Dental Policy Updates
The South Carolina Department of Health and Human Services (SCDHHS) is issuing the following policies for dental providers effective for dates of service on and after April 1, 2018:
- Reimbursement for the following oral surgery procedure codes will require pre-payment review: D7220, D7230, D7240, D7241, D7250. Providers must submit the required documentation, as indicated in the Dental Office Reference Manual (ORM).
- Reimbursement for restorative treatment of retained primary teeth for beneficiaries age 21 years and older will require pre-payment review. Providers must submit radiographs and supporting documentation to justify the need for the procedure in order for the treatment to be reimbursed by SCDHHS. All policies and procedures described in the Dental ORM for restorative procedures for permanent teeth are applicable to restorative treatment for retained primary teeth.
- Reimbursement for restorative procedures is based on the number of surfaces restored, not on the number of restorations per surface, or per tooth. Additionally, reimbursement for a tooth restored within 12-months after the placement of a dental sealant or a restoration by the same provider or provider location is subject to payment adjustment based on the initial service, regardless of the surface combinations involved in the procedure.
- Reimbursement for a tooth extracted within 12-months after the placement of a dental sealant or a restoration by the same provider or provider location is subject to payment adjustment based on the initial service.
- For Medicaid reimbursement, a medically necessary problem-focused exam (D0140) is only allowed with diagnostic services and/or non-planned treatment services that address the reason for the exam. The placement of dental sealants is also allowable on the same date of service as the medically necessary problem-focused exam (D0140); however, there must be documentation of medical necessity justifying the exam. A problem-focused exam for the sole purpose of placing dental sealants is NOT allowed for Medicaid reimbursement.
- For dental extractions, documentation required for submission must be maintained in the patient's records and must include the following:
- A detailed narrative demonstrating medical necessity; AND
- Appropriate pre-treatment diagnostic images such as: intraoral/extraoral radiographs or Computed Tomography (CT) scan that clearly show the affected tooth, its surrounding hard and soft tissues and the adjacent teeth (Note: In rare circumstances, if diagnostic images were not possible to obtain, but patient's physical, mental or environmental status warrants the procedure, the SCDHHS may consider a detailed justification that documents why images were unattainable); AND
- Documentation in support of at least one of the following criteria:
- tooth is determined to be non-restorable
- tooth is compromising the patient's dental health and/or overall health and development
- provider's clinical judgement determines that there is no other alternative treatment option.
For questions regarding this bulletin, please contact the DentaQuest Provider Service Center at (888) 307-6553.
Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.