Transcription of ADA Dental Code List Microsoft
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ADA Dental Code List Microsoft
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 o
D0120 Periodic oral evaluation – established patient N/A N/A Preventive D0140 Limited oral evaluation – ... (pathology or operative report if applicable) If submitting under medical, submit diagnosis or narrative. Medical policy 9.02.503 (Computerized Diagnostic Imaging for Complex Maxillofacial Procedures) Preventive D0365 Cone beam CT ...
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