New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 56 - MANUAL FOR DENTAL SERVICES
Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS)
Section 10:56-3.3 - D1000-D1999 PREVENTIVE

Universal Citation: NJ Admin Code 10:56-3.3

Current through Register Vol. 56, No. 18, September 16, 2024

(a) Dental prophylaxis:

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NOTE: Patients 16 years of age or older, maxillary and mandibular arches; includes additional scaling.

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NOTE 1: Patients 16 years of age or older, maxillary or mandibular arch, includes additional scaling.

NOTE 2: Code to be used if patient is edentulous in one arch.

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NOTE: Patients up to and including 15 years of age, maxillary and mandibular arches; includes additional scaling, includes additional scaling.

1. The following codes should be used when a beneficiary is developmentally disabled or neurologically impaired. (See N.J.A.C. 10:56-2.9(a)1 ii.)

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NOTE: Patients 16 years of age or older, maxillary and mandibular arches.

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NOTE: Patients up to and including 15 years of age, maxillary and mandibular arches.

(b) Topical fluoride treatment (office procedure):

1. Topical application of stannous fluoride or acid fluoride phosphate-one treatment following a complete prophylaxis (fee includes both services).

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NOTE: Patients up to and including 15 years of age, maxillary and mandibular arches.

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NOTE: Patients up to and including 15 years of age, maxillary and mandibular arches.

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NOTE: Patients age 16 up to and including 20 years of age, maxillary and mandibular arches.

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NOTE: Patients age 16 up to and including 20 years of age, maxillary and mandibular arches.

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NOTE: Patients age 16 up to and including 20 years of age, maxillary or mandibular arch. Code to be used if patient is edentulous in one arch.

2. The following codes should be used when a beneficiary is developmentally disabled or neurologically impaired (see N.J.A.C. 10:56-2.9(a)1 ii) when the topical application of fluoride in conjunction with a complete prophylaxis (code includes both services) is necessary.

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NOTE: Patients up to and including 15 years of age, maxillary and mandibular arches.

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NOTE: Patients age 16 up to and including 20 years of age, maxillary and mandibular arches.

(c) Other Preventive Services

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NOTE 1: Unfilled premolars and permanent molars.

NOTE 2: Beneficiaries up to and including 16 years of age.

(d) Space Maintenance (passive appliances)

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NOTE: Utilizing band(s) or stainless steel crowning.

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NOTE: Lingual or palatal arch utilizing bands or stainless steel crowning.

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NOTE: The complete description of procedure(s) and the reason(s) the procedure was performed must be included in the report.

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