Or. Admin. Code § 410-123-1620 - Pertaining to Coding
(1) The
Authority requires providers to use the standardized code sets adopted by the
Health Insurance Portability and Accountability Act (HIPAA) and the Centers for
Medicare and Medicaid Services (CMS).
(2) Unless otherwise directed in rule,
providers must accurately code claims according to the national standards in
effect for the date the service(s) was provided.
(3) Procedure codes:
(a) For dental services, and procedures that
are directly related to the teeth and the structures supporting the teeth, use
Current Dental Terminology (CDT) codes as maintained and distributed by the
American Dental Association (ADA). Contact the ADA to obtain a current copy of
the CDT reference manual;
(b) For
physician provided oral health services performed due to an underlying medical
condition (i.e., procedures on or in preparation for treatment of the jaw,
tongue, cheek, roof of mouth), use Health Care Common Procedure Coding System
(HCPCS) and Current Procedural Terminology (CPT) codes; and
(c) Such procedures are covered under the
Authority's medical surgical program (refer to Chapter 410, Division
130).
(4) Diagnosis
codes:
(a) International Classification of
Diseases 10th Clinical Modification (ICD-10-CM) diagnosis codes are not
required for dental services submitted on an ADA claim form; and
(b) When OAR
410-123-1260 requires services
to be billed on a professional claim form, ICD-10-CM diagnosis codes are
required (refer to Chapter 410, Division 130).
(5) Ancillary codes:
(a) Medication and deep sedation are provided
for hospitalization, for conditions appearing above the funding line of the
Prioritized List, and subject to the Prioritized List's ancillary guideline
notes.
(b) Must be medically
necessary and dentally appropriate. Some ancillary codes are not eligible for
separate payment (Refer to OAR
410-123-1260 for more detail on
codes not to be billed separately).
(c) Approved ancillary codes (subject to OAR
410-123-1260) for all members
are as follows:
(A) D7990- Emergency
Tracheotomy;
(B) D9211 - Regional
block anesthesia;
(C) D9212 -
Trigeminal division block anesthesia;
(D) D9220 - Deep sedation/general anesthesia,
first 30 minutes;
(E) D9221 - Deep
sedation/general anesthesia, each additional 15 minutes;
(F) D9222 - Deep sedation/general anesthesia,
first 15 minutes;
(G) D9239 -
Intravenous moderate (conscious) sedation/analgesia, first 15
minutes;
(H) D9310 - Consultation -
diagnostic service provided by dentist or physician other than requesting
dentist or physician; and
(I) D9997
- Dental case management, patients with special health care needs.
(d) D9248 - (non-intravenous
conscious sedation) is covered for EPSDT beneficiaries as follows:
(A) Limited to four (4) times per year for
members age 13 and younger;
(B)
Includes payment for monitoring and Nitrous Oxide; and
(C) Requires use of multiple agents to
receive payment.
(e)
D9410 - (House/extended care facility call) is covered only for urgent or
emergent dental visits that occur outside of a dental office. This code is not
reimbursable for provision of preventive services or for services provided
outside of the office for the provider or facilities' convenience.
Notes
Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.