N.J. Admin. Code § 10:56-3.12 - D9000-D9999 ADJUNCTIVE GENERAL SERVICES

(a) Unclassified treatment:

				Maximum Fee
HCPCS	Allowance
IND	Code	Mod	Procedure Description	S	$	NS
d	D9110	Palliative (Emergency) Treatment	10.00	9.00
of Dental Pain--Minor Procedures

NOTE: Emergency treatment of dental pain or infection, palliative (flat fee for all services performed, when not covered by separately listed procedure). Diagnosis and description of treatment is required. Per tooth or per site.

(b) Anesthesia:

D9210	Local Anesthesia Not in	13.00	11.00
Conjunction with Operative or
Surgical Procedures

NOTE 1: Infiltration and/or nerve block for diagnostic purposes or purposes other than anesthesia.

NOTE 2: Complete report must be available in patient records.

D9211	Regional block anesthesia	13.00	11.00
D9212	Trigeminal division block	18.00	16.00
anesthesia
D9220	22	General Anesthesia	125.00	125.00

NOTE: This code applies when the dentist performing the services (attending dentist) also administers the general anesthesia or in conjunction with oral surgery services only.

(c) Special general anesthesia:

1. (Basic units--See American Society of Anesthesiologists Relative Value Guide--2000).

D9220	General anesthesia--first 30	22.00	22.00
minutes
D9221	General anesthesia--each	11.00	11.00
additional 15 minutes

NOTE 1: Time units are for each additional 15 minute period or major portion thereof limited to "table" or "chair" time only. Maximum reimbursable is two hours.

NOTE 2: The general anesthesia codes above are limited to use in restorative dentistry alone or restorative dentistry in conjunction with other dental services requiring anesthetic management. These codes are reimbursable only to the dentist whose sole function is to administer general anesthesia.

NOTE 3: An anesthesia record must be available which shows elapsed anesthesia time, and pinpoints time and amounts of drugs administered, pulse rate and character, blood pressure, respiration, and so forth.

D9230	Analgesia, anxiolysis, inhalation	15.00	14.00
of nitrous oxide
D9241	Intravenous sedation/	50.00	49.00
analgesia--first 30 minutes

NOTE: Parenteral Conscious Sedation.

D9242	Intravenous sedation/	11.00	11.00
analgesia--each additional 15
minutes

NOTE: Maximum reimbursable is eight units.

D9248

Non-intravenous conscious sedation

40.00

40.00

(d) Professional consultation (diagnostic service provided by a dentist other than practitioner providing treatment):

1. A complete report must be available.

d	D9310	Consultation (diagnostic service	22.00	17.00
provided by dentist or physician
other than practitioner providing
treatment)

(e) Professional visits

D9410	House/extended care facility call	20.50	19.00
D9420	Hospital Call	32.00	27.00

NOTE: Code to be used for Hospital Day--Initial--Inpatient or Same Day Surgery.

D9420

Hospital Call

19.00

17.00

NOTE 1: Code to be used for Hospital Day--Subsequent.

NOTE 2: Consisting of care and treatment by the Practitioner subsequent to date of "Hospital Day--Initial" and including those procedures ordinarily performed during a hospital visit dependent upon the practitioner's discipline.

NOTE 3: Not reimbursable for those services that include follow-up days.

D9430	Office Visit for Observation	9.00	7.00
(During Regularly Scheduled
Hours)--No Other Services Performed

NOTE: Code may also be used when post-operative services are necessary following a major surgical procedure (for example, bony impactions, fractures, etc.)

(f) Drugs:

D9610	Therapeutic Drug Injection	2.50	2.50
D9610	22	Therapeutic Drug Injection	13.00	11.00

NOTE: Injection of one or more muscles of mastication in conjunction with treatment of T.M.J. dysfunction.

d*	D9630	Other Drugs and/or Medicaments, By	BR	BR
Report

(g) Miscellaneous services:

D9910	Application of Desensitizing	6.00	5.00
Medicaments

NOTE 1: Application to tooth/teeth for cervical sensitivity, erosions, etc.

NOTE 2: This code is not to be used for bases, liners or adhesives under restorations.

NOTE 3: Per visit.

D9911	Application of desensitizing resin	35.50	33.00
for cervical and/or root surface,
per tooth

NOTE 1: This code is not to be used for bases, liners or adhesives under restorations.

NOTE 2: Specify tooth code(s).

D9920

Behavior Management

15.00

13.00

NOTE 1: Code to be used for those beneficiaries with developmental and other disabilities whose disorders necessitated an excessive amount of time to accomplish treatment (for example, mental retardation, neurological disorders, etc.). For use of this code, the dentist shall specify the beneficiary's disability which necessitates the use of this code on the MC-10A, Request for Prior Authorization, under Section 20, Remarks where services exceed the thresholds listed in note 2 below.

NOTE 2: Payment will be based on place of service and utilization thresholds in units (one unit equals 15 minutes) as follows:

Place of Service	Utilization Threshold
Office or Clinic	2
Inpatient/Outpatient Hospital	4
Skilled Nursing Facility	2

NOTE 3: The type of disorder and the number of time units requested must be entered on the Dental Services Claim form (MC-10).

NOTE 4: Prior authorization is required for all occurrences of this code that exceed the thresholds.

NOTE 5: Code to be used in addition to other procedures performed.

D9930	Treatment of Complications (Post	9.00	8.00
Surgical)--Unusual Circumstances

NOTE: This code may also be used for post-operative treatment beyond that normally provided as part of the basic procedure or when provided by practitioner other than one who provided the original service or in excess of "follow-up days." (California Relative Value Study--1964), per visit.

D9940

Occlusal Guards

50.00

45.00

NOTE 1: Special periodontal appliance (including occlusal guards and athletic mouth guards).

NOTE 2: Office procedure.

D9940

22

Occlusal Guards

65.00

58.00

NOTE 1: Special periodontal appliance (including occlusal guards and athletic mouth guards).

NOTE 2: Laboratory procedure.

D9951

Occlusal Adjustment--Limited

6.00

5.00

NOTE: One to three teeth.

D9952	22	Occlusal Adjustment--Complete	68.00	60.00
D9971	Odontoplasty 1-2 teeth; includes	6.00	5.00
removal of enamel projections
D9974	Internal bleaching--per tooth	33.00	33.00
d**	D9999	Unspecified Adjunctive Procedure,	BR	BR
By Report

NOTE: To be used only when no code number exists or existing code is not precisely applicable. Complete description of condition and proposed treatment must be submitted to the Medicaid dental consultant.

Notes

N.J. Admin. Code § 10:56-3.12

As amended, R.1981 d.331, effective 9/10/1981.
See: 13 N.J.R. 413(a), 13 N.J.R. 575(a).
Delete text of (e)22 and substitute new text therefor.
As amended, R.1983 d.584, effective 1/1/1984.
See: 15 N.J.R. 1160(a), 15 N.J.R. 2170(a).
Further requirements for reimbursement added.
Amended by R.1986 d.385, effective 9/22/1986.
See: 18 N.J.R. 1337(a), 18 N.J.R. 1958(a).
Substantially amended.
Public notice: Pursuant to the provisions of N.J.S.A. 30:4D-2, 3, 5, 6 and 7 and the New Jersey Appropriations Act (P.L. 1988, c.47), maximum fee allowance increased at (b) Adjunctive general services effective 8/1/1988.
See: 20 N.J.R. 2101(a).
Administrative Correction to (c).
See: 20 N.J.R. 1375(a).
Amended by R.1996 d.428, effective 9/16/1996.
See: 28 N.J.R. 3069(a), 28 N.J.R. 4243(a).
Amended by R.1998 d.353, effective 7/20/1998.
See: 30 N.J.R. 514(a), 30 N.J.R. 2654(a).
In (g), rewrote NOTE 1 and NOTE 4.
Amended by R.2000 d.426, effective 10/16/2000.
See: 32 N.J.R. 2411(a), 32 N.J.R. 3836(a).
Changed Maximum Fee Allowances throughout.
Amended by R.2001 d.10, effective 1/2/2001.
See: 32 N.J.R. 3377(a), 33 N.J.R. 65(a).
In (c)1, substituted "Society" for "College" following "American", and substituted "2000" for "1967" following "Guide--".
Amended by R.2003 d.16, effective 1/6/2002.
See: 34 N.J.R. 2681(a), 35 N.J.R. 232(a).
Rewrote the section.
Amended by R.2003 d.132, effective 3/17/2003.
See: 34 N.J.R. 3921(a), 35 N.J.R. 1424(a).
Rewrote (g).