016.06.07 Ark. Code R. 027
The Child Health Services (EPSDT) periodic and interperiodic dental screening exams consist of an inspection of the oral cavity by a licensed dentist. The purpose of the dental screening exams is to check for obvious dental abnormalities and to assure access to needed dental care. Regular screening exams should be performed in accordance with the recommendations of the Child Health Service (EPSDT) periodicity schedule.
The Child Health Services (EPSDT) periodic dental screening exam is limited to two screening exams per every six (6) months plus one (1) day for individuals under age 21. These benefits may be extended if documentation is provided that verifies medical necessity. See Section 262.100 to view the procedure code for periodic dental screening exams.
Individuals under age 21 enrolled in the EPSDT Program may receive an interperiodic dental screening exam as often as is medically necessary. Prior authorization from the Division of Medical Services Dental Care Unit is required for this service and must be requested on the ADA Claim Form. View or print form ADA-J510 or request prior authorization online with a brief narrative through the Provider Electronic Solutions (PES) Application Software or other vendor software. See Section 262.100 for the interperiodic dental screening exam procedure code.
Infant oral health care examinations must be based on the recommendations of the American Academy of Pediatric Dentistry. Essential elements of an infant oral health care visit are a thorough medical and dental history, oral examination, parental counseling, preventive health education and determination of appropriate periodic re-evaluation. See Section 201.500 for information regarding the dentist's role in the EPSDT Program.
A complete series of intraoral radiographs is allowable within a single state fiscal year (SPY) of July 1 through June 30 only once every five years, any limits may be exceeded based on medical necessity (e.g., traumatic accident).
The following ADA procedure codes are covered by the Arkansas Medicaid Program. These codes are payable for beneficiaries under the age of 21.
Beside each code is a reference chart that indicates whether X-rays are required and when prior authorization (PA) is required for the covered procedure code. If a concise report is required, this information is included in the PA column.
* Revenue code
***(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the covered service.
** Prior authorization is required for panoramic x-rays performed on children under six years of age. (See section 216.100)
ADA Code | Description | PA Yes/No | Submit X-Ray with Treatment Plan Yes/No |
Child He | alth Services (EPSDT) Dental Screening (See sec | tion 215.000) No Yes, and requires report | |
D0120 | *** (CHS/EPSDT Dental Screening Exam) | No | |
D0140 | *** (CHS/EPSDT Interperiodic Dental Screening Exam) | No | |
Radiogra | phs (See sections 216.000 - 216.300) | ||
D0210 | Intraoral - complete series (including bitewings) | No No No No No No No No** Yes | No |
D0220 | Intraoral - periapical - first film | No | |
D0230 | Intraoral - periapical - each additional film | No | |
D0240 | Intraoral - occlusal film | No | |
D0250 | Extraoral - first film | No | |
D0260 | Extraoral - each additional film | No | |
D0272 | Bitewings - two films | No | |
D0330 | Panoramic film | No | |
D0340 | Cephalometric film | No | |
Tests an | d Laboratory | ||
D0350 | Oral/facial photographic images | Yes | No |
D0470 | Diagnostic casts | Yes | No |
Preventi | ve | ||
Dental P | rophylaxis (See section 217.100) | ||
D1120 | Prophylaxis - child *** (ages 0-9) | No No n 217.100) | No |
D1110 | Prophylaxis - adult *** (ages 10-20) | No | |
Topical F | luoride Treatment (Office Procedure) (See Sectio | ||
D1203 | Topical application of fluoride (prophylaxis not included) - child *** (ages 0-20) | No | No |
Dental S | ealants (See section 217.200) | ||
D1351 | Sealant per tooth *** (1st and 2nd permanent molars only) | No | No |
Space M | aintainers (See section 218.000) | ||
D1510 | Space maintainer - fixed - unilateral | Yes Yes Yes | Yes |
D1515 | Space maintainer - fixed - bilateral | Yes | |
D1525 | Space maintainer - removable-bilateral | Yes |
Restorati | ons (See sections 219.000 - 219.200) | ||
Amalgam | Restorations (including polishing) (See section 2 | 19.100) | |
D2140 | Amalgam - one surface | No | No |
D2150 | Amalgam - two surfaces | No | No |
D2160 | Amalgam - three surfaces | No | No |
D2161 | Amalgam - four or more surfaces | No | No |
Composi | te Resin Restorations (See section 219.200) | ||
D2330 | Resin - one surface, anterior, permanent | No | No |
D2331 | Resin - two surfaces, anterior, permanent | No | No |
D2332 | Resin - three surfaces, anterior, permanent | No | No |
D2335 | Resin - four or more surfaces or involving incisal angle, permanent | Yes | Yes |
Crowns - | Single Restoration Only (See section 220.000) | ||
D2710 | Crown - resin (laboratory) | Yes | Yes |
D2752 | Crown - porcelain -ceramic substrate | Yes | Yes |
D2920 | Re-cement crown | No | Yes |
D2930 | Prefabricated stainless steel crown - primary | No | No |
D2931 | Prefabricated stainless steel crown - permanent | Yes | Yes |
Endodon | tia (See section 221.000) | ||
Pulpotom | y | ||
D3220 | Therapeutic pulpotomy (excluding final restoration) | No | No |
D3221 | Gross pulpal debridement, primary and permanent teeth | Yes | No |
Root can | al therapy (including treatment plan, clinical proc | edures an | d follow-up care) |
D3310 | One canal (excluding final restoration) | Yes | Yes |
D3320 | Two canals (excluding final restoration) | Yes | Yes |
D3330 | Three canals (excluding final restoration) | Yes | Yes |
Periapica | l Services | ||
D3410 | Apicoectomy (per tooth) - first root | Yes | Yes |
Periodon | tal Procedures (See section 222.000) | ||
Surgical | Services (including usual postoperative services) | ||
D4341 | Periodontal scaling and root planing | Yes | Yes |
D4910 | Periodontal maintenance procedures (following active therapy) | Yes | Yes |
Complet | e dentures (Removable Prosthetics Services) (See | section 223 | .000) |
D5110 | Complete denture - maxillary | Yes | Yes |
D5120 | Complete denture - mandibular | Yes | Yes |
Partial D | entures (Removable Prosthetic Services) (See sec | tion 223.000 | ) |
D5211 | Upper partial - acrylic base (including any conventional clasps and rests) | Yes | Yes |
D5212 | Lower partial - acrylic base (including any conventional clasps and rests) | Yes | Yes |
Repairs | to Partial Denture (See section 223.000) | ||
D5610 | Repair acrylic saddle or base | Yes | No |
D5620 | Repair cast framework | Yes | No |
D5640 | Replace broken teeth - per tooth | Yes | No |
D5650 | Add tooth to existing partial denture | Yes | No |
Fixed Pr | osthodontic Services (See section 224.000) | ||
D6930 | Re-cement bridge | Yes | No |
Oral Sur | gery (See section 225.000) | ||
Simple E section 2 | xtractions (includes local anesthesia and routine 25.100) | postoperati | ve care) (See |
D7111 | Extraction, coronal remnants-deciduous tooth | No | No |
D7140 | Extraction, erupted tooth or exposed root (elevation and/or forceps removal) | No | No |
Surgical section 2 | Extractions (includes local anesthesia and routin 25.200) | e postopera | tive care) (See |
D7210 | Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth | Yes | Yes |
D7220 | Removal of impacted tooth - soft tissue | Yes | Yes |
D7230 | Removal of impacted tooth - partially bony | Yes | Yes |
D7240 | Removal of impacted tooth - completely bony | Yes | Yes |
D7241 | Removal of impacted tooth - completely bony, with unusual surgical complications | Yes | Yes |
D7250 | Surgical removal of residual tooth roots (cutting procedure) | Yes | Yes |
Other Su | rgical Procedures | ||
D7270 | Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth and/or alveolus | Yes | Yes |
D7280 | Surgical exposure of impacted or unerupted tooth for orthodontic reasons (including orthodontic attachments) | Yes | Yes |
D7285 | Biopsy of oral tissue - hard | Yes | Yes |
D7286 | Biopsy of oral tissue - soft | Yes | Yes |
Osteopla | sty for Prognathism, Micrognathism or Apertogn | athism | |
D7510 | Incision and drainage of abscess, intraoral soft tissue | Yes | No |
Frenulec | tomy | ||
D7960 | Frenulectomy (Frenectomy or Frenotomy) Separate procedure | Yes | Yes |
Orthodo | ntics (See section 226.000) | ||
Minor Tr | eatment of Control Harmful Habits | ||
D8210 | Removable appliance therapy | Yes | Yes |
D8220 | Fixed appliance therapy | Yes | Yes |
Compreh | ensive Orthodontic Treatment - Permanent Den | tition | |
D8070 | Class I Malocclusion | Yes | Yes |
D8080 | Class II Malocclusion | Yes | Yes |
D8090 | Class III Malocclusion | Yes | Yes |
Other Or | thodontic Devices | ||
D8999 | Unspecified orthodontic procedure, by report | Yes | Yes |
Anesthe | sia | ||
D9220 | General Anesthesia - first 30 minutes | Yes | Yes |
D9221 | General Anesthesia - each 15 minutes | Yes | No |
D9230 | Analgesia N20 | No, but requires report for request for more than 1 unit per day | No |
D9248 | Non-I.V. Conscious Sedation | Yes and requires report | No |
Consulta | tions (See section 214.000) | ||
D9310 | ***(Second opinion examination) Consultation, diagnostic service provided by dentist or physician other than practitioner providing treatment | Yes | No |
Outpatie | nt Hospital Services (See section 228.200) | ||
0361* | Outpatient hospitalization - for hospital only | Yes | No |
0360* | Outpatient hospitalization - for hospital only | Yes | No |
0369* | Outpatient hospitalization - for hospital only | Yes | No |
0509* | Outpatient hospitalization - for hospital only | Yes | No |
Smoking | Cessation | ||
D1320 | Tobacco counseling for the control and prevention of oral disease | No | No |
D9920 | Behavior management, by report *** (tobacco counseling) | No | No |
Unclassi | fied Treatment | ||
D9110 | Palliative treatment with dental pain | Yes | No |
016.06.07 Ark. Code R. 027