Local Coverage Article Billing and Coding

Billing and Coding: Routine Dental Services

A52977

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Contractor Information

Article Information

General Information

Article ID
A52977
Article Title
Billing and Coding: Routine Dental Services
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
10/01/2017
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2022 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2022 American Dental Association. All rights reserved.

Copyright © 2022, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Medicare Benefit Policy Manual, Publication 100-02, Chapter 16

Article Guidance

Article Text

Under the general exclusion of coverage, items and services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth are not covered by Medicare. Structures directly supporting the teeth can be defined as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process.

Coding Information

CPT/HCPCS Codes

Group 1

(1 Code)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
XX000 Not Applicable

CPT/HCPCS Modifiers

N/A

ICD-10-CM Codes that Support Medical Necessity

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

(188 Codes)
Group 1 Paragraph

The following ICD-10-CM codes are considered to be routine dental diagnoses and will be excluded from Medicare payment.

This list is not necessarily exhaustive or complete. Other diagnoses may be added in the future.

In addition, many HCPCS codes for dental services have an “X” status on the Medicare Physician Fee Schedule and are statutorily non-covered because of the routine dental exclusion. Please refer to the current Medicare Physician Fee Schedule for a list of those codes.


Group 1 Codes
CodeDescription
K00.0 Anodontia
K00.1 Supernumerary teeth
K00.2 Abnormalities of size and form of teeth
K00.3 Mottled teeth
K00.4 Disturbances in tooth formation
K00.5 Hereditary disturbances in tooth structure, not elsewhere classified
K00.6 Disturbances in tooth eruption
K00.7 Teething syndrome
K00.8 Other disorders of tooth development
K00.9 Disorder of tooth development, unspecified
K02.3 Arrested dental caries
K02.52 Dental caries on pit and fissure surface penetrating into dentin
K02.53 Dental caries on pit and fissure surface penetrating into pulp
K02.61 Dental caries on smooth surface limited to enamel
K02.62 Dental caries on smooth surface penetrating into dentin
K02.63 Dental caries on smooth surface penetrating into pulp
K02.7 Dental root caries
K02.9 Dental caries, unspecified
K03.0 Excessive attrition of teeth
K03.1 Abrasion of teeth
K03.2 Erosion of teeth
K03.3 Pathological resorption of teeth
K03.4 Hypercementosis
K03.5 Ankylosis of teeth
K03.6 Deposits [accretions] on teeth
K03.7 Posteruptive color changes of dental hard tissues
K03.81 Cracked tooth
K03.89 Other specified diseases of hard tissues of teeth
K03.9 Disease of hard tissues of teeth, unspecified
K04.01 Reversible pulpitis
K04.02 Irreversible pulpitis
K04.1 Necrosis of pulp
K04.2 Pulp degeneration
K04.3 Abnormal hard tissue formation in pulp
K04.4 Acute apical periodontitis of pulpal origin
K04.5 Chronic apical periodontitis
K04.6 Periapical abscess with sinus
K04.7 Periapical abscess without sinus
K04.90 Unspecified diseases of pulp and periapical tissues
K04.99 Other diseases of pulp and periapical tissues
K05.00 Acute gingivitis, plaque induced
K05.01 Acute gingivitis, non-plaque induced
K05.10 Chronic gingivitis, plaque induced
K05.11 Chronic gingivitis, non-plaque induced
K05.20 Aggressive periodontitis, unspecified
K05.211 Aggressive periodontitis, localized, slight
K05.212 Aggressive periodontitis, localized, moderate
K05.213 Aggressive periodontitis, localized, severe
K05.219 Aggressive periodontitis, localized, unspecified severity
K05.221 Aggressive periodontitis, generalized, slight
K05.222 Aggressive periodontitis, generalized, moderate
K05.223 Aggressive periodontitis, generalized, severe
K05.229 Aggressive periodontitis, generalized, unspecified severity
K05.30 Chronic periodontitis, unspecified
K05.311 Chronic periodontitis, localized, slight
K05.312 Chronic periodontitis, localized, moderate
K05.313 Chronic periodontitis, localized, severe
K05.319 Chronic periodontitis, localized, unspecified severity
K05.321 Chronic periodontitis, generalized, slight
K05.322 Chronic periodontitis, generalized, moderate
K05.323 Chronic periodontitis, generalized, severe
K05.329 Chronic periodontitis, generalized, unspecified severity
K05.4 Periodontosis
K05.5 Other periodontal diseases
K05.6 Periodontal disease, unspecified
K06.010 Localized gingival recession, unspecified
K06.011 Localized gingival recession, minimal
K06.012 Localized gingival recession, moderate
K06.013 Localized gingival recession, severe
K06.020 Generalized gingival recession, unspecified
K06.021 Generalized gingival recession, minimal
K06.022 Generalized gingival recession, moderate
K06.023 Generalized gingival recession, severe
K06.1 Gingival enlargement
K06.2 Gingival and edentulous alveolar ridge lesions associated with trauma
K06.3 Horizontal alveolar bone loss
K06.8 Other specified disorders of gingiva and edentulous alveolar ridge
K06.9 Disorder of gingiva and edentulous alveolar ridge, unspecified
K08.0 Exfoliation of teeth due to systemic causes
K08.101 Complete loss of teeth, unspecified cause, class I
K08.102 Complete loss of teeth, unspecified cause, class II
K08.103 Complete loss of teeth, unspecified cause, class III
K08.104 Complete loss of teeth, unspecified cause, class IV
K08.109 Complete loss of teeth, unspecified cause, unspecified class
K08.111 Complete loss of teeth due to trauma, class I
K08.112 Complete loss of teeth due to trauma, class II
K08.113 Complete loss of teeth due to trauma, class III
K08.114 Complete loss of teeth due to trauma, class IV
K08.119 Complete loss of teeth due to trauma, unspecified class
K08.121 Complete loss of teeth due to periodontal diseases, class I
K08.122 Complete loss of teeth due to periodontal diseases, class II
K08.123 Complete loss of teeth due to periodontal diseases, class III
K08.124 Complete loss of teeth due to periodontal diseases, class IV
K08.129 Complete loss of teeth due to periodontal diseases, unspecified class
K08.131 Complete loss of teeth due to caries, class I
K08.132 Complete loss of teeth due to caries, class II
K08.133 Complete loss of teeth due to caries, class III
K08.134 Complete loss of teeth due to caries, class IV
K08.139 Complete loss of teeth due to caries, unspecified class
K08.191 Complete loss of teeth due to other specified cause, class I
K08.192 Complete loss of teeth due to other specified cause, class II
K08.193 Complete loss of teeth due to other specified cause, class III
K08.194 Complete loss of teeth due to other specified cause, class IV
K08.199 Complete loss of teeth due to other specified cause, unspecified class
K08.20 Unspecified atrophy of edentulous alveolar ridge
K08.21 Minimal atrophy of the mandible
K08.22 Moderate atrophy of the mandible
K08.23 Severe atrophy of the mandible
K08.24 Minimal atrophy of maxilla
K08.25 Moderate atrophy of the maxilla
K08.26 Severe atrophy of the maxilla
K08.3 Retained dental root
K08.401 Partial loss of teeth, unspecified cause, class I
K08.402 Partial loss of teeth, unspecified cause, class II
K08.403 Partial loss of teeth, unspecified cause, class III
K08.404 Partial loss of teeth, unspecified cause, class IV
K08.409 Partial loss of teeth, unspecified cause, unspecified class
K08.411 Partial loss of teeth due to trauma, class I
K08.412 Partial loss of teeth due to trauma, class II
K08.413 Partial loss of teeth due to trauma, class III
K08.414 Partial loss of teeth due to trauma, class IV
K08.419 Partial loss of teeth due to trauma, unspecified class
K08.421 Partial loss of teeth due to periodontal diseases, class I
K08.422 Partial loss of teeth due to periodontal diseases, class II
K08.423 Partial loss of teeth due to periodontal diseases, class III
K08.424 Partial loss of teeth due to periodontal diseases, class IV
K08.429 Partial loss of teeth due to periodontal diseases, unspecified class
K08.431 Partial loss of teeth due to caries, class I
K08.432 Partial loss of teeth due to caries, class II
K08.433 Partial loss of teeth due to caries, class III
K08.434 Partial loss of teeth due to caries, class IV
K08.439 Partial loss of teeth due to caries, unspecified class
K08.491 Partial loss of teeth due to other specified cause, class I
K08.492 Partial loss of teeth due to other specified cause, class II
K08.493 Partial loss of teeth due to other specified cause, class III
K08.494 Partial loss of teeth due to other specified cause, class IV
K08.499 Partial loss of teeth due to other specified cause, unspecified class
K08.50 Unsatisfactory restoration of tooth, unspecified
K08.51 Open restoration margins of tooth
K08.52 Unrepairable overhanging of dental restorative materials
K08.530 Fractured dental restorative material without loss of material
K08.531 Fractured dental restorative material with loss of material
K08.539 Fractured dental restorative material, unspecified
K08.54 Contour of existing restoration of tooth biologically incompatible with oral health
K08.55 Allergy to existing dental restorative material
K08.56 Poor aesthetic of existing restoration of tooth
K08.59 Other unsatisfactory restoration of tooth
K08.81 Primary occlusal trauma
K08.82 Secondary occlusal trauma
K08.89 Other specified disorders of teeth and supporting structures
K08.9 Disorder of teeth and supporting structures, unspecified
K09.1 Developmental (nonodontogenic) cysts of oral region
M26.20 Unspecified anomaly of dental arch relationship
M26.211 Malocclusion, Angle's class I
M26.212 Malocclusion, Angle's class II
M26.213 Malocclusion, Angle's class III
M26.219 Malocclusion, Angle's class, unspecified
M26.220 Open anterior occlusal relationship
M26.221 Open posterior occlusal relationship
M26.23 Excessive horizontal overlap
M26.24 Reverse articulation
M26.25 Anomalies of interarch distance
M26.29 Other anomalies of dental arch relationship
M26.30 Unspecified anomaly of tooth position of fully erupted tooth or teeth
M26.31 Crowding of fully erupted teeth
M26.32 Excessive spacing of fully erupted teeth
M26.33 Horizontal displacement of fully erupted tooth or teeth
M26.34 Vertical displacement of fully erupted tooth or teeth
M26.35 Rotation of fully erupted tooth or teeth
M26.36 Insufficient interocclusal distance of fully erupted teeth (ridge)
M26.37 Excessive interocclusal distance of fully erupted teeth
M26.39 Other anomalies of tooth position of fully erupted tooth or teeth
M26.4 Malocclusion, unspecified
M26.70 Unspecified alveolar anomaly
M26.71 Alveolar maxillary hyperplasia
M26.72 Alveolar mandibular hyperplasia
M26.73 Alveolar maxillary hypoplasia
M26.74 Alveolar mandibular hypoplasia
M26.79 Other specified alveolar anomalies
M26.81 Anterior soft tissue impingement
M26.82 Posterior soft tissue impingement
M26.89 Other dentofacial anomalies
M26.9 Dentofacial anomaly, unspecified
M27.3 Alveolitis of jaws
M27.61 Osseointegration failure of dental implant
M27.62 Post-osseointegration biological failure of dental implant
M27.63 Post-osseointegration mechanical failure of dental implant
M27.69 Other endosseous dental implant failure

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

CodeDescription
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
085x Critical Access Hospital

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

N/A

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
10/01/2017 R3

As required by CR 10901, article is converted to a formal billing and coding type article. There is no change in coverage.

10/01/2017 R2

Effective 10/1/2017, article is revised per the annual ICD-10 code update to:

Add ICD-10-CM codes: K06.010, K06.011, K06.012, K06.013, K06.020, K06.021, K06.022, K06.023.

Delete ICD-CM -10-CM codes: K06.0. 

 

10/01/2016 R1 Article was reformatted and non-covered diagnoses were removed from Limitations of Coverage and added to the appropriate diagnosis field. This article now includes Part A contract numbers effective 10/1/16. The following diagnoses were added as excluded due to the ICD-10 annual update effective 10/1/16: K02.52, K02.53, K04.01, K04.02, K05.211, K05.212, K05.213, K05.219, K05.221, K05.222, K05.223, K05.229, K05.311, K05.312, K05.313, K05.319, K05.321, K05.322, K05.323, K05.329, K06.3, K06.8, K06.9, K08.111, K08.112, K08.113, K08.114, K08.119, K08.121, K08.122, K08.123, K08.124, K08.129, K08.131. K08.132, K08.133, K08.134, K08.139, K08.191, K08.192, K08.193, K08.194, K08.199, K08.411, K08.412, K08.413, K08.414, K08.421, K08.422, K08.423, K08.424, K08.431, K08.432, K08.433, K08.434, K08.491, K08.492, K08.493, K08.494, K08.539, K08.81, K08.82, K08.89 and M26.219. The following diagnoses were deleted due to the ICD-10 annual update effective 9/30/16: K04.0, K05.21, K05.22, K05.31, K05.32 and K08.8. Additionally, the following diagnoses were deleted effective 9/30/16: K04.8, M26.00, M26.01, M26.02, M26.03, M26.04, M26.05, M26.06, M26.07, M26.09, M26.10, M26.11, M26.12, M26.19, M26.50, M26.51, M26.52, M26.53, M26.54, M26.55, M26.56, M26.57, M26.59, S02.5XXA, S02.5XXB. However, providers must have documentation available for review to support these services are reasonable and necessary and not routine dental services.

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