ADA Dental Code List Microsoft

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2021 ADA Code List for Microsoft Plans Use this list or our code check tool to confirm if pre-determination (pre-D) or Dental review is required. If more than one class is listed, refer to benefit details for the correct class or submit a pre-D. See PACAAR (PCM) ADA code list or non-individual employer groups ADA code list for all other Premera prefixes. KEY: Red: Authorization/documentation requirements blue : Not covered services Grey: Deleted codes ADA Procedure Code Description Dental Review or Pre-D Documentation Required Class D0120 Periodic oral evaluation established patient N/A N/A Preventive D0140 Limited oral evaluation problem focused N/A N/A Preventive D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver N/A N/A Preventive D0150 Comprehensive oral evaluation new or established patient N/A N/A Preventive

055366 (07-09-2021) An Independent Licensee of the Blue Cross Blue Shield Association . D0350 2D oral/facial photographic image obtained intra-orally or extra-orally N/A Not covered – unless billed for orthodontia work up and orthodontia benefit are available. Provider will need to indicate if taken for orthodontia.

  Blue, Independent, Licensee, An independent licensee of the blue