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
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