††††† 907 KAR 1:626. Reimbursement of dental services.

 

††††† RELATES TO: KRS 205.520, 42 C.F.R. 440.100, 447.200-205, 42 U.S.C. 1396a-d

††††† STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3)

††††† NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and Family Services, Department for Medicaid Services, has the responsibility to administer the Medicaid Program. KRS 205.520(3) authorizes the cabinet, by administrative regulation, to comply with any requirement that may be imposed or opportunity presented by federal law for the provision of medical assistance to Kentucky's indigent citizenry. This administrative regulation establishes the method for determining the amount payable by the cabinet for a dental service.

 

††††† Section 1. Definitions. (1) "Comprehensive orthodontic procedure" means a medically necessary dental service for a dentofacial malocclusion which requires the application of braces for correction.

††††† (2) "Current Dental Terminology" or "CDT" means a publication by the American Dental Association of codes used to report dental procedures or services.

††††† (3) "Debridement" means a procedure that is performed:

††††† (a) For removing thick or dense deposits on the teeth which is required if tooth structures are so deeply covered with plaque and calculus that a dentist or staff cannot check for decay, infections, or gum disease; and

††††† (b) Separately from a regular cleaning and is usually a preliminary or first treatment when an individual has developed very heavy plaque or calculus.

††††† (4) "Department" means the Department for Medicaid Services or its designee.

††††† (5) "Disabling malocclusion" means that a patient has a condition that meets the criteria established in 907 KAR 1:026, Section 13(7).

††††† (6) "Incidental" means that a medical procedure is performed at the same time as a primary procedure and:

††††† (a) Requires little additional practitioner resources; or

††††† (b) Is clinically integral to the performance of the primary procedure.

††††† (7) "Integral" means that a medical procedure represents a component of a more complex procedure performed at the same time.

††††† (8) "Manually priced" or "MP" means that a procedure is priced according to complexity.

††††† (9) "Medically necessary" or "medical necessity" means that a covered benefit is determined to be needed in accordance with 907 KAR 3:130.

††††† (10) "Mutually exclusive" means that two (2) procedures:

††††† (a) Are not reasonably performed in conjunction with one another during the same patient encounter on the same date of service;

††††† (b) Represent two (2) methods of performing the same procedure;

††††† (c) Represent medically impossible or improbable use of CDT codes; or

††††† (d) Are described in CDT as inappropriate coding of procedure combinations.

††††† (11) "Prepayment review" or "PPR" means a departmental review of a claim to determine if the requirements established in 907 KAR 1:026 have been met prior to authorizing payment.

††††† (12) "Prior authorization" or "PA" means approval which a provider shall obtain from the department before being reimbursed for a covered service.

††††† (13) "Provider" is defined in KRS 205.8451(7).

††††† (14) "Recipient" is defined in KRS 205.8451(9).

††††† (15) "Timely filing" means receipt of a claim by Medicaid:

††††† (a) Within twelve (12) months of the date the service was provided;

††††† (b) Within twelve (12) months of the date retroactive eligibility was established; or

††††† (c) Within six (6) months of the Medicare adjudication date if the service was billed to Medicare.

††††† (16) "Usual and customary charge" means the uniform amount which the individual dentist charges in the majority of cases for a specific dental procedure or service.

 

††††† Section 2. Reimbursement. (1) Reimbursement for a covered service shall be the lesser of the:

††††† (a) Dentistís usual and customary charge;

††††† (b) Reimbursement limits specified in Sections 3 and 4 of this administrative regulation;

††††† (c) Manually-priced amount; or

††††† (d) Prior authorized fee.

††††† (2) If a rate has not been established for a covered dental service, the department shall set an upper limit for the procedure by:

††††† (a) Averaging the reimbursement rates assigned to the service by three (3) other payer or provider sources; and

††††† (b) Comparing the calculated average obtained from these three (3) rates to rates of similar procedures paid by the department.

††††† (3) If cost sharing is required, the cost sharing shall be in accordance with 907 KAR 1:604.

††††† (4) For a service covered under Medicare Part B, reimbursement shall be in accordance with 907 KAR 1:006.

††††† (5) A service which is not billed within timely filing requirements shall not be reimbursed.

††††† (6) If performed concurrently, separate reimbursement shall not be made for a procedure that has been determined by the department to be incidental, integral, or mutually exclusive to another procedure.

 

††††† Section 3. Reimbursement Rates for Dental Services. (1) The following maximum upper limits for reimbursement shall apply for a service provided to a recipient under twenty-one (21) years of age:

Kentucky Medicaid Dental Services

Description

Upper Limit

Authorization Requirement

Diagnostic Procedures

Limited oral evaluation (trauma related injuries or acute infection only)

$33

PPR required

Comprehensive oral evaluation

$26

 

Intraoral complete series

$63.70

 

Intraoral periapical, first film

$10.40

 

Intraoral periapical, each additional film

$7.80

 

Bitewing, single film

$9.10

 

Bitewing, 2 films

$18.20

 

Bitewing, 4 films

$29.90

 

Panoramic film

$39

PA required for ages 5 and under

Cephalometric film

$61.10

 

Preventative Procedures

Prophylaxis

$48.10

 

Sealant per tooth (ages 5-20)

$19.50

 

Space maintainer, fixed unilateral

$135.20

 

Space maintainer, fixed bilateral

$262.60

 

Space maintainer, removable unilateral

$134

 

Space maintainer, removable bilateral

$202

 

Restorative Procedures

Amalgam, 1 surface

$49.40

 

Amalgam, 2 surfaces

$65.00

 

Amalgam, 3 surfaces

$76.70

 

Amalgam, 4 or more surfaces

$93.60

 

Resin, 1 surface, anterior

$57.20

 

Resin, 2 surfaces, anterior

$71.50

 

Resin, 3 surfaces, anterior

$85.80

 

Resin, 4 or more surfaces, anterior

$101.40

 

Resin, 1 surface, posterior

$57.20

 

Resin, 2 surfaces, posterior

$71.50

 

Resin, 3 surfaces, posterior

$85.80

 

Resin, 4 or more surfaces, posterior

$101.40

 

Prefab stainless steel crown primary

$119.60

 

Prefab stainless steel crown permanent

$133.90

 

Prefab resin crown

$113.10

 

Pin retention, per tooth, in add. to restoration

$13

 

Endodontic Procedures

Pulp cap direct

$17

 

Therapeutic pulpotomy

$67.60

 

Root canal therapy anterior

$274.30

 

Root canal therapy bicuspid

$344.50

 

Root canal therapy molar

$481

 

Apicoectomy anterior

$201.50

 

Apicoectomy, bicuspid first root

$201.50

 

Apicoectomy, molar first root

$201.50

 

Replace missing or broken tooth on denture

$40.30

 

Apicoectomy, per tooth each additional root

$197

 

Periodontic Procedures

Gingivectomy, gingivoplasty per quadrant

$336.70

PPR required

Gingivectomy, gingivoplasty per tooth

$135.20

PPR required

Periodontal scaling and root planing per

quadrant

$101.40

PA required

Full mouth debridement

$68.50

Pregnant women only

Removable Prosthodontic Procedures

Repair resin denture base

$61.10

 

Repair cast framework

$97.50

 

Replace broken teeth, per tooth on a denture

$36.40

 

Reline complete maxillary denture

$128.70

 

Reline complete mandibular denture

$128.70

 

Interim partial upper

$319.80

 

Interim partial lower

$336.70

 

Maxillofacial Prosthetic Procedures

Nasal prosthesis

$2,036

 

Auricular prosthesis

$1,881

 

Facial prosthesis

$3,408

 

Obturator (temporary)

$1121.90

 

Obturator (permanent)

$1,992

 

Mandibular resection prosthesis

$1,660

 

Speech aid-pediatric (13 and under)

$2,036

 

Speech aid (14 - 20)

$2,036

 

Palatal augmentation prosthesis

$1,550

 

Palatal lift prosthesis

$1,836

 

Oral surgical splint

$896

 

Unspecified maxillofacial prosthetic procedure

MP

PPR required

Oral and Maxillofacial Surgery Procedures

Extraction, deciduous tooth

$49.40

 

Extraction, erupted tooth or exposed root

$49.40

 

Surgical removal of erupted tooth

$93.60

 

Removal of impacted tooth (soft tissue)

$127.40

 

Removal of impacted tooth (partially bony)

$179.40

 

Removal of impacted tooth (completely bony)

$215.80

 

Removal of impacted tooth (comp. bony or unusual)

$222.30

 

Removal of torus palatinus (maxillary arch)

$302.47

 

Removal of torus mandibularis (lower left quadrant)

$209.28

 

Removal of torus mandibularis (lower right quadrant)

$209.28

 

Surgical access of an unerupted tooth

MP

PPR required

Surgical removal of residual tooth roots

$107.90

 

Oroantral fistula closure

$135.20

 

Alveoplasty in conjunction with extraction per quadrant

$101.40

 

Alveoplasty not in conjunction with extraction per quadrant

$101.40

 

Excision of benign lesion

$87.10

 

Incision and drainage of abscess (intraoral)

$67.60

 

Incision and drainage of abscess (extraoral)

$80.60

 

Removal of foreign body

$201.50

 

Temporomandibular splint therapy

$424

PA required

Suture of recent small wound

$67.60

 

Frenulectomy

$167.60

 

Orthodontic Procedures

Removable appliance therapy

$362

PA required

Fixed appliance therapy

$259

PA required

Preorthodontic exam and treatment plan

PA Fee

PA required

Orthodontic treatment

PA Fee

PA required

Unspecified orthodontic procedure-final 1/3

PA Fee

PA required

Adjunctive General Services

Palliative treatment of dental pain

$27.30

 

Intravenous sedation

$158.60

 

Hospital call

$67.60

 

††††† (2) The following maximum upper limits for reimbursement shall apply for a service provided to a recipient twenty-one (21) years of age and older:

Kentucky Medicaid Dental Services

Description

Upper Limit

Authorization Requirement

Diagnostic Procedures

Limited oral evaluation (trauma related injuries only)

$33

PPR required

Comprehensive oral evaluation

$26

 

Intraoral complete series

$49

 

Intraoral periapical, first film

$8

 

Intraoral periapical, each additional film

$6

 

Bitewing, single film

$7

 

Bitewing, 2 films

$14

 

Bitewing, 4 films

$23

 

Panoramic film

$39

 

Cephalometric film

$47

 

Preventative Procedures

Prophylaxis

$37

 

Restorative Procedures

Amalgam, 1 surface

$38

 

Amalgam, 2 surfaces

$50

 

Amalgam, 3 surfaces

$59

 

Amalgam, 4 or more surfaces

$72

 

Resin, 1 surface, anterior

$44

 

Resin, 2 surfaces, anterior

$55

 

Resin, 3 surfaces, anterior

$66

 

Resin, 4 or more surfaces, anterior

$78

 

Resin, 1 surface, posterior

$44

 

Resin, 2 surfaces, posterior

$55

 

Resin, 3 surfaces, posterior

$66

 

Resin, 4 or more surfaces, posterior

$78

 

Pin retention, per tooth, in add. to restoration

$13

 

Endodontic Procedures

Apicoectomy anterior

$155

 

Apicoectomy, bicuspid first root

$155

 

Apicoectomy, molar first root

$155

 

Apicoectomy, per tooth each additional root

$197

 

Periodontic Procedures

Full mouth debridement

$68.50

Pregnant women only

Gingivectomy, gingivoplasty per quadrant

$259

PPR required

Gingivectomy, gingivoplasty per tooth

$104

PPR required

Periodontal scaling and root planing per

quadrant

$78

PA required

Maxillofacial Prosthetic Procedures

Nasal prosthesis

$2,036

 

Auricular prosthesis

$1,881

 

Facial prosthesis

$3,408

 

Obturator (temporary)

$863

 

Obturator (permanent)

$1,992

 

Mandibular resection prosthesis

$1,660

 

Speech aid - Adult

$2,036

 

Palatal augmentation prosthesis

$1,550

 

Palatal lift prosthesis

$1,836

 

Oral surgical splint

$896

 

Unspecified maxillofacial prosthetic procedure

MP

PPR required

Oral and Maxillofacial Surgery Procedures

Extraction, deciduous tooth

$38

 

Extraction, erupted tooth or exposed root

$38

 

Surgical removal of erupted tooth

$72

 

Removal of impacted tooth (soft tissue)

$98

 

Removal of impacted tooth (partially bony)

$138

 

Removal of impacted tooth (completely bony)

$166

 

Removal of impacted tooth (comp. bony or unusual)

$171

 

Removal of torus palatinus (maxillary arch)

$302.47

 

Removal of torus mandibularis (lower left quadrant)

$209.28

 

Removal of torus mandibularis (lower right quadrant)

$209.28

 

Surgical access of an unerupted tooth

MP

PPR required

Surgical removal of residual tooth roots

$83

 

Oroantral fistula closure

$104

 

Alveoplasty in conjunction with extraction per quadrant

$78

 

Alveoplasty not in conjunction with extraction per quadrant

$78

 

Excision of benign lesion

$67

 

Incision and drainage of abscess (intraoral)

$52

 

Incision and drainage of abscess (extraoral)

$62

 

Removal of foreign body

$155

 

Suture of recent small wound

$52

 

Frenulectomy

$129

 

Adjunctive General Services

Palliative treatment of dental pain

$21

 

Hospital call

$52

 

††††† (3) A comprehensive orthodontic procedure shall be reimbursed as follows:

††††† (a) Except as specified in paragraph (b) of this subsection, an orthodontic consultation, including examination and development of a treatment plan, $112;

††††† (b) The Medicaid reimbursement rate for an orthodontic consultation shall not exceed fifty-six (56) dollars if:

††††† 1. The provider determines that comprehensive orthodontic treatment services are not needed;

††††† 2. The provider is unable or unwilling to provide the needed orthodontic treatment services; or

††††† 3. Prior authorization for comprehensive orthodontic services is not approved by the department or is not requested by the provider;

††††† (c) A service for an early phase of moderately severe or severe disabling malocclusion:

††††† 1. $1,367 for an orthodontist; or

††††† 2. $1,234 for a general dentist;

††††† (d) A service for a moderately severe disabling malocclusion:

††††† 1. $1,825 for an orthodontist; or

††††† 2. $1,659 for a general dentist; or

††††† (e) A service for a severe disabling malocclusion:

††††† 1. $3,000 total for an orthodontist; or

††††† 2. $2,674 total for a general dentist.

††††† (4) Reimbursement for comprehensive orthodontic treatment shall consist of two (2) payments.

††††† (a) The first payment shall be two-thirds (2/3) of the prior authorized payment amount.

††††† (b) The second payment shall:

††††† 1. Be one-third (1/3) of the prior authorized payment amount; and

††††† 2. Not be billed until six (6) monthly visits are completed following the banding date.

††††† (c) The two (2) payments shall be inclusive of all services associated with the comprehensive orthodontic treatment.

 

††††† Section 4. Oral Surgeons. Except for a service specified in 907 KAR 1:026, Section 12(8), a service provided by an oral surgeon shall be reimbursed in accordance with 907 KAR 3:010.

 

††††† Section 5. Supplemental Payments. (1) In addition to a payment made pursuant to Sections 2 through 4 of this administrative regulation, the department shall make a supplemental payment to a dental school faculty dentist who is employed by a state-supported school of dentistry in Kentucky.

††††† (2) The supplemental payment shall be:

††††† (a) In an amount which, if combined with other payments made in accordance with this administrative regulation, does not exceed the dentistís charge for a service he has provided:

††††† 1. As a dental school faculty; and

††††† 2. For which the payment is made directly or indirectly to the dental school;

††††† (b) Based on the funding made available through an intergovernmental transfer of funds for this purpose by a state-supported school of dentistry in Kentucky; and

††††† (c) Made on a quarterly basis.

 

††††† Section 6. Appeal Rights. An appeal of a department decision regarding a Medicaid provider based upon an application of this administrative regulation shall be in accordance with 907 KAR 1:671. (21 Ky.R. 217; eff. 9-21-94; Am. 25 Ky.R. 659; 1383; eff. 11-18-98; 27 Ky.R. 1102; 1492; eff. 12-21-2000; 28 Ky.R. 962; eff. 12-19-01; 30 Ky.R. 1645; 1945; eff. 2-16-04; 33 Ky.R. 613; 1393; 1575; eff. 1-5-07; 35 Ky.R. 442; eff. 10-31-2008.)