CPT code Q2034, Q2035, Q2036, Q2037, Q2038 and Q2039

Procedure code and Description

Q2034: Influenza virus vaccine, split virus, for intramuscular use (Agriflu)

Q2035: Influenza virus vaccine, split virus, when administered to individuals 3 years of age & older, for intramuscular use (AFLURIA)

Q2036: Influenza virus vaccine, split virus, when administered to individuals 3 years of age & older, for intramuscular use (FLULAVAL)

Q2037: Influenza virus vaccine, split virus, for use in individuals 3 years of age & older, for intramuscular use (Fluvirin)

Q2038: Influenza virus vaccine, split virus, for use in individuals 3 years of age & older, for intramuscular use (Fluzone)

Q2039: Influenza virus vaccine, split virus, when administered to individuals 3 years of age & older, for intramuscular use


Vaccination:



 An injection of a killed microbe in order to stimulate the immune system against the microbe, thereby preventing disease. Vaccinations, or immunizations, work by stimulating the immune system, the natural diseasefighting system of the body. The healthy immune system is able to recognize invading bacteria and viruses and produce substances (antibodies) to destroy or disable them. Immunizations prepare the immune system to ward off a disease. To immunize against viral diseases, the virus used in the vaccine has been weakened or killed. To only immunize against bacterial diseases, it is generally possible to use a small portion of the dead bacteria to stimulate the formation of antibodies against the whole bacteria. In addition to the initial immunization process, it has been found that the Effectiveness of immunizations can be improved by periodic repeat injections or “boosters.”


Clients age 19 and older

This section applies to clients age 19 and older. Refer to the Professional Administered Drugs Fee Schedule for a listing of covered vaccines for clients age 19 and older. Codes with a fee are paid according to the Professional Administered Drugs Fee Schedule.

Note: DOH supplies free vaccines for children 0-18 years only. For clients 18 years of age and younger, see the agency’s Early and Periodic Screening,

Diagnosis and Treatment (EPSDT) Program Billing Guide.

• Bill the agency for the cost of the vaccine by reporting the procedure code for the vaccine given.
• Bill for the administration of the vaccine using CPT codes 90471 (one vaccine) and90472 (each additional vaccine). Reimbursement is limited to one unit of 90471 and one unit of 90472 (maximum of two vaccines).
• Bill for administration of nasal vaccine using CPT code 90473 (one vaccine) and 90474 (each additional vaccine). Reimbursement is limited to one unit of 90473 and one unit of 90474 (maximum of two vaccines).
• Providers are reimbursed for the vaccine using the agency’s maximum allowable fee schedule.
• Providers must bill 90471 and 90472 on the same claim as the procedure code for the vaccine.

If an immunization is the only service provided, bill only for the administration of the vaccine and the vaccine itself (if appropriate). Do not bill an E/M code unless a significant and separately identifiable condition exists and is reflected by the diagnosis. In this case, bill the E/M code with modifier 25. If the E/M code is billed without modifier 25 on the same date of service as a vaccine administration, the agency will deny the E/M code. Exception: The E/M code 99211 cannot be billed with a vaccine or the vaccine administration code.

Note: Meningococcal vaccines (CPT codes 90733 and 90734) require EPA. See EPA #870000421.

For Medicare beneficiaries, the seasonal influenza vaccine is usually administered once a year during the fall or winter months. Additional influenza vaccines (ie, the number of doses of a vaccine or the type of influenza vaccine) are covered by Medicare when medically necessary. Influenza vaccine plus its administration is a covered Part B benefit. Influenza vaccine is NOT a Part D covered drug.


FREQUENTLY ASKED QUESTIONS

Does the Medicare Part B deductible, coinsurance, or copayment apply for Part B-covered immunizations?
When physicians or suppliers agree to accept assignment, the Part B deductible, coinsurance, or copayment do not apply to the seasonal influenza virus, pneumococcal, and Hepatitis B vaccines or their administration.

If a beneficiary gets a seasonal influenza virus vaccine twice in a 12-month period, will Medicare still pay for it?
Yes, Medicare pays for one seasonal influenza virus vaccination per influenza season; however, a beneficiary could get the seasonal influenza virus vaccine twice in a calendar year for two different influenza seasons, and Medicare would pay the provider for each. For example, a beneficiary who received a seasonal influenza virus vaccination in January 2018 for the 2017–2018 influenza season could receive another seasonal influenza virus vaccination in November 2018 for the 2018–2019 influenza season, and Medicare would pay for both vaccinations.

Should providers administer the pneumococcal vaccination if a beneficiary is uncertain of his or her vaccination history?

Yes, if a beneficiary is uncertain about his or her vaccination history, and the provider cannot obtain verification from the beneficiary’s medical records, provide the vaccine. Medicare beneficiaries are eligible for the initial pneumococcal vaccine and a different pneumococcal vaccine one year after the first vaccine (at least 11 months have passed following the month when the last pneumococcal vaccine was administered).

Beneficiaries may be liable for the costs of the revaccination if they exceed the benefit maximum or if the timing of these services is sooner than the required 11 full months following the month of the last pneumococcal vaccine. We encourage providers to closely track vaccination history.

Does Medicare cover the hepatitis B vaccine for all Medicare beneficiaries?

No, Medicare covers the hepatitis B vaccine for certain beneficiaries at intermediate to high risk for the hepatitis B virus (HBV). These individuals include health care professionals who have frequent contact with blood or blood-derived body fluids during routine work, individuals with End-Stage Renal Disease (ESRD), individuals living with an HBV carrier, and individuals diagnosed with diabetes mellitus. Other situations could qualify a beneficiary as being at intermediate or high risk of contracting HBV. Medicare beneficiaries not eligible for this benefit are those currently positive for hepatitis B antibodies.

CPT 99050, 99051, 99053, 99056, 99058, 99060 - Service after hours

Procedure code and description

99050 Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (eg, holidays, Saturday or Sunday), in addition to basic service

99051 Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service

99053 Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service

99056 Service(s) typically provided in the office, provided out of the office at request of patient, in addition to basic service

99058 Service(s) provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service

99060 Service(s) provided on an emergency basis, out of the office, which disrupts other scheduled office services, in addition to basic service



Services Outside of Business Hours
Texas Medicaid limits reimbursement for after-hours charges (procedure codes 1-99050, 1-99056, and 1-99060) to office-based providers rendering services after routine office hours and/or on an emergency basis. An office-based provider may bill an after hours charge in addition to a visit for providing services after his/her routine office hours. This should be billed when a provider, in his/her clinical judgment, deems it medically necessary to interrupt his/her schedule to care for a client with an emergent condition. A provider’s routine office hours are those hours posted at the physician’s office as the usual office hours.

Texas Medicaid reimburses office-based physicians an inconvenience charge when any of the following exists:

The physician leaves the office or home to see a client in the emergency room.

The physician leaves the home and returns to the office to see a client after the physician’s routine office hours.

The physician is interrupted from routine office hours to attend to another client’s emergency outside of the office. Charges for inconvenience or after hours services, by emergency department-based physicians or emergency department-based groups are not reimbursed separately.


Policy Overview

After hours or weekend care (CPT®) codes represent services provided,when anindividual physicianor other health care professionalis required to render the services outside of regular posted office hours to treat a patient's urgent illness or condition.This policy outlines when after hours or weekend care codes are considered for separate reimbursement.

Reimbursement Guidelines

The Centers for Medicare and Medicaid Services (CMS) considers reimbursement for Current Procedural Terminology (CPT®) codes 99050, 99051, 99053, 99056, 99058 and 99060 to be bundled into the payment for other services provided on the same day.

CPT Codes 99053, 99056, 99058 or 99060

Consistent with CMS, UnitedHealthcare will not separately reimburse CPT codes 99053, 99056, 99058 or 99060.

CPT Codes 99050 and 99051

Although CMS considers CPT codes 99050 and 99051 to be bundled into the payment for other services provided on the same day, UnitedHealthcarewill provide additional compensation to participating primary care providers for seeing patients in situations that would otherwise require more costly urgent care or emergency room settings by reimbursing CPT code 99050 in addition to basic servicesand CPT code 99051 in addition to acute care services (not preventive  medicine codes).

UnitedHealthcare will reimburse after hours CPT codes99050 and 99051 to participating primary care providers when reported in one of the following CMS non-facility place of service (POS) designations only:

**School (CMS POS 03)
**Indian Health Service Free-standing Facility (CMS POS 5)
**Tribal 638 Free-Standing Facility (CMS POS 7)
**Office (CMS POS 11)**Independent Clinic (CMS POS 49)
**Federally Qualified Health Center (CMS POS 50)
**State or Local Public Health Clinic (CMS POS 71)
**Rural Health Clinic (CMS POS 72)UnitedHealthcare will reimburse the following participating primary care providers for CPT codes 99050and 99051:
**Adolescent Medicine, Pediatric-Adolescent, Pediatrics    
**Family Nurse Practitioner, Nurse Practitioner, Pediatric Nurse Practitioner, Advanced Registered Nurse Practitioner     
**Family Practice**General Practice**Geriatric Medicine**Gynecology, Obstetrics & Gynecology, Obstetrics**Internal Medicine**Certified Nurse Midwife


Q: Why doesn't UnitedHealthcare provide reimbursement for CPT codes 99053, 99056, 99058 or 99060?
A:The After Hours and Weekend Care policy is intended to reimburse participating primary care providers for services that are outside their regular posted business hours as an alternative to more costly emergency room or urgent care center services. Reimbursement for CPT codes 99053, 99056, 99058 or 99060 would not accomplish this purpose and are not reimbursed by CMS.

2Q:  When will UnitedHealthcare provide reimbursement for CPTcode 99050?
A:  UnitedHealthcare will provide reimbursement for CPT code 99050 during times other than regularly scheduledoffice hours, or days when the office is normally closed(eg, holidays, Saturday or Sunday), in addition to basic service.

3Q:  When will UnitedHealthcare provide reimbursement for CPT code 99051?
A:  UnitedHealthcare will provide reimbursement for CPT code 99051 during regularly scheduled evening, weekend, or holiday office hours, in addition to acute care services (not preventive medicine services).


CPT Code 99050 and 99051

Although CMS considers CPT codes 99050 and 99051 to be bundled into the payment for other services provided on the same day, Oxford will provide additional compensation to participating primary care providers for seeing patients in situations that would otherwise require more costly urgent care or emergency room settings by reimbursing CPT code 99050 in addition to basic service codes and CPT code 99051 in addition to acute care services (not preventive medicine codes).

Oxford will reimburse after hours CPT code s99050and 99051 to participating primary care providers when reported with basic services in one of the following CMS non-facility place of service (POS) designations only:

POS Code Description

03 School
05 Indian health service free-standing facility
07 Tribal
638 free-standing facility
11 Office
49 Independent clinic
50 Federally qualified health center
71State or local public health clinic
72 Rural health clinic

Oxford will reimburse the following participating primary care providers for CPT codes 99050and 99051:

* Adolescent medicine, pediatric-adolescent, pediatrics
* Family nurse practitioner, nurse practitioner, pediatric nurse practitioner, advanced registered nurse practitioner
* Family practice
*General practice
* Geriatric medicine
* Gynecology, obstetrics & gynecology, obstetrics
* Internal medicine
* Certified nurse midwif


POLICY from BCBS insurance
CPT 99050 is reported when services are provided in the office at times other than regularly scheduled office hours or days when the office is normally closed. The Health Plan refers to this time as “After Hours,” and defines “After Hours” as services rendered between 5:00 p.m. and 8:00 a.m. on weekdays, and anytime on weekends and holidays when the office is usually closed.

CPT code 99050 is eligible for separate reimbursement, in addition to the basic covered service, if the basic service provided meets all of the criteria described below:

• It is reported with an office setting place of service;
• It is rendered at a time other than the practice’s regularly scheduled and/or posted office hours;
and
• The basic service time is based on arrival time, not actual time services commence.

CPT code 99050 is not eligible for separate reimbursement when it is reported with a preventive diagnosis and/or a preventive service.

CPT code 99051 is reported when services are provided in the office during regularly scheduled evening, weekend, or holiday office hours. CPT code 99051 is eligible for separate reimbursement, in addition to the basic covered service, if the basic service provided meets all of the criteria described below:

• It is reported with an office setting place of service; and
• The basic service time for evening hours is based on arrival time, not actual time the service commenced.
Adjunctive E/M services described by the codes 99053, 99056, 99058, and 99060 are not eligible for separate reimbursement.

CPT G0446. G0447, G0473 - Obesity counseling

CPT code and Description

G0446 – annual, face-to-face intensive behavioral counseling (IBT) for cardio-vascular disease (CVD), individual, 15 minutes

G0447 – face-to-face behavioral counseling for obesity, 15 minutes

G0473 – face-to-face behavioral counseling for obesity, group (2–10), 30 minutes.

Reimbursement Guidelines

For eligible adult health plan members with obesity, defined as Body Mass Index (BMI) equal toor greater than 30 kg/m2, Optum will align reimbursement with Medicare including:

One face-to-face visit every week for the first month;
One face-to-face visit every other week for months 2-6; and
One face-to-face visit every month for months 7-12 [if the member meets the 3kg (6.6 lbs.) weight loss requirement during the first 6 months.

  For adult members who do not achieve a weight loss of at least 3 kg (6.6 pounds) during the first 6 months of intensive therapy, a reassessment of their readiness to change and BMI is appropriate after an additional 6-month period.

These visits must be provided by a qualified health care provider.For eligible children and adolescent (6-18 years) health plan members with overweight, defined as having an age/gender-specific BMI at or above the 85th percentile, Optum will align reimbursement with the recommendations of the U.S. Preventive Services Task Force.

CPT codes for obesity screening and counseling are: 

• 99401 – preventive medicine counseling and/or risk factor intervention/s provided to an individual (separate procedure); approximately 15 minutes

99402 – preventive medicine counseling and/or risk factor intervention/s provided to an individual (separate procedure); approximately 30 minutes

HCPCS codes related to obesity screening and counseling are:

G0446 – annual, face-to-face intensive behavioral counseling (IBT) for cardio-vascular disease (CVD), individual, 15 minutes•

G0447 – face-to-face behavioral counseling for obesity, 15 minutes

G0473 – face-to-face behavioral counseling for obesity, group (2–10), 30 minutes.

Modifier Description
GQ Via asynchronous telecommunications system

GT Via interactive audio and video telecommunication systems

Place of Service Code Description

02   Telehealth11Physician’s office

19   Off Campus-Outpatient Hospital

22   On Campus-Outpatient hospital

Billing Requirements - Medicare Guidelines

Diagnostic Codes


Effective for claims with dates of service on or after November 29, 2011, Medicare will recognize HCPCS code G0447, Face-to-Face Behavioral Counseling for Obesity, 15 minutes. G0447 must be billed along with 1 of the ICD-9 codes for BMI 30.0 and over (V85.30-V85.39, V85.41-V85.45). The type of service (TOS) for G0447  is 1.  (ICD-10 codes will be Z68.30-Z68.39, Z68.41- Z68.45)

Effective for claims with dates of service on or after November 29, 2011, Medicare contractors will deny claims for HCPCS G0447 that are not submitted with the appropriate diagnostic code (V85.30-V85.39, V85.41-V85.45).

Claims submitted with HCPCS G0447 that are not submitted with these diagnosis codes will be denied with the following messages:

•Claim Adjustment Reason Code (CARC) 167 – "This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present."

•Remittance Advice Remark Code (RARC) N386 – "This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp

•Group Code PR (Patient Responsibility), assigning financial responsibility to the beneficiary (if a claim is received with a GA modifier indicating a signed ABN is on file). . If you do not have web access, you may contact the contractor to request a copy of the NCD."

•Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a claim is received with a GZ modifier indicating no signed ABN is on file)



Insurance Coverage

For Medicare beneficiaries with obesity, who are competent and alert at the time that counseling is provided and whose counseling is furnished by a qualified primary care physician or other primary care practitioner and in a primary care setting, CMS covers

• One face-to-face visit every week for the first month;
• One face-to-face visit every other week for months 2-6;
• One face-to-face visit every month for months 7-12, if the beneficiary meets the 3kg (6.6 lbs) weight loss requirement as discussed below

At the six-month visit, a reassessment of obesity and a determination of the amount of weight loss must be performed. To be eligible for additional  face-to-face visits occurring once a month for an additional six months, beneficiaries must have achieved a reduction in weight of at least 3kg (6.6 lbs)  over the course of the first six months of intensive therapy. This determination must be documented in the physician office records for applicable beneficiaries consistent with usual practice. For beneficiaries who do not achieve a weight loss of at least 3kg (6.6 lbs) during the first six months of intensive therapy, a reassessment of their readiness to change and BMI is appropriate after an additional six month period.


Intensive behavioral intervention should be consistent with the 5-A framework:

1. Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.

2. Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.

3. Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior.

4. Assist: Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed-upon goals by acquiring the skills, confidence and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.

5. Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.Effective July 2, 2012, for claims processed with dates of service on or after November 29, 2011, Medicare will pay for G0447 with appropriate ICD-9  code no more than 22 times in a 12-month period. 

Effective January 1, 2015, for claims processed with dates of service on or after January 1, 2015, Medicare  will pay for G0447 and G0473 with appropriate ICD-9 code (ICD-10-CM code beginning October 1, 2015) no more than 22 times in a 12-month period

Medical billing specialist Job - Profile, skillset and duties

Lucrative career opportunities for medical billing specialists

When you think of large hospital networks, the first picture that comes to mind are doctors and nurses who are perhaps working relentlessly round the clock to restore the health of individuals who are suffering from some disease or injury. But to ensure that medical practitioners can concentrate on their jobs and the families of patients do not face any trouble, there is a large support group providing services round the clock as well.

Skillset required to become a medical billing specialist

Medical billing specialist jobs require a high level of understanding and analytics. If you are interested in becoming a medical billing specialist you must have a thorough knowledge of medical terminology, healthcare coding and collection system on the one hand and have excellent knowledge of the healthcare reimbursement process, debt collection laws, excellent coding and analytical skills on the other.

* Medical terminology
• Physiology and anatomy
• Medical billing instructions
• Medical coding instructions
• Knowledge in Medical software for billing.
• Working independently
• Paying Detailed attention
• Understanding the anatomy and physiology
• Knowing diagnosis and procedure coding
• Being able to think critically
• Communicate effectively
• Understanding the terminology
• Knowing how to enter the information in the insurance claim forms


 It is not just your professional expertise that matters as a medical billing specialist. There are several other soft skills required to become a medical billing specialist. For instance, you must excellent communication capabilities and the desire to provide great customer service. It is important for you to bear in mind that you have to be especially sensitive to the needs of the patients’ families who are not in the best frame of mind with a loved one in the hospital.

If you think you have it in you to become a medical billing specialist, after having gone through the extensive list of requirements that we have pointed out here, it is time to answer the next question that you have now about How do I become a medical billing specialist


Education and training required to attain a job


To become a medical billing specialist, you may opt for a training programme that is of a nine month- to a year long course that is offered at allied health schools or even at some vocational or technical schools. Alternatively, you can check out the two years associate degree programmes that community colleges provide for certification as a medical billing specialist.

There are several other online programmes or distant learning opportunities that you can choose from, for basic training and certification as a medical training specialist. At this point, however we need to bring to your attention that while certification is not mandatory to get a job as a medical billing specialist, it certainly gives you an edge over other candidates when you are in the process of seeking employment.

Further, with a certification will also enhance the potential of you receiving a higher salary than those who do not have any certification or formal training as a medical billing specialist. An individual without any certification may have to show 1-3 years’ experience in working with an established medical care provider to be able to procure a job, whereas with specialized training and certification you are likely to be employed without any experience to show.

Having understood how to become a medical billing specialist, the responsibilities the job entails and the training and certification it requires, you would perhaps eager to know at this stage, how much do billing specialist make. The range of salary of a medical billing specialist falls in the range of $ 38,000 to $45,000 in the present year. However, as mentioned earlier, salaries may vary greatly depending upon many factors such as education, training, experience and additional skills to mention a few.

Duties involved in Medical billing specialist

Medical billing duties There are tasks you are supposed to do in virtually every day and every position:

• Maintaining up- to-date on insurance claims regulations and rules.
• Sending claims and statements to patients.
• Entering charges to the accounts of patients in the software.
•  Post payments and reimbursement to patients’ claims.
•Follow up to  insurance regarding unpaid claims.
• Sending appeal rejected or not payable claims.
• Keep insurance and law employees informed.
• Ensure the request and receipt of prior authorization.


Job profile of a medical billing specialist

With hospital administration getting superior each day with use of technology one of jobs that is in high demand in the medical profession is that of a medical billing specialist. The question that you are likely to ask at this point is what are the duties of medical billing specialist. Here is what you need to know if you are interested in the same.

Medical billing specialists are trained professionals who are entrusted with cash flow of the hospital administration. Thus, their duties entail the coding and processing of the information that they receive from the medical care providers, translate it onto the invoice. They also work closely with the patient parties, the insurance companies and the government agencies to ensure that payments go through smoothly, without any hassle to both the patient party on the one hand and the medical care providers on the other



Opportunities galore for medical billing specialists today

The career opportunities for medical billing specialists are vast in the modern-day context. As a trained and certified medical biller, you are likely to be absorbed in medical facilities such as hospitals, clinics, private practices among other. Further, there are many government agencies and insurance providers are also increasingly hiring medical billing specialists as processes are becoming more detailed.

Employment in most of these organizations is a full-time engagement, during normal business hours. After gaining certain years of experience you may also seek opportunities to work as contract employee and accept work of more than one facility or physician and opt to work from home. Thus, as you can see, the job of a medical billing specialists is a rather lucrative one, with opportunities in healthcare expanding by leaps and bounds. Thus, if you have it in you to become one, it is prudent to seek certification and training for the job right away. 


Medicaid coverage on specaility dental, general dental

Medicaid Coverage of Dental Benefits for Adults

Key Points


• Poor oral health is widespread among adults in the United States and especially affects those with low incomes.

– Adults with incomes below 100 percent of the federal poverty level (FPL) are three times more likely to have untreated dental caries—commonly known as cavities—than adults with incomes above 400 percent FPL.

– Thirty-seven percent of adults age 65 and older with incomes below 100 percent FPL had complete tooth loss compared to 16 percent of those with incomes at or above 200 percent FPL.

• Individuals with a range of chronic conditions are more susceptible to oral disease.

Oral disease can also exacerbate chronic disease symptoms. Poor oral health can limit communication, social interaction, and employability.

• Medicaid programs are required to cover dental services for children and youth under age 21 but there are no minimum coverage requirements for adults. As a result, adult dental benefits vary widely across states. For example, as of February 2015:

– 19 states provided emergency-only adult dental benefits for non-pregnant,

non-disabled adults;
– 27 states covered preventive services;
– 26 states covered restorative services;
– 19 states covered periodontal services;
– 25 states covered dentures;
– 25 states covered oral surgery;
– 2 states covered orthodontia; and
– 9 states placed an annual dollar limit
on covered dental services.


• States change Medicaid coverage of adult dental benefits on a regular basis, cutting benefits when budgets are tight and expanding them when more funds are available.

• Initiatives to improve access to dental services include using mobile clinics and telehealth technologies, increasing the number of providers serving Medicaid enrollees, and funding demonstrations to encourage Medicaid enrollees to increase dental utilization. For example:

– In 2014, the Health Resources and Services Administration supported 238 school-based health center oral health activities through capital grants.

– The National Health Service Corps and some states offer student loan repayment assistance to dentists who commit to working in high-need, underserved, or rural areas.

– Minnesota and Alaska have amended state scope-of-practice laws to allow mid-level dental practitioners to provide dental services.



 Types of Adult Dental Services Covered for Non-Pregnant, Non-Disabled Adults under Medicaid, 2015

Type of service Number of states Services typically included Emergency only 18 Emergency extractions, other procedures for immediate pain relief



 More extensive 33

 Preventive 28 Examinations, cleanings, and sometimes fluoride application or sealants

 Restorative 26 Fillings, crowns, endodontic (root canal) therapy

 Periodontal 19 Periodontal surgery, scaling, root planing (cleaning below the gum line)

 Dentures 26 Full and partial dentures

 Oral surgery 25 Non-emergency extractions, other oral surgical procedures

 Orthodontia 2 Braces, headgear, retainers




Children’s Dental Services Covered by the All Kids Program or the Early Periodic Screening, Diagnosis and Treatment (EPSDT) Program:

Type of Service Frequency Age Range Additional Details


Exam   --     Every six months 0-20 years old Completion of mandated school dental exam form is considered part of the oral exam; Exam necessary even if no pain/problems exists


Cleaning    --     Every six months 0-20 years old Routine prophylaxis

Fluoride    -Three treatments every 12 months   -0-2 years old           every 12 months- One treatment 3-20 years old -

ealants Once per lifetime 5-17 years old


X-Rays -- One complete set every three years 0-20 years old

Fillings One per tooth per 12 months 0-20 years old


Crowns One per tooth per 60 months 0-20 years old Pre-authorization and x-ray documentation required*


Extractions -- 0-20 years old Removal of teeth free from pathology is not covered; some extractions require prior authorization*


Root Canals -- One per tooth per lifetime 0-20 years old Refer to the Dental Office Reference Manual (DORM) as additional guidance and limitations
may exist*




SPECIALTY DENTAL BENEFITS


Specialty dentistry refers to services that are not covered under the Medicaid dental benefit but are covered for CSHCS enrollees who have a qualifying diagnosis that may include specialty dental services. Services include, but are not limited to, dental implants, orthodontia and specialty crown and bridge. All CSHCS beneficiaries do not qualify for specialty dental services. Qualification for specialty dental services is based on the specific diagnoses and treatment plan. Examples of CSHCS diagnoses that may qualify for specialty dental services include:

* Amelogenesis imperfecta, Dentinogenesis imperfecta

* Anodontia which has significant effect on function

* Cleft palate

* Ectodermal dysplasia, epidermolysis bullosa with significant tooth involvement

* Juvenile periodontosis

* Juvenile rheumatoid arthritis and related connective tissue disorders with jaw dysfunction secondary to tempromandibular joint arthritic involvement

* Post-operative care related to neoplastic jaw disease

* Severe malocclusion requiring orthognathic surgery

* Severe maxillofacial or craniofacial anomalies that require surgical intervention

* Traumatic injuries to the dental arches

To request approval as a CSHCS Specialty provider, dentists must contact MDHHS. (Refer to the Directory Appendix for contact information.)


GENERAL DENTAL BENEFITS

General dentistry refers to services covered under the Medicaid dental benefit that may be covered for CSHCS enrollees who have a qualifying diagnosis that includes general dental services. Examples include, but are not limited to, diagnostic, preventive, restorative, endodontia, prosthodontia, and oral surgery. MDHHS may determine a beneficiary eligible for certain general dentistry services when the CSHCS qualifying diagnosis is related to conditions eligible for this coverage as identified below:

* Chemotherapy or radiation which results in significant dental side effects

* Cleft lip/palate/facial anomaly

* Convulsive disorders with gum hypertrophy

* Cystic Fibrosis

* Hemophilia and/or other coagulation disorders

* Pre- and post-transplant

To request approval as a CSHCS General Dentistry provider, dentists must contact MDHHS. (Refer to the Directory Appendix for contact information.)

NOTE: Hospital charges (e.g., general anesthesia, facility charges, etc.) may be covered for dental services provided through the inpatient or outpatient hospital facility for beneficiaries with certain CSHCS diagnoses even though CSHCS does not cover the dental care itself.



CARE COORDINATION BENEFIT

Beneficiaries enrolled in CSHCS with identified needs may be eligible to receive Care Coordination services.

Care Coordination services may be provided by the local health department. LHD staff includes registered nurses (RNs), social workers, or paraprofessionals under the direction and supervision of RNs.



Staff must be trained in the service needs of the CSHCS population and demonstrate skill and sensitivityin communicating with children with special needs and their families.

Care Coordination is not reimbursable for beneficiaries also receiving Case Management services during the same LHD billing period, which is usually a calendar quarter. In the event Care Coordination services are no longer appropriate and Case Management services are needed, the change in services may only be made at the beginning of the next billing period.

Families/beneficiaries can contact the LHD for assistance in obtaining Care Coordination services.

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