New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 56 - MANUAL FOR DENTAL SERVICES
Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS)
Section 10:56-3.12 - D9000-D9999 ADJUNCTIVE GENERAL SERVICES

(a) Unclassified treatment:

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:

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.

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:

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

(e) Professional visits

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

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.

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:

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

(g) Miscellaneous services:

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.

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

NOTE 2: Specify tooth code(s).

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:

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.

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.

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

NOTE 2: Office procedure.

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

NOTE 2: Laboratory procedure.

NOTE: One to three teeth.

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.