics
Narrative and radiographs
if the procedure is
performed due to attrition,
erosion, abrasion (wear),
abfraction, corrosion, or for
periodontal, orthodontic, or
other splinting.
Narrative
Effective 2/1/2015
Resin-based composite - four or
more surfaces or involving incisal
angle (anterior)
Resin-based composite crown,
anterior
Inlays, onlays and crowns
PA
PA
Photographs (optional)
Provisional crown - further
treatment or completion of
diagnosis necessary prior to final
impression
PA
Narrative
Required Documentation Chart 2015
PS 11/14
PA
Page 2 of 10
ADA
CDT-2015
D2931D2933
D2950
D2952D2953
D2954 &
D2957
D2960D2962
D2970
D2971
D2975
D2980
D2981
D2982
D2983
D2999
D3110
D3220
D3222
D3230
D3240
D3331
D3332
D3333
D3346
Description
Stainless steel crowns
Prefabricated resin crown
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
Required Documentation Chart 2015
PS 11/14
Radiographic
Image(s)
PA
If permanent
tooth
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
Page 3 of 10
ADA
CDT-2015
D3347
Description
Retreatment of previous root
canal therapy - bicuspid
D3348
Retreatment of previous root
canal therapy - molar
D3999
Unspecified endodontic
procedure, by report
Gingivectomy or gingivoplasty four or more contiguous teeth or
tooth bounded spaces per
quadrant
D4210
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
PA both preand postoperative xrays
Perio Chart
Yes
Yes
Bitewings
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
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
D4266D4267
D4263D4264
Yes, for the
following groups
ONLY:
Toms River BOE
(#07166)
Yes, for the
following groups
ONLY:
Toms River BOE
(#07166)
Yes
Gingival flap procedure,
including root planing - one to
three contiguous teeth or tooth
bounded spaces per quadrant
D4261
Other
Narrative
D4241
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
Guided tissue regeneration - per
site
PA
Yes
Required Documentation Chart 2015
PS 11/14
Yes, if in
conjunction with
D7955
Narrative which must
indicate if it is or is not
being used for implants
Page 4 of 10
ADA
CDT-2015
D4268
Description
Surgical revision procedure, per
tooth
Radiographic
Image(s)
PA
Perio Chart
Yes
Medical EOB
Other
Narrative which must
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
D4270
Soft tissue graft procedures
Yes
D4273
Subepithelial connective tissue
graft procedures, per tooth
Yes
D4274
Distal or proximal wedge
procedure
Soft tissue allograft
Yes
D4276
Combined connective tissue and
double pedicle graft, per tooth
Yes
D4277
Free soft tissue graft procedure
(including donor site surgery),
first tooth or edentulous tooth
position in graft
Yes
D4278
Free soft tissue graft procedure
(including donor site surgery),
each additional contiguous tooth
or edentulous tooth position in
same graft site
Yes
D4320D4321
D4341*
Provisional splinting
PA
Yes
Periodontal scaling and root
planing - four or more teeth per
quadrant
Effective
1/1/2015
Yes
Narrative if more than two
quadrants performed on
same day
Yes
Narrative if more than two
quadrants performed on
same day
D4275
D4342*
Periodontal scaling and root
planing - one to three teeth, per
quadrant
Yes
Appropriate
radiographs of
the affected
area taken
within 36
months
Effective
1/1/2015
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
Appropriate
radiographs of
the affected
area taken
within 36
months
Required Documentation Chart 2015
PS 11/14
Page 5 of 10
ADA
CDT-2015
D4381
D4910
D4999
D5810D5821
D5863
Description
Localized delivery of
chemotherapeutic agents via a
controlled release vehicle into
diseased crevicular tissue, per
tooth
Radiographic
Image(s)
PA
DDNJ
Requirement
Periodontal maintenance
procedures
Unspecified periodontal
procedure, by report
Interim partial dentures
Perio Chart
Medical EOB
Other
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
Narrative
Narrative
PA, and/or
FMX, and/or
Pano
PA, and/or
FMX, and/or
Pano
PA
6010 PA
6040 Pano
6050 Pano
PAs must show adjacent
teeth
D6013
Surgical placement of mini
implant
D6051
Interim abutment
D6110D6117,
D6094,
D6194
D6101
Implant Supported Prosthetics
PA, and/or
FMX, and/or
Pano
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
PA and/or
FMX and/or
Pano
Yes
PA and/or
FMX and/or
Pano
Yes
PA
Yes
D6102
D6103
D6104
D6080,
D6090D6095,
D6100,
D6190,
D6199
Required Documentation Chart 2015
PS 11/14
PA
Narrative
Yes
Narrative
Page 6 of 10
ADA
CDT-2015
D6205D6252
D6253
Description
Fixed partial denture pontics
Radiographic
Image(s)
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
D7220
Removal of impacted tooth - soft
tissue
PA and/or
Pano
D7230
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
PA and/or
Pano
D6545D6792,
D6794
D6793
D6980
D6999
D7210
D7240
D7241
D7250
D7251
Required Documentation Chart 2015
PS 11/14
Perio Chart
Medical EOB
Other
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
PA and/or
Pano
Yes, for the
following groups
ONLY:
Hartford Hospital
(#04590)
Effective 2/1/2015
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.
Yes, for the
following groups
ONLY:
Capital Health
(#03121)
Hartford Hospital
(#04590)
Yes
Yes
Yes
Narrative
Yes, for the
following groups
ONLY:
Hartford Hospital
(#04590)
Narrative
Narrative and Operative
Report
Page 7 of 10
ADA
CDT-2015
D7260
D7261
D7270
D7272
D7280
D7282
D7283
D7285D7286
D7287
D7288
D7290
D7291
D7295
D7340
D7350
D7410D7461
D7465
D7490
D7510D7511
D7520D7521
D7530
D7540
D7550
D7560
D7610D7680
Description
Radiographic
Image(s)
Oroantral fistula closure
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
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
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
Required Documentation Chart 2015
PS 11/14
Medical EOB
Yes
PA
Yes
PA and/or
Pano
Yes
Other
Narrative
PA and/or
Pano
PA
PA
PA
Cytology sample collection
Brush biopsy - transepithelial
sample collection
Surgical repositioning of teeth
Perio Chart
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
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)
Page 8 of 10
ADA
CDT-2015
D7710D7780
D7810D7877
Description
Radiographic
Image(s)
Perio Chart
Medical EOB
Other
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
Narrative
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
D7970
Excision of hyperplastic tissue per arch
D7971
Excision of pericoronal gingiva
D7980D7999
D8010D8040
D8050D8060
D8070D8090
D8210D8220
D8660
Other repair procedures
D8670
Periodic orthodontic treatment
visit (as part of contract)
Orthodontic retention (removal of
appliances, construction and
placement of retainer(s))
D7951
D8680
Limited orthodontic treatment
Operative Report and
Narrative (if PTE)
Operative Report and
Narrative (if PTE)
PA
Yes
Yes, if
natural teeth
and/or
implants are
involved in
surgery
Narrative
Yes
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.
Required Documentation Chart 2015
PS 11/14
Page 9 of 10
ADA
CDT-2015
D8690
D8691
D8692
D8693
D8694
D8999
D9110
D9120
Description
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
Deep sedation/general anesthesia
D9241D9242
Intravenous conscious
sedation/analgesia
D9310
Consultation
D9450
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
D9612
D9630
D9920
Perio Chart
Medical EOB
Orthodontic treatment (alternative
billing to a contract fee)
Repair of orthodontic appliance
D9220D9221
D9610
Radiographic
Image(s)
Other
Narrative
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
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 2015
PS 11/14
Yes, if in
conjunction with
another procedure
that requires a
Med EOB
Narrative
Page 10 of 10