Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1149 - DENTISTS' SERVICES
PAYMENT FOR DENTISTS' SERVICES
Section 1149.52 - Payment conditions for various dental services

(a) The fee paid by the Department for an inpatient surgical service includes pre-operative and postoperative visits as designated in the MA Program fee schedule.

(b) The Department pays only one dentist for performing a particular surgical service or procedure.

(c) Payment is made at reduced rates for space maintainers, crowns and dentures specified in MA Program fee schedule, if one of the following conditions are met:

(d) Payment is made for dental procedures performed in the short procedure unit of a hospital only if:

(e) Payment is made to dentists for inpatient hospital visits only if the conditions established in § 1150.54(a) (relating to surgical services) are met and daily dental care is provided by the dentist for a condition or diagnosis unrelated to daily medical care provided by a physician.

(f) Payment is made for an outpatient dental consultation only if:

(g) Payment for an inpatient dental consultation is made only if:

(h) Payment for diagnostic radiological services performed in the dentist's office is made only if the dentist performs an oral examination of the patient prior to the radiological service.

(i) Payment is made to the dentist for general anesthesia provided in the office only if the recipient has a diagnosed medical problem, noted in the remarks section of the invoice, where use of local anesthesia is contraindicated as the sole agent in completion of the procedure. A surgical procedure by an oral surgeon or pedodontist need not be documented but it must be indicated in the remarks section of the invoice that the procedure was performed by the appropriate practitioner. However, the remarks section of the invoice does not have to be completed if general anesthesia was specifically included as part of a prior authorization requirement and that request was approved before the procedure was initiated.

(j) Payment is made only if the Department has prior authorized the following:

(k) The fees for dentures include relining and adjustments made during a period of 180 days following insertion of the dentures.

(l) Payment is made for restorative services based on the number of surfaces restored, not on the number of restorations made per surface. For example, two restorations on the same surface of a tooth is considered to be a single restoration of one tooth surface. Fees for services include local anesthesia, polishing, cement bases and necessary medications, if applicable.

(m) The fees for crowns include buildup of the natural crown using either composite or amalgam. Payment for permanent crowns is made for fully developed permanent teeth and deciduous molars with no permanent successor. However, payment is made for stainless steel and temporary plastic crowns when made for primary or developing permanent teeth and not made in conjunction with the construction of a permanent crown.

(n) The fee for root canal therapy includes an apicoectomy if it is performed by the same dentist within 180 days of initial treatment. If an apicoectomy is performed by another dentist within 180 days of the initial treatment, the dentist will receive the fee for an apicoectomy as specified in Chapter 1150 (relating to MA Program payment policies).

(o) Payment for dental services performed on a hospital inpatient basis are compensable if the individual has a concomitant medical illness or handicapping condition and dental services need to be provided. This justification has to be written in the remarks section of the invoice in order for payment to be approved.

(p) Payment for removal of superficial root fragments not completely covered by bone will be considered as a simple extraction or surgical extraction of tooth, erupted.