Transcription of ADA Dental Code List Microsoft - premera.com
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ADA Dental Code List Microsoft - premera.com
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.)
of written report Yes Diagnosis or narrative of condition Preventive D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation, and transmission of written report Yes Diagnosis or …
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