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 D0160 Detailed and extensive oral evaluation problem focused, by report N/A N/A Preventive D0170 Re-evaluation limited, problem focused (established patient.)

(Temporomandibular Joint Dysfunction) Preventive D0320 Temporomandibular joint arthrogram, including injection N/A Not covered under dental. If submitting under medical, submit diagnosis and/or narrative. Medical Policy 2.01.21 (Temporomandibular Joint Dysfunction) Not covered D0321 Other temporomandibular joint radiographic images, by report

  Joint, Dysfunction, Temporomandibular, Temporomandibular joint, Temporomandibular joint dysfunction