DENTISTRY GROUND RULES

1. GENERAL: The allowable fee for any dental service or procedure is the provider’s usual and customary charge or the maximum fee schedule allowance, whichever is less. The maximum fee schedule allowance for a particular service or procedure is determined by multiplying the listed Unit Value by the current dollar Conversion Factor applicable to dentistry. The Unit Values and Conversion Factor for dentistry are not applicable to any other section of the fee schedule. UNLISTED SERVICE OR PROCEDURE: When an unlisted service or procedure is performed, the procedure should be identified and the amount charged substantiated " by report" (BR). PROCEDURES LISTED WITHOUT A SPECIFIED UNIT VALUE: "BR" in the Unit Value column indicates that the amount charged for this service shall be determined "by report" because the service is too unusual or variable to be assigned a Unit Value. Pertinent information should be furnished concerning the nature, extent, and need for the procedure or service, the time, skill, and equipment necessary, etc. MATERIAL SUPPLIED BY A DENTIST: Supplies and materials provided by a dentist (e.g., sterile trays, supplies, drugs) over and above those usually included with the office visits or other services rendered may be listed separately. Statement of charges will need to reflect any drugs, trays, supplies, and materials that were provided. Payment shall not exceed the cost of the item(s) to the dentist plus 25% of the cost or the cost of the item(s) plus $15.00 per item, whichever is less. CONCURRENT CARE: When the condition of the patient requires the skills of two or more dentists or health care providers to treat different conditions, payment is due each dentist or health care provider who plays an active role in the treatment program. The services rendered by each dentist or health care provider shall be distinct, identifiable, and adequately documented in the records and reports. ALTERNATING DENTISTS AND/OR HEALTH CARE PROVIDERS: When dentists or health care providers of similar skills alternate in the care of a patient (e.g., partners, groups of same facility, covering providers on weekends or vacation periods), each dentist and health care provider shall charge individually for the services personally rendered; such charges shall be in accordance with this Fee Schedule. PRORATION OF SCHEDULED FEE: When the schedule specifies a Unit Value for a definite treatment, and the patient is transferred from one dentist or health care provider to another, the applicable Unit Value is to be apportioned between the health care providers. The providers involved shall agree upon the amount of proration, and shall render separate bills accordingly with an explanatory note. MODIFIERS: Procedure codes for dentistry may be modified under the circumstances described below. The circumstances are to be identified by the addition of a hyphen and the appropriate two-digit modifier code. The modifiers that may be used are as follows: -22 -52 Unusual Services: A report is required. Reduced Values: Under certain circumstances, the listed value for a procedure is reduced or eliminated because of common practice, or at the dentist’s election. Primary Emergency Services: When a dental procedure is carried out by a dentist who will not be providing the follow-up care, the value shall be 70% of the listed value. Surgical Procedure Only: When one dentist performs the surgical procedure itself and another provides the follow-up care, the fee may be apportioned between them. Identify the dentist performing the surgery with this modifier. The “global fee” is not to be increased, but prorated between the dentists.

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-53

-54

CPT only copyright 2004 American Medical Association. All Rights Reserved.

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DENTISTRY GROUND RULES
-55 Follow-Up Care Only: When one dentist performs the main procedure itself and another provides the follow-up care, the value may be apportioned between them. Identify the dentist providing the follow-up care with this modifier. The “global fee” is not to be increased, but prorated between the dentists. Pre-Operative Care Only: When one dentist performs the care up until surgery and another dentist then takes over the care, the value may be apportioned between them. Identify the dentist providing the pre-operative care with this modifier. The “global fee” is not to be increased, but prorated between the dentists. Multiple Modifiers: By Report

-56

-99 9.

FAILURE OF PATIENT TO KEEP A SCHEDULED APPOINTMENT: In the event a patient fails to keep a scheduled appointment, the health care provider is not to bill for any services that would have been provided by said appointment nor shall there be any reimbursement for such scheduled services (i.e., reimbursement for a “no show” appointment is not allowed). This rule does not apply with regard to a deposition, testimony, or IME. COST CONTAINMENT: Nothing in this section shall preclude an employer (or insurance carrier) from entering into payment agreements to promote the continuity of care and the reduction of health care costs. Such payment agreements, if less, will supersede the limitation amounts specified herein. Please refer to K.S.A. 44-510i(e) for further clarification, if necessary.

10.

CONVERSION FACTOR = $35.75

CPT only copyright 2004 American Medical Association. All Rights Reserved.

96

DENTISTRY
(CONVERSION FACTOR = $35.75) CODE D0120 D0140 D0150 D0160 D0170 D0180 D0210 D0220 D0230 D0240 D0250 D0260 D0270 D0272 D0274 D0277 D0290 D0310 D0320 D0321 D0322 D0330 D0340 D0350 D0415 D0416 D0421 D0425 D0431 D0460 D0470 D0472 D0473 D0474 D0475 D0476 D0477 D0478 D0479 D0480 D0481 D0482 D0483 D0484 D0485 D0502 D0999 D1110 D1120 D1201 D1203 D1204 UNIT VALUE 0.76 0.98 1.10 1.45 BR BR 2.24 0.43 0.35 0.60 1.00 0.50 0.43 0.70 1.00 BR BR BR BR BR BR 1.91 2.00 BR BR BR BR BR BR 0.73 1.52 BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR 1.50 1.07 1.33 0.64 0.69 CODE D1205 D1310 D1320 D1330 D1351 D1510 D1515 D1520 D1525 D1550 D2140 D2150 D2160 D2161 D2330 D2331 D2332 D2335 D2390 D2391 D2392 D2393 D2394 D2410 D2420 D2430 D2510 D2520 D2530 D2542 D2543 D2544 D2610 D2620 D2630 D2642 D2643 D2644 D2650 D2651 D2652 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 UNIT VALUE 1.67 BR 0.30 0.67 0.83 5.26 7.41 4.00 6.00 0.93 1.96 2.48 3.01 3.60 2.41 3.06 3.75 4.46 BR BR BR BR BR BR BR BR 12.53 14.33 BR BR 17.07 16.67 14.30 15.95 17.00 17.35 18.21 18.50 12.40 14.17 17.00 13.00 15.77 17.00 11.90 BR 17.37 BR BR 19.67 19.17 17.22 CODE D2752 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2799 D2910 D2915 D2920 D2930 D2931 D2932 D2933 D2934 D2940 D2950 D2951 D2952 D2953 D2954 D2955 D2957 D2960 D2961 D2962 D2971 D2975 D2980 D2999 D3110 D3120 D3220 D3221 D3230 D3240 D3310 D3320 D3330 D3331 D3332 D3333 D3346 D3347 D3348 D3351 D3352 D3353 D3410 UNIT VALUE 17.98 BR BR BR BR 18.39 13.83 14.54 BR BR 1.30 BR 1.55 4.39 5.31 BR BR BR 1.61 4.34 0.53 6.34 BR 5.00 BR BR 8.65 BR 16.81 BR BR BR BR 1.36 1.29 2.77 BR 3.12 3.19 10.83 12.93 16.06 BR BR BR BR BR BR BR BR BR 9.37

Current Dental Terminology copyright 2002, 2004 American Dental Association. All rights reserved.

97

DENTISTRY
(CONVERSION FACTOR = $35.75) CODE D3421 D3425 D3426 D3430 D3450 D3460 D3470 D3910 D3920 D3950 D3999 D4210 D4211 D4240 D4241 D4245 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4268 D4270 D4271 D4273 D4274 D4275 D4276 D4320 D4321 D4341 D4342 D4355 D4381 D4910 D4920 D4999 D5110 D5120 D5130 D5140 D5211 D5212 D5213 D5214 D5225 D5226 D5281 D5410 UNIT VALUE BR BR BR BR 8.51 BR BR BR BR BR BR 8.99 3.07 6.00 BR BR BR 15.27 BR BR BR BR BR BR BR BR BR BR BR BR BR BR 5.73 4.49 BR BR BR 2.13 BR BR 27.04 26.98 28.27 28.28 19.27 19.33 29.09 29.04 BR BR 14.18 1.06 CODE D5411 D5421 D5422 D5510 D5520 D5610 D5620 D5630 D5640 D5650 D5660 D5670 D5671 D5710 D5711 D5720 D5721 D5730 D5731 D5740 D5741 D5750 D5751 D5760 D5761 D5810 D5811 D5820 D5821 D5850 D5851 D5860 D5861 D5862 D5867 D5875 D5899 D5911 D5912 D5913 D5914 D5915 D5916 D5919 D5922 D5923 D5924 D5925 D5926 D5927 D5928 D5929 UNIT VALUE 1.06 1.06 1.06 3.23 2.71 3.19 4.75 4.38 2.73 3.50 4.54 BR BR 9.60 10.00 8.00 8.00 5.42 5.42 5.17 5.17 8.24 8.26 7.37 7.37 10.83 10.83 10.00 10.00 2.00 2.00 BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR CODE D5931 D5932 D5933 D5934 D5935 D5936 D5937 D5951 D5952 D5953 D5954 D5955 D5958 D5959 D5960 D5982 D5983 D5984 D5985 D5986 D5987 D5988 D5999 D6010 D6040 D6050 D6053 D6054 D6055 D6056 D6057 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 UNIT VALUE BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR 25.00 BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR

Current Dental Terminology copyright 2002, 2004 American Dental Association. All rights reserved.

98

DENTISTRY
(CONVERSION FACTOR = $35.75) CODE D6079 D6080 D6090 D6094 D6095 D6100 D6190 D6194 D6199 D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6780 D6781 UNIT VALUE BR BR BR BR BR BR BR BR BR BR 19.66 14.00 16.00 BR 19.17 17.33 15.99 BR BR BR BR BR 12.78 BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR 18.43 BR BR BR 19.23 17.35 15.60 18.33 BR CODE D6782 D6783 D6790 D6791 D6792 D6793 D6794 D6920 D6930 D6940 D6950 D6970 D6971 D6972 D6973 D6975 D6976 D6977 D6980 D6985 D6999 D7111 D7140 D7210 D7220 D7230 D7240 D7241 D7250 D7260 D7261 D7270 D7272 D7280 D7282 D7283 D7285 D7286 D7287 D7288 D7290 D7291 D7310 D7320 D7321 D7340 D7350 D7410 D7411 D7412 D7413 D7414 UNIT VALUE BR BR 18.50 13.83 14.54 BR BR BR 2.32 BR BR BR BR BR BR BR BR BR BR BR BR BR BR 4.32 5.00 6.19 7.51 8.83 4.55 12.00 BR 5.00 BR 6.00 BR BR 4.68 4.68 BR BR 12.00 0.92 3.84 5.08 BR BR BR 5.16 BR BR BR BR CODE D7415 D7440 D7441 D7450 D7451 D7460 D7461 D7465 D7471 D7472 D7473 D7485 D7490 D7510 D7511 D7520 D7521 D7530 D7540 D7550 D7560 D7610 D7620 D7630 D7640 D7650 D7660 D7670 D7671 D7680 D7710 D7720 D7730 D7740 D7750 D7760 D7770 D7771 D7780 D7810 D7820 D7830 D7840 D7850 D7852 D7854 D7856 D7858 D7860 D7865 D7870 D7871 UNIT VALUE BR BR BR 10.00 16.00 10.00 16.00 BR BR BR BR BR BR 4.00 BR 5.58 BR 1.21 2.62 BR BR 40.00 35.00 45.00 40.00 BR BR 14.87 BR BR 50.00 44.00 55.76 45.00 BR BR 26.00 BR 68.84 BR BR BR BR BR BR BR BR BR BR BR BR BR

Current Dental Terminology copyright 2002, 2004 American Dental Association. All rights reserved.

99

DENTISTRY
(CONVERSION FACTOR = $35.75) CODE D7872 D7873 D7874 D7875 D7876 D7877 D7880 D7899 D7910 D7911 D7912 D7920 D7940 D7941 D7943 D7944 D7945 D7946 D7947 D7948 D7949 D7950 D7953 D7955 D7960 D7963 D7970 D7971 D7972 D7980 D7981 D7982 D7983 D7990 D7991 D7995 D7996 D7997 D7999 D8010 D8020 D8030 D8040 D8050 D8060 D8070 D8080 D8090 D8210 D8220 D8660 D8670 UNIT VALUE BR BR BR BR BR BR 14.19 BR 3.36 6.26 BR BR BR BR BR BR BR BR BR BR BR BR BR BR 5.56 BR 6.10 6.00 BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR 6.00 7.00 BR BR CODE D8680 D8690 D8691 D8692 D8999 D9110 D9210 D9211 D9212 D9215 D9220 D9221 D9230 D9241 D9242 D9248 D9310 D9410 D9420 D9430 D9440 D9450 D9610 D9630 D9910 D9911 D9920 D9930 D9940 D9941 D9942 D9950 D9951 D9952 D9970 D9971 D9972 D9973 D9974 D9999 UNIT VALUE BR BR BR BR BR 1.83 0.83 0.37 BR 0.30 BR BR 0.92 BR BR BR 3.00 2.78 2.97 1.07 2.00 BR BR 0.66 0.83 BR BR BR 7.91 2.38 BR BR 2.61 8.33 BR BR BR BR BR BR

Current Dental Terminology copyright 2002, 2004 American Dental Association. All rights reserved.

100

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