HDS PROCEDURE CODE GUIDELINES INTRODUCTION

The HDS Procedure Code Guidelines (PCG) provides a framework of rules and policies for benefit
determination. Please note that specific group contract provisions, limitations, and exclusions take
precedence over these guidelines. Certain contractual items (e.g. time limits, frequency of procedure, age
limits, etc.) can vary among groups, therefore they have not all been listed.

For instructions on using HDS Online and DenTel to obtain group benefit information and limits and/or
patient’s eligibility verification for specific benefits, please contact HDS Professional Relations.

A. General Guidelines
Where stated, general guidelines precede the category of the procedure and are related to each
procedure code listed in the category. Terms of the group contracts may vary. Group contracts will
take precedence over the HDS Procedure Code Guidelines.

B. PCG Submission Requirements

A “submission requirement” is additional information that is required in order to make a benefit
determination. The columns for these requirements are: “Valid Tooth/Quad/Arch/Surface” and
“Submission Requirements”. The following details the expectation for the items listed in these
columns:

1. Valid Tooth/Quad/Arch/Surface column: Specifies the tooth number, quadrant, arch or surface
applicable to the procedure. When a range of teeth or multiple teeth are indicated for one
procedure, include all applicable tooth numbers in a narrative or tooth chart.

2. Submission Requirements column: Attached information that is required to process the claim.
A procedure submitted without the required attachment is not billable to the patient and is not
payable by HDS. When mailing attachments for electronically submitted claims, indicate the
claim number and send to the attention of: “Electronic Claims”. If attachments are not received
within 5 days of the electronic claim submission, services are not billable to the patient. The
following defines each type of” submission requirement”:

a. X-ray Images: X-ray image submissions must be of diagnostic quality, free of positional
errors, radiographic artifacts, and should have adequate image contrast and resolution.

When reviewing the submission requirements in this Procedure Code Guideline manual, a
pre-operative x-ray image is always required unless otherwise noted. Post-operative X-ray
images are required for certain procedures and are specifically noted under Submission
Requirements.

1) Original X-ray images are considered part of the patient's clinical record and should be
retained by the dentist. HDS assumes that duplicate copies of X-ray images are
submitted for claims processing purposes.

2) X-ray image submissions should be mounted, dated and identified with the patient’s
name, tooth number/area, dentist’s name and address. Duplicated X-ray images must
be labeled as "left" and "right." When submitting a manual claim, secure the X-ray
image to the claim form.

3) When scanning X-ray film images using HDS Online, the original X-ray film must be
placed with the raised dot faced down on the image scanner. Incorrectly scanned X-ray
images will delay review and payment of the submitted claim.

4) When submitting claims with X-ray image attachments, dental offices should keep the
original X-ray for their records and submit copies of X-ray images along with the claim
to HDS. Original X-ray images will not be returned unless the following are provided to
HDS:

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i. The X-ray image must be labeled, “Return X-ray.”

ii. A self-addressed, stamped envelope must accompany each claim with an X-ray
image requesting to be returned. Multiple X-ray image claims with only one
envelope will NOT be returned. An X-ray image labeled “Return X-ray” with no
envelope provided will be discarded.

5) Intraoral photographic images are not accepted in lieu of X-ray images, however they can
be submitted to augment X-ray images and demonstrate areas not clearly depicted on an
X-ray image.

b. Narrative: The corresponding guidelines may state the criteria to include in the narrative.
When narrative criteria are not specified in the guidelines, please include the following:
1) Diagnosis
Example: Acute periapical abscess #30 with fluctuant swelling on buccal

2) Determination of Treatment (Brief description of the procedure performed)

Example: I & D of acute periapical abscess

3) Procedure or Treatment Performed (Steps of surgical procedure, to include location

and instrument used)
Example: Incision on buccal of #30 with #15 scalpel, drain placed and
secured with one 3-0 black silk suture.

c. Periodontal Chart: The periodontal chart is expected to indicate:

 Patient's name
 Date of periodontal probing examination
 6-point pocket depth measurements on all teeth
 Areas of clinical attachment loss
 Probing sites that exhibit bleeding

For benefit purposes, a current periodontal charting (recorded less than 6 months prior to the
date of service) must be submitted.

d. Operative Report: The operative report should indicate diagnosis, operation, site of procedure
and instrument(s) used. For surgical procedures, an operative report may be submitted in lieu of
a narrative.

e. Pathology Report: The report from the pathology laboratory where the specimen was
submitted.

f. Other Carrier Medical Statement: Certain surgical procedures may be a benefit of the patient’s
medical plan. If the patient has medical coverage, an “other carrier medical statement” of
payment indicating the “primary payment” is required. If the medical carrier is an HMO, the other
carrier medical statement is not required. Instead, note the name of the HMO in the comment
section of the claim.

g. Other Carrier Statement of Benefits: The report from a non-HDS dental insurance carrier that
summarizes how reimbursement was determined. If HDS is secondary, services are not billable
to the patient until the amount of the primary carrier’s benefit is received.

h. Tooth Chart: The tooth chart must be dated and include the patient’s name. Missing teeth should
be indicated on the tooth chart. Tooth charting on manual claim forms is accepted as well as
missing teeth numbers entered in the claim narrative on both manual and electronically
submitted claims.
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i. Laboratory Invoice: A detailed invoice from the dental laboratory listing services and charges.
A dental laboratory prescription does not meet the laboratory invoice submission requirement.

C. Reduced Attachment Program (RAP)

RAP was developed to streamline the claims submission process and reduce the volume of submitted
attachments (i.e. x-rays or narratives) for HDS participating dentists.

The HDS Procedure Code Guidelines provide a base level of submission requirements for dental
procedure codes. With RAP, HDS may waive these requirements for certain select procedure codes.

For electronic claims, the HDS computer system uses a sampling algorithm based on a dentist’s
historical practice patterns and the disposition of previously adjudicated claims. It is normal for claims
submitted via the HDS website or through an electronic dental practice management system to be
approved without an attachment. However, HDS may still periodically require attachments.

For hardcopy claims, dental offices must comply with all submission requirements. However, based
on historical claim adjudication history, HDS may waive submission requirements for specific dentists,
clinical procedures, and time periods.

D. Additional Information
HDS may request additional information (e.g. X-ray images, clinical photographs, clinical notes,
periodontal chart, narrative, itemized dental laboratory invoice, pathology reports, study models,
materials, chair time, diagrams, etc.) to clarify a specific service.

E. By Report
“By Report” procedure codes require the review of documentation before the allowed benefit can be
determined. Submitted documentation should include the following where applicable:

 Clinical diagnosis
 Narrative (description of service, materials used, tooth numbers, surfaces, quadrants or
area of mouth, chair time)
 Itemized dental laboratory invoice
 Pathology reports
 X-ray images
 Any other supporting documentation

F. Definitions
The following are definitions of frequently used HDS terms:

1. Alternate Benefit – In cases where alternate methods of treatment exist, benefits are provided
for the least costly professionally accepted treatment. This determination is not intended to
reflect negatively on the dentist's treatment plan or to recommend which treatment should be
provided. It is a determination of benefits under the terms of the patient's coverage. The dentist
and the patient should decide on the course of treatment. If the treatment rendered is other than
the one benefited, the HDS approved fee will be the submitted charge.

2. Covered Benefit – Any procedure for which HDS has established a Maximum Plan Allowance

3. Coordination of Benefits (COB) – Occurs when a patient/subscriber has dental coverage under
HDS and another non-HDS carrier.

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4. Deny – When a procedure is denied, it is not payable by HDS but it is collectable from the patient
up to the approved amount. If the fee is not payable because of a deductible, annual maximum,
waiting period or frequency limitation, the dentist may bill up to the Maximum Plan Allowance.
When a procedure is not a covered benefit and is denied, the dentist may bill up to the submitted
fee.

5. Not billable to the patient (NBP)– When the fee for a procedure is not billable to the patient, it is
not payable by HDS and is not collectable from the patient.

6. Dual Coverage – Occurs when a patient/subscriber is covered under two or more HDS dental
plans.

7. In Conjunction with – "In conjunction with” means as part of another procedure or course of
treatment including, but not limited to, being rendered on the same day.

8. Maximum Plan Allowance – The maximum eligible amount for payment to a Member Dentist for
a Covered Benefit. The Maximum Plan Allowance is determined by HDS as to each Covered
Benefit.

9. Shaded fields – Fields shaded in gray indicate procedures that may be benefited as an alternate
benefit. In some cases a procedure may be a regular benefit for some groups and an alternate
benefit for others. Specific group benefits can be obtained on HDS Online or HDS Fax Back.

10. Same Dentist – The definition of “same dentist” includes providers that generally practice with
the same payee.

G. Abbreviations
1. Tooth numbers
 Primary teeth: A - T
 Permanent teeth: 1 - 32
 Supernumerary teeth:
- Add 50 to the permanent tooth number (e.g.: #14 will be #64)
- Add ‘S’ to primary tooth number (e.g.: C will be CS)

2. Quadrants
 Upper Left: UL
 Upper Right: UR
 Lower Left: LL
 Lower Right: LR

3. Arches
 Upper Arch: UA
 Lower Arch: LA

4. Tooth Surface
 D - distal
 F - facial (labial or buccal)
 I - incisal
 L - lingual
 M - mesial
 O - occlusal

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H. HDS Policy for Cosmetic and Other Patient-Elected Services

Services elected by the patient for cosmetic procedures or for restoring/altering vertical dimension
(VDO) are not covered benefits. The dentist must explain that the services will be denied.

1. The dental office should submit a preauthorization for these services with a narrative stating that
the patient has elected the services for cosmetic reasons or for altering VDO. Both the patient
and the dental office will then receive a report indicating if the services are covered by HDS or
processed as non-benefits.

2. For services that are not benefited by HDS, the dental office, prior to rendering the service,
should obtain the patient’s written consent on a form that clearly discloses to the patient the extra
financial charge that will be incurred.

3. If a preauthorization is not submitted, the dental office should submit a claim with an
accompanying narrative that states “services elected by patient for cosmetic reasons”.

4. The patient’s Explanation of Benefits and the dentist’s Remittance Advice will indicate the
patient’s responsibility for the cost of the service.

HDS reserves the right to review these services for compliance reasons. If it is deemed that services
were performed due to dental necessity, the HDS plan benefit will take precedence over cosmetic
reasons.

I. Informed Consent
Informed consent is more than simply getting a patient to sign a written consent form. It is a process
of communication between a patient and dentist that results in the patient authorization or agreement
to undergo a specific dental treatment. A dentist must provide the patient the information that a
reasonable patient needs in order to make an informed and intelligent decision regarding a proposed
treatment. It should include the significant risks, benefits, and alternatives to the proposed treatment
along with the option of no treatment. In general, a dentist must obtain informed consent from the
patient prior to all surgeries, invasive treatments and treatments that have a risk of serious
complications (whether due to the particulars of the patient, the nature of the treatment, or otherwise).

1. A Dentist Must Disclose the Following to Obtain Informed Consent

 The condition being treated

 The nature and character of the proposed treatment or procedure
 The anticipated results of the proposed treatment
 The recognized possible alternative forms of treatment for the condition, including no
treatment
 The recognized serious possible risks, complications, and anticipated benefits involved in
the proposed treatment and in possible alternative treatments

2. Method and Timing of Disclosures

 Disclosures can be made orally, in writing, or by use of brochures or other materials, but
must be in a manner that the patient can be reasonably expected to understand with an
opportunity for the patient to ask questions.
 A signed consent form, by itself, does not suffice to show a proper informed consent.
Rather, the process used must be effective in obtaining a true informed consent. It is the
dentist’s duty, not the patient’s duty, to ensure that there is informed consent.
 It is highly recommended that the dentist also inform the patient of the proposed services
that are covered by the patient’s insurance and which are not, to avoid misunderstanding
and payment disputes after the services are performed.
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J. Administration
1. Timely submission of claims – Claims must be received for HDS Commercial plans with all
required documents no later than 12 months from the date of service. If the claim is received after
12 months from the date of service, the dentist by contract cannot charge the patient a
copayment and/or amounts HDS does not pay. A denial exception can be made after 12 months
past the date of service only when the patient fails to communicate his/her coverage to the
dentist. Note: claim submission deadlines may vary among Delta Dental Plans; please contact
the specific Delta Dental Plan for more information.

Some Government programs (e.g., Medicare Advantage) may have a 180 day claim submission
deadline for Medicare network providers. Claims received after 180 days will not be billable to the
patient.

2. Appeals –HDS must receive the appeal within one year from the date of the action, omission, or
decision being contested. If the appeal concerns a benefit coverage or payment dispute, HDS
must receive the appeal within one year from the date of the explanation of benefits (EOB) in
which HDS first informed the enrollee of the denial or limitation of a claim for benefits. Requests
that do not comply with the requirements of the appeals process will not be recognized or treated
as an appeal by HDS. All information in support of the treatment should be included with the
request. If no new information is provided, no further appeals will be considered.

Some Government programs (e.g., Medicare Advantage) may have a 120 calendar day appeal
filing deadline from the day that the provider receives the remittance advice.

3. Eligibility Guarantee – HDS offers an eligibility guarantee as part of our commitment to provide
a high level of service to our participating dentists and to guarantee payment of covered services.
Inaccuracies in eligibility may occur when HDS is not notified in a timely manner that a patient’s
status has changed. In these cases, the eligibility guarantee will ensure payment of covered
services if the following conditions are met:

 Eligibility verification must be performed on the date of service with documentation either
from HDS Online or DenTel. Calls to Customer Service are not applicable for the
Eligibility Guarantee.
 If, on the date of service, eligibility was verified for more than one HDS plan, but at the
time the claim processed:
 Two or more coverages are active- Claim will process under the active
coverages.
 Only one coverage is active - Claim will process under the active coverage only.
 No coverage is active - Claim will process under the former primary plan only.
 Eligibility Guarantee does not apply when Other Carrier plan coverage exists on the date
of service.
 Only eligibility is subject to this guarantee. Product maximums, frequencies and other
processing criteria will be subject to HDS claims adjudication.
 Group contracts may have specific provisions that govern claims submission timelines
and/or payment restrictions upon termination. In these special situations, the Eligibility
Guarantee may not apply.

4. Preauthorization – Provided upon request and recommended for major services and treatment
plans, the preauthorization gives an estimated preauthorized benefit amount of how much a
proposed treatment plan will be covered under a patient’s benefit plan and what the patient’s out-
of-pocket cost will be. A preauthorization reserves the HDS payment amount against the patient’s
plan maximum for up to one year from the processing date. Actual benefits are subject to plan
benefits, plan maximum, fee schedules and eligibility status on the date of service.

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5. Continuation Policy – HDS requires restorations and other qualified multi-stage services to be
submitted using the insertion or completion date. If the conditions listed below are met, HDS will
benefit the service even though the patient no longer has coverage.

 Preparation was completed prior to the patient’s termination date.

 Restoration insertion or service completion date is within 30 days of patient’s termination
date.
 Patient has no current coverage with another HDS plan or other carrier during the 30
days after termination.
 Orthodontic procedures do not qualify for the continuation policy.

6. Group Contract Provisions – HDS may negotiate special time limitations or benefit coverages
with individual employer groups. Those special provisions override the Procedure Code
Guidelines and will be noted in the group’s benefit description. When determining plan benefits,
HDS considers previous restorative, endodontic, periodontic, prosthodontic, oral surgery and
orthodontic services performed within the applicable time limitations, including prior services
performed under a different group contract.

7. Treatment limitations – If an HDS Plan limits the number of times a particular benefit (e.g. oral
prophylaxis) is available annually, that limit will apply even if an Eligible Person is covered by two
or more HDS dental plans. The Eligible Person is not entitled to that Benefit more frequently than
permitted by the most generous HDS Plan.

8. Medicaid and Medicare –Specific sections throughout these Guidelines refer to Government
Program benefits for “Supplemental Medicaid” and “Medicare”.

The “Supplemental Medicaid” plan is for adult Medicaid recipients who are also covered under
the HDS Supplemental Medicaid Plan through a Managed Care Organization (MCO). If you treat
a patient covered under this plan and have not joined the HDS Supplemental Medicaid provider
network, services for the patient will be denied. NOTE: This is not the State of Hawaii’s Med-
QUEST program administered by HDS (i.e. HDS Medicaid) which covers children and emergent
dental services only for adults.

The “Medicare” plan is for eligible recipients who are covered under the HDS Medicare
Advantage Plan through a Medicare Advantage Organization (MAO). If you treat a patient
covered under this plan and have not joined the HDS Medicare Advantage provider network,
services for the patient will be denied.

9. Autorecovery/Overpayment –When HDS makes an overpayment to a participating dentist, and

the dentist does not promptly send an explanation and refund back to HDS, the overpayment is
generally recovered by automatic deduction (autodeduction).

K. Office Reviews and Fraud and Abuse

HDS periodically conducts office reviews of participating dentists as a contractual obligation to
employer groups and to ensure that the participating dentists are in compliance with HDS Member
Dentist contract documents. These reviews are conducted to verify that services were rendered as
billed to HDS, ensure HDS patients were charged appropriately and to provide opportunities to
discuss proper claims submission procedures. A dentist may be selected at random for an office
review or if there is a pattern of unusual claims submission, a history of patient complaints to HDS or
unusually high utilization when compared to his/her peers. Examples of fraudulent activities are listed
below:

 Misrepresentation of services
 Billing for services not rendered
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 Falsifying dates of service

 Failing to disclose coordination of benefits
 Waiving patient copayments
 Altering records for the purpose of enhancing billing
 Unbundling of claims
 Unlicensed personnel performing clinical services
 Upcoding of services

L. The Remittance Advice Report

HDS provides a weekly Remittance Advice report (RA) that is available on HDS Online. Below are the
definitions of the most pertinent items:

1. Approved Amount – Your total reimbursement per procedure is limited to the Approved Amount.

 For covered benefits, your Approved Amount will be the lower of your Submitted Amount, or
the HDS Maximum Plan Allowance for the respective procedure code.
 For most Alternate Benefits, you may charge the HDS patient up to your Submitted Amount.
Accordingly, for most Alternate Benefits, the Approved Amount is equal to your Submitted
Amount.
 For all non-covered benefits, the Approved Amount is equal to your Submitted Amount.

2. Allowed Amount – The HDS co-payment percentage is applied to the Allowed Amount to
determine the benefit. Most of the time, the Allowed Amount will be equal to the Approved
Amount. There are three occasions when the Allowed Amount is not the same as the Approved
Amount:

 Non-covered procedures are submitted

 An Alternate Benefit is involved
 A Deductible applies

For more information regarding these exceptions, please contact the HDS Customer Service
department.

3. Patient Portion – HDS determines the patient portion by calculating the Approved Amount less
the HDS payment and any Other Carrier payment.

4. Deductibles – When a patient's plan includes a Deductible, the Allowed Amount is reduced by
the Deductible amount. The benefit percentage is then applied to this Allowed Amount to
determine the HDS payment and patient share amounts.

Deductible example using a Covered Benefit:

 Approved Amount = Covered Benefit Maximum Plan Allowance = $100

 Benefit Percentage = 80%
 Deductible = $25
1) Subtract the Deductible from the Maximum Plan Allowance to arrive at the Allowed
Amount for benefit calculations.
 [$100 MPA] — [$25 Deductible] = $75 Allowed Amount

2) Determine the HDS Payment by multiplying the Allowed Amount by the Benefit
Percentage for the respective procedure.
 [$75 Allowed Amount] x [80% Benefit Percentage] = $60 HDS Payment

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3) Calculate the Patient Share by subtracting the HDS Payment from the Approved
Amount.
 [$100 Approved Amount] — [$60 HDS Payment] = $40 Patient Share

5. Explanation Codes – Sometimes the terms Denied or Not Billable to the Patient will appear in
the explanation. For clarification, when a service is Denied, HDS will not pay for the procedure
and the patient is fully responsible for the Approved Amount. If a procedure is not billable to the
patient, HDS will not pay for the procedure and the office is not permitted to collect any amount
from the patient for that procedure.

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Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

DIAGNOSTIC D120 – D999

D0120 Periodic Oral Evaluation – established
Exams
patient
D0140 Limited Oral Evaluation – problem
Exams
focused
D0145 Oral evaluation for a patient under three
years of age and counseling with primary Exams
caregiver
D0150 Comprehensive Oral Evaluation – new or
Exams
established patient
D0160 Detailed and extensive oral evaluation –
Alt-Exams
problem focused, by report
D0170 Re-evaluation – limited, problem focused
(established patient; not post-operative Alt-Exams
visit)
D0171 Re-evaluation – post-operative office visit Deny or NBP
D0180 Comprehensive periodontal evaluation –
Exams
new or established patient
D0190 Screening of patient NBP
D0191 Assessment of patient NBP
D0210 Intraoral - complete series of radiographic
X-Rays
images
D0220 Intraoral - periapical first radiographic
X-Rays
image
D0230 Intraoral - periapical each additional
X-Rays
radiographic image
D0240 Intraoral - occlusal radiographic image X-Rays
D0250 Extra-oral – 2D projection radiographic
image created using a stationary radiation X-Rays
source, and detector
D0251 Extra-oral posterior dental radiographic
Deny
image
D0270 Bitewing - single radiographic image Bitewings
D0272 Bitewings - two radiographic images Bitewings
D0273 Bitewings - three radiographic images Bitewings
D0274 Bitewings - four radiographic images Bitewings
D0277 Vertical bitewings - 7 to 8 radiographic Bitewings
images
D0310 Sialography Deny
D0320 Temporomandibular joint arthrogram,
Deny
including injection
D0321 Other temporomandibular radiographic
Deny
images, by report
D0322 Tomographic survey Deny
D0330 Panoramic radiographic image X-Rays
D0340 2Dcephalometric radiographic image-
Ortho
acquisition, measurement and analysis
D0350 2 D oral/facial photographic image
Ortho
obtained intraorally or extraorally
D0351 3D photographic image Deny

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Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

D0364 Cone beam CT capture and interpretation Deny

with limited field of view – less than one
whole jaw
D0365 Cone beam CT capture and interpretation Deny
with field of view of one full dental arch –
mandible
D0366 Cone beam CT capture and interpretation Deny
with field of view of one full dental arch –
maxilla, with or without cranium
D0367 Cone beam CT capture and interpretation Deny
with field of view of both jaws, with or
without cranium
D0368 Cone beam CT capture and interpretation Deny
for TMJ series including two or more
exposures
D0369 Maxillofacial MRI capture and Deny
interpretation
D0370 Maxillofacial ultrasound capture and Deny
interpretation
D0371 Sialoendoscopy capture and Deny
interpretation
D0380 Cone beam CT image capture with Deny
limited field of view – less than one whole
jaw
D0381 Cone beam CT image capture with field Deny
of view of one full dental arch – mandible
D0382 Cone beam CT image capture with field Deny
of view of one full dental arch – maxilla,
with or without cranium
D0383 Cone beam CT image capture with field Deny
of view of both jaws, with or without
cranium
D0384 Cone beam CT image capture for TMJ Deny
series including two or more exposures
D0385 Maxillofacial MRI image capture Deny
D0386 Maxillofacial ultrasound image capture Deny
D0391 Interpretation of diagnostic image by a Deny
practitioner not associated with capture of
the image, including report
D0393 Treatment simulation using 3D image Deny
volume
D0394 Digital subtraction of two or more images Deny
or image volumes of the same modality
D0395 Fusion of two or more 3D image volumes Deny
of one or more modalities
D0411 HbA1c in-office point of service testing Deny
D0412 Blood glucose level test: in office using a Deny
glucose meter
D0414 Laboratory processing of microbial
specimen to include culture and Deny
sensitivity studies, preparation and
transmission of written report
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Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

D0415 Collection of microorganisms for culture

Deny
and sensitivity
D0416 Viral Culture Deny
D0417 Collection and preparation of saliva
Deny
sample for laboratory diagnostic testing
D0418 Analysis of saliva sample Deny
D0419 Assessment of salivary flow by
Diagnostic
measurement
D0422 Collection and preparation of genetic
sample material for laboratory analysis Deny
and report
D0423 Genetic test for susceptibility to diseases-
Deny
specimen analysis
D0425 Caries susceptibility tests Deny
D0431 Adjunctive pre-diagnostic test that aids in
detection of mucosal abnormalities
including premalignant and malignant Deny
lesions, not to include cytology or biopsy
procedures
D0460 Pulp vitality tests Diagnostic
D0470 Diagnostic casts Ortho X
D0472 Accession of tissue, gross examination,
preparation and transmission of written X-rays
report
D0473 Accession of tissue, gross and
microscopic examination, preparation and X-rays
transmission of written report
D0474 Accession of tissue, gross and
microscopic examination, including
assessment of surgical margins for X-rays
presence of disease, preparation and
transmission of written report
D0475 Decalcification procedure Deny
D0476 Special stains for microorganisms Deny
D0477 Special stains not for microorganisms Deny
D0478 Immunohistochemical stains Deny
D0479 Tissue in-situ hybridization, including
Deny
interpretation
D0480 Accession of exfoliative cytologic smears,
microscopic examination, preparation and Diagnostic
transmission of written report
D0481 Electron microscopy Deny
D0482 Direct immunofluorescence Deny
D0483 Indirect immunofluorescence Deny
D0484 Consultation on slides prepared
Diagnostic
elsewhere
D0485 Consultation, including preparation of
slides from biopsy material supplied by Alt-Diagnostic Path Rpt
referring source

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Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

D0486 Accession of transepithelial cytologic

sample, microscopic examination,
Deny
preparation and transmission of written
report
D0502 Other oral pathology procedures, by
Deny
report
D0600 Non-ionizing diagnostic procedure
capable of quantifying, monitoring, and
Deny or NBP
recording changes in structure of enamel,
dentin, and cementum
D0601 Caries risk assessment and
Deny
documentation, with a finding of low risk
D0602 Caries risk assessment and
documentation, with a finding of moderate Deny
risk
D0603 Caries risk assessment and
Deny
documentation, with a finding of high risk
D0604 Antigen testing for a public health related
Deny
pathogen, including coronavirus
D0605 Antibody testing for a public health
Deny
related pathogen, including coronavirus
D0606 Molecular testing for a public health
Deny
pathogen, including coronavirus
D0701 Panoramic radiographic image – image
NBP
capture only
D0702 2-D cephalometric radiographic image –
NBP
image capture only
D0703 2-D/facial photographic image obtained
intra-orally or extra-orally – image capture NBP
only
D0704 3-D photographic image – image capture
NBP
only
D0705 Extra-oral posterior dental radiographic
NBP
image – image capture only
D0706 Intraoral – occlusal radiographic image –
NBP
image capture only
D0707 Intraoral – periapical radiographic image
NBP
– image capture only
D0708 Intraoral – bitewing radiographic image –
NBP
image capture only
D0709 Intraoral – complete series of
NBP
radiographic images – image capture only
D0999 Unspecified diagnostic procedure, by
Alt-By Rpt X
report
PREVENTIVE D1000 – D1999
D1110 Prophylaxis – adult Cleaning
D1120 Prophylaxis – child Cleaning
D1206 Topical application of fluoride varnish Fluoride
D1208 Topical application of fluoride – excluding
Fluoride
varnish
D1310 Nutritional counseling for control of dental
Deny
disease
Revised: 01/01/2022
Effective: 01/01/2022
4
HDS PROCEDURE CODE GUIDELINES SUBMISSION REQUIREMENTS

Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

D1320 Tobacco counseling for the control and

Deny
prevention of oral disease
D1321 Counseling for the control and prevention
of adverse oral, behavioral, and systemic
Deny
health effects associated with high-risk
substance abuse
D1330 Oral hygiene instructions Deny
D1351 Sealant – per tooth Sealants
D1352 preventive resin restoration in a moderate
to high caries risk patient – permanent Deny
tooth
D1353 Sealant repair – per tooth Deny
D1354 Application of caries arresting
Fluoride
medicament - per tooth
D1355 Caries preventive medicament application
Deny
– per tooth
D1510 Space maintainer – fixed, unilateral-per
Space Maint
quadrant
D1516 Space maintainer – fixed – bilateral,
Space Maint
maxillary
D1517 Space maintainer-fixed-bilateral, Space
mandibular Maintainer
D1520 Space maintainer – removable, unilateral-
Deny
per quadrant
D1526 Space maintainer – removable, bilateral Space Maint
maxillary
D1527 Space maintainer-removable-bilateral Space Maint
mandibular
D1551 Re-cement or re-bond bilateral space - Space Maint
maintainer-maxillary
D1552 Re-cement or re-bond bilateral space Space Maint
maintainer-mandibular
D1553 Re-cement or re-bond unilateral space Space Maint
maintainer – per quadrant
D1556 Removal of fixed unilateral space Space Maint
maintainer-per quadrant
D1557 Removal of fixed bilateral space Space Maint
maintainer-maxillary
D1558 Removal of fixed bilateral space Space Maint
maintainer-mandibular
D1575 Distal shoe space maintainer -fixed, Space Maint
unilateral-per quadrant
D1701 Pfizer BioNtech COVID 19 vaccine – first Deny
dose
D1702 Pfizer BioNtech COVID 19 vaccine – Deny
second dose
D1703 Moderna COVID 19 vaccine Deny
administration – first dose
D1704 Moderna COVID 19 vaccine Deny
administration – second dose
D1705 AstraZeneca COVID 19 vaccine Deny
administration – first dose
Revised: 01/01/2022
Effective: 01/01/2022
5
HDS PROCEDURE CODE GUIDELINES SUBMISSION REQUIREMENTS

Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

D1706 AstraZeneca COVID 19 vaccine Deny

administration – second dose
D1707 Janssen COVID 19 administration Deny
D1999 Unspecified preventive procedure, by By Rpt X
report
RESTORATIVE D2000 – D2999
D2140 Amalgam – one surface, primary or
Routine Rest
permanent
D2150 Amalgam – two surfaces, primary or
Routine Rest
permanent
D2160 Amalgam – three surfaces, primary or
Routine Rest
permanent
D2161 Amalgam – four or more surfaces,
Routine Rest
primary or permanent
D2330 Resin-based composite – one surface,
Routine Rest
anterior
D2331 Resin-based composite – two surfaces,
Routine Rest
anterior
D2332 Resin-based composite – three surfaces,
Routine Rest
anterior
D2335 Resin-based composite – four or more
surfaces or involving incisal angle Routine Rest
(anterior)
D2390 Resin-based composite crown, anterior Routine Rest X
D2391 Resin-based composite – one surface, Routine Rest-
posterior Premolars Surf F
Alt -Routine Rest
Other Teeth/Surf
(for most plans)
D2392 Resin-based composite – two surfaces, Alt-Routine Rest
posterior (for most plans)
D2393 Resin-based composite – three surfaces, Alt-Routine Rest
posterior (for most plans)
D2394 Resin-based composite – four or more Alt-Routine Rest
surfaces, posterior (for most plans)
D2410 Gold foil – one surface Alt-Routine Rest
(for most plans)
D2420 Gold foil – two surfaces Alt-Routine Rest
(for most plans)
D2430 Gold foil – three surfaces Alt-Routine Rest
(for most plans)
D2510 Inlay – metallic - one surface Crown X
D2520 Inlay – metallic - two surfaces Crown X
D2530 Inlay – metallic - three or more surfaces Crown X
D2542 Onlay – metallic - two surfaces Crown X
D2543 Onlay – metallic - three surfaces Crown X
D2544 Onlay – metallic - four or more surfaces Crown X
D2610 Inlay – porcelain/ceramic - one surface Alt-Crown
X
(for most plans)
D2620 Inlay – porcelain/ceramic - two surfaces Alt-Crown
X
(for most plans)
Revised: 01/01/2022
Effective: 01/01/2022
6
HDS PROCEDURE CODE GUIDELINES SUBMISSION REQUIREMENTS

Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

D2630 Inlay – porcelain/ceramic - three or more Alt-Crown

X
surfaces (for most plans)
D2642 Onlay – porcelain/ceramic - two surfaces Alt-Crown
X
(for most plans)
D2643 Onlay – porcelain/ceramic - three Alt-Crown
X
surfaces (for most plans)
D2644 Onlay – porcelain/ceramic - four or more Alt-Crown
X
surfaces (for most plans)
D2650 Inlay – resin-based composite - one Alt-Crown
X
surface (for most plans)
D2651 Inlay – resin-based composite - two Alt-Crown
X
surfaces (for most plans)
D2652 Inlay – resin-based composite - three or Alt-Crown
X
more surfaces (for most plans)
D2662 Onlay – resin-based composite - two Alt-Crown
X
surfaces (for most plans)
D2663 Onlay – resin-based composite - three Alt-Crown
X
surfaces (for most plans)
D2664 Onlay – resin-based composite - four or Alt-Crown
X
more surfaces (for most plans)
D2710 Crown – resin-based composite (indirect) Crown X
D2712 Crown – ¾ resin-based composite
Crown X
(indirect)
D2720 Crown – resin with high noble metal Crown X
D2721 Crown – resin with predominantly base
Crown X
metal
D2722 Crown – resin with noble metal Crown X
D2740 Crown – porcelain/ceramic Crown X
D2750 Crown – porcelain fused to high noble
Crown X
metal
D2751 Crown – porcelain fused to predominantly
Crown X
base metal
D2752 Crown – porcelain fused to noble metal Crown X
D2753 Crown-porcelain fused to titanium and
Crown X
titanium alloys
D2780 Crown – 3/4 cast high noble metal Crown X
D2781 Crown – 3/4 cast predominantly base
Crown X
metal
D2782 Crown – 3/4 cast noble metal Crown X
D2783 Crown – 3/4 porcelain/ceramic Crown X
D2790 Crown – full cast high noble metal Crown X
D2791 Crown – full cast predominantly base
Crown X
metal
D2792 Crown – full cast noble metal Crown X
D2794 Crown – titanium and titanium alloys Alt-Crown
X
(for most plans)
D2799 Interim crown – further treatment or
completion of diagnosis necessary prior Adjunctive X X
to final impression
D2910 Re-cement or re-bond inlay, onlay,
Routine Rest
veneer or partial coverage restoration

Revised: 01/01/2022
Effective: 01/01/2022
7
HDS PROCEDURE CODE GUIDELINES SUBMISSION REQUIREMENTS

Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

D2915 Re-cement or re-bond indirectly

Routine Rest
fabricated or prefabricated post and core
D2920 Re-cement or re-bond crown Routine Rest
D2921 Reattachment of tooth fragment, incisal
Routine Rest
edge or cusp
D2928 Prefabricated porcelain/ceramic crown – Alt-Routine Rest
permanent tooth (for most plans)
D2929 Prefabricated porcelain/ceramic crown – Alt-Routine Rest
primary tooth (for most plans)
D2930 Prefabricated stainless steel crown –
Routine Rest
primary tooth
D2931 Prefabricated stainless steel crown –
Routine Rest
permanent tooth
D2932 Prefabricated resin crown Routine Rest
D2933 Prefabricated stainless steel crown with
Routine Rest
resin window
D2934 Prefabricated esthetic coated stainless
Routine Rest
steel crown – primary tooth
D2940 Protective restoration Adjunctive
D2941 Interim therapeutic restoration – primary
Deny
dentition
D2949 Restorative foundation for an indirect
NBP
restoration
D2950 Core buildup, including any pins Routine X
D2951 Pin retention – per tooth, in addition to
Routine Rest
restoration
D2952 Post and core in addition to crown,
Crown X
indirectly fabricated
D2953 Each additional indirectly fabricated post
NBP
– same tooth
D2954 Prefabricated post and core in addition to
Routine Rest X
crown
D2955 Post removal Routine Rest X X
D2957 Each additional prefabricated post –
NBP
same tooth
D2960 Labial veneer (resin laminate) – chairside Routine Rest
D2961 Labial veneer (resin laminate) –
Crown X
laboratory
D2962 Labial veneer (porcelain laminate) –
Crown X
laboratory
D2971 Additional procedures to customize a
crown to fit under an existing partial Crown
denture framework
D2975 Coping Deny
D2980 Crown repair necessitated by restorative Alt-By Rpt Lab
X
material failure (for most plans) Invoice
D2981 Inlay repair necessitated by restorative Alt-By Rpt Lab
(for most plans)
X
material failure Invoice
D2982 Onlay repair necessitated by restorative Alt-By Rpt Lab
(for most plans)
X
material failure Invoice

Revised: 01/01/2022
Effective: 01/01/2022
8
HDS PROCEDURE CODE GUIDELINES SUBMISSION REQUIREMENTS

Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

D2983 Veneer repair necessitated by restorative Alt-By Rpt Lab

(for most plans)
X
material failure Invoice
D2990 Resin infiltration of incipient smooth
Deny
surface lesions
D2999 Unspecified restorative procedure, by Lab
By Rpt X
report Invoice
ENDODONTICS D3000 – D3999
D3110 Pulp cap – direct (excluding final
Endo X
restoration)
D3120 Pulp cap – indirect (excluding final
Endo X
restoration)
D3220 Therapeutic pulpotomy (excluding final
restoration) – removal of pulp coronal to
Endo
the dentinocemental junction and
application of medicament
D3221 Pulpal debridement, primary and
Endo
permanent teeth
D3222 Partial pulpotomy for apexogenesis 
permanent tooth with incomplete root Endo X
development
D3230 Pulpal therapy (resorbable filling) –
anterior, primary tooth (excluding final Endo X
restoration)
D3240 Pulpal therapy (resorbable filling) –
posterior, primary tooth (excluding final Endo X
restoration)
D3310 Endodontic therapy, anterior tooth
Endo Post-Op
(excluding final restoration)
D3320 Endodontic therapy, premolar tooth Endo
Post-Op
(excluding final restoration)
D3330 Endodontic therapy, molar tooth Endo
Post-Op
(excluding final restoration)
D3331 Treatment of root canal obstruction; non- Pre-Op
Endo
surgical access Post-Op
D3332 Incomplete endodontic therapy;
inoperable, unrestorable or fractured Endo X
tooth
D3333 Internal root repair of perforation defects Endo X X
D3346 Retreatment of previous root canal Pre-Op
Endo X
therapy – anterior Post-Op
D3347 Retreatment of previous root canal Pre-Op
Endo X
therapy – premolar Post-Op
D3348 Retreatment of previous root canal Pre-Op
Endo X
therapy – molar Post-Op
D3351 Apexification/recalcification/pulpal
regeneration – initial visit (apical
Endo X
closure/calcific repair of perforations,
root resorption, etc.)

Revised: 01/01/2022
Effective: 01/01/2022
9
HDS PROCEDURE CODE GUIDELINES SUBMISSION REQUIREMENTS

Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

D3352 Apexification/recalcification/pulpal
regeneration - interim medication
replacement (apical closure/calcific Endo Post-Op
repair of perforations, root resorption,
pulp space disinfection, etc.)
D3353 Apexification/recalcification – final visit
(includes completed root canal therapy –
Endo Post-Op
apical closure/calcific repair of
perforations, root resorption, etc.)
D3355 Pulpal regeneration – initial visit Endo X
D3356 Pulpal regeneration – interim medication
Endo Post-Op
replacement
D3357 Pulpal regeneration – completion of
Endo Post-Op
treatment
D3410 Apicoectomy/periradicular surgery – Pre-Op
Endo
anterior Post-Op
D3421 Apicoectomy/periradicular surgery – Pre-Op
Endo
premolar (first root) Post-Op
D3425 Apicoectomy/periradicular surgery – Pre-Op
Endo
molar (first root) Post-Op
D3426 Apicoectomy/periradicular surgery – Pre-Op
Endo
(each additional root) Post-Op
D3428 Bone graft in conjunction with
periradicular surgery – per tooth, single Deny
site
D3429 Bone graft in conjunction with
periradicular surgery – each additional
Deny
contiguous tooth in the same surgical
site
D3430 Retrograde filling – per root Endo Post-Op
D3431 Biologic materials to aid in soft and
osseous tissue regeneration in Deny
conjunction with periradicular surgery
D3432 Guided tissue regeneration, resorbable
barrier, per site, in conjunction with Deny
periradicular surgery
D3450 Root amputation – per root Endo X
D3460 Endodontic endosseous implant Deny
D3470 Intentional reimplantation (including
Deny
necessary splinting)
D3471 Surgical repair of root resorption -
Endo X Op Rep
anterior
D3472 Surgical repair of root resorption -
Endo X Op Rep
premolar
D3473 Surgical repair of root resorption - molar Endo X Op Rep
D3501 Surgical exposure of root surface without
apicoectomy or repair of root resorption- Endo X Op Rep
anterior
D3502 Surgical exposure of root surface without
apicoectomy or repair of root resorption- Endo X Op Rep
premolar

Revised: 01/01/2022
Effective: 01/01/2022
10
HDS PROCEDURE CODE GUIDELINES SUBMISSION REQUIREMENTS

Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

D3503 Surgical exposure of root surface without

apicoectomy or repair of root resorption- Endo X Op Rep
molar
D3910 Surgical procedure for isolation of tooth
NBP
with rubber dam
D3911 Intraorifice barrier NBP
D3920 Hemisection (including any root
removal), not including root canal Endo X
therapy
D3921 Decoronation or submergence of an
Endo Op Rep
erupted tooth
D3950 Canal preparation and fitting of
NBP
preformed dowel or post
D3999 Unspecified endodontic procedure, by
By Rpt X
report
PERIODONTICS D4000 – D4999
D4210 Gingivectomy or gingivoplasty – four or
more contiguous teeth or tooth bounded Perio X
spaces per quadrant
D4211 Gingivectomy or gingivoplasty – one to
Additional
three contiguous teeth or tooth bounded Perio X
Teeth #
spaces per quadrant
D4212 Gingivectomy or gingivoplasty to allow
access for restorative procedure, per Perio X X
tooth
D4230 Anatomical crown exposure - four or
more contiguous teeth or tooth bounded Deny
spaces per quadrant
D4231 Anatomical crown exposure - one to
three teeth or tooth bounded spaces Deny
per quadrant
D4240 gingival flap procedure, including root
planing - four or more contiguous teeth Perio X
or tooth bounded spaces per quadrant
D4241 Gingival flap procedure, including root
planing – one to three teeth contiguous Additional
Perio X
teeth or tooth bounded spaces per Teeth #
quadrant
D4245 Apically positioned flap Deny
D4249 Clinical crown lengthening – hard tissue Perio X
D4260 Osseous surgery (including elevation of
a full thickness flap and closure) – four
Perio X
or more contiguous teeth or tooth
bounded spaces per quadrant
D4261 Osseous surgery (including elevation of
a full thickness flap and closure) – one Additional
Perio X
to three contiguous teeth or tooth Teeth #
bounded spaces per quadrant
D4263 Bone replacement graft – retained
Perio
natural tooth-first site in quadrant

Revised: 01/01/2022
Effective: 01/01/2022
11
HDS PROCEDURE CODE GUIDELINES SUBMISSION REQUIREMENTS

Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

D4264 Bone replacement graft – retained

natural tooth- each additional site in Perio
quadrant
D4265 Biologic materials to aid in soft and
Perio
osseous tissue regeneration, per site
D4266 Guided tissue regeneration - resorbable
Perio
barrier, per site barrier, per site
D4267 Guided tissue regeneration -
Alt-Perio
nonresorbable barrier, per site (includes
(for most plans)
membrane removal)
D4268 Surgical revision procedure, per tooth NBP
D4270 Pedicle soft tissue graft procedure Deny
D4273 Autogenous connective tissue graft
procedure (including donor and recipient
Perio X
surgical sites) first tooth, implant, or
edentulous tooth position in graft
D4283 Autogenous connective tissue graft
procedure (including donor and recipient
surgical sites) – each additional Perio X
contiguous tooth, implant or edentulous
tooth position in same graft site
D4274 Mesial/distal wedge procedure, single
tooth (when not performed in conjunction
Deny
with surgical procedures in the same
anatomical area)
D4275 Non-autogenous connective tissue graft
(including recipient site and donor
Perio X
material) first tooth, implant, or
edentulous tooth position in graft
D4285 Non-autogenous connective tissue graft
procedure (including recipient surgical
site and donor material)- each additional Perio X
contiguous tooth, implant or edentulous
tooth position in same graft site
D4276 Combined connective tissue and pedicle
Deny
graft, per tooth
D4277 Free soft tissue graft procedure (including
recipient and donor surgical sites) first
Perio X
tooth, implant or edentulous tooth position
in graft
D4278 Free soft tissue graft procedure (including
recipient and donor surgical sites), each
additional contiguous tooth, implant or Perio X
edentulous tooth position in same graft
site
Splint – intracoronal; natural teeth or
D4322 Deny or NBP
prosthetic crowns
Splint – extracoronal; natural teeth or
D4323 Deny or NBP
prosthetic crowns
D4341 Periodontal scaling and root planing - four
Perio X
or more teeth per quadrant

Revised: 01/01/2022
Effective: 01/01/2022
12
HDS PROCEDURE CODE GUIDELINES SUBMISSION REQUIREMENTS

Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

D4342 Periodontal scaling and root planing - one Additional

Perio X
to three teeth per quadrant Teeth #
D4346 Scaling in presence of generalized
moderate or severe gingival
Cleaning
inflammation-full mouth, after oral
evaluation
D4355 Full mouth debridement to enable
comprehensive evaluation and diagnosis Cleaning
on a subsequent visit
D4381 Localized delivery of Antimicrobial agents
via a controlled release vehicle into
Deny
diseased crevicular tissue, per tooth, by
report
D4910 Periodontal maintenance Perio
D4920 Unscheduled dressing change (by
someone other than treating dentist or Perio
their staff)
D4921 Gingival irrigation – per quadrant Deny or NBP
D4999 Unspecified periodontal procedure, by
By Rpt X
report
PROSTHODONTICS (REMOVABLE) D5000 – D5899
D5110 Complete denture – maxillary Prostho
D5120 Complete denture – mandibular Prostho
D5130 Immediate denture – maxillary Prostho
D5140 Immediate denture – mandibular Prostho
D5211 Maxillary partial denture – resin base
(including retentive/clasping materials, Prostho X
rests and teeth)
D5212 Mandibular partial denture – resin base
(including retentive/clasping materials, Prostho X
rests and teeth)
D5213 Maxillary partial denture – cast metal
framework with resin denture bases
Prostho X
(including retentive/clasping materials,
rests and teeth)
D5214 Mandibular partial denture – cast metal
framework with resin denture bases
Prostho X
(including retentive/clasping materials,
rests and teeth)
D5221 Immediate maxillary partial denture -
resin base (including retentive/clasping Prostho X
materials, rests and teeth)
D5222 Immediate mandibular partial denture -
resin base (including retentive/clasping Prostho X
materials, rests and teeth)
D5223 Immediate maxillary partial denture – cast
metal framework with resin denture bases
Prostho X
(including retentive/clasping materials,
rests and teeth)

Revised: 01/01/2022
Effective: 01/01/2022
13
HDS PROCEDURE CODE GUIDELINES SUBMISSION REQUIREMENTS

Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

D5224 Immediate mandibular partial denture –

cast metal framework with resin denture
Prostho X
bases (including retentive/clasping
materials, rests and teeth)
D5225 Maxillary partial denture – flexible base
Prostho X
(including any clasps, rests and teeth)
D5226 Mandibular partial denture – flexible base
Prostho X
(including any clasps, rests and teeth)
D5227 Immediate maxillary partial denture –
flexible base (including any clasps, rests Prostho X
and teeth)
D5228 Immediate mandibular partial denture –
flexible base (including any clasps, rests Prostho X
and teeth)
D5282 Removable unilateral partial denture –
one piece cast metal (including Prostho X
clasps and teeth), maxillary
D5283 Removable unilateral partial denture –
one piece cast metal (including Prostho X
clasps and teeth), mandibular
D5284 Removable unilateral partial denture -
one piece flexible base (including clasps Prostho X
and teeth) – per quadrant
D5286 Removable unilateral partial denture -
one piece resin (including clasps and Prostho X
teeth) – per quadrant
D5410 Adjust complete denture – maxillary Prostho
D5411 Adjust complete denture – mandibular Prostho
D5421 Adjust partial denture – maxillary Prostho
D5422 Adjust partial denture – mandibular Prostho
D5511 Repair broken complete denture base, Prostho
mandibular
D5512 Repair broken complete denture base, Prostho
maxillary
D5520 Replace missing or broken teeth –
Prostho
complete denture (each tooth)
D5611 Repair resin partial denture base,
Prostho
mandibular
D5612 Repair resin partial denture base,
Prostho
maxillary
D5621 Repair cast partial framework, mandibular Prostho
D5622 Repair cast partial framework, maxillary Prostho
D5630 Repair or replace broken retentive
Prostho
clasping materials – per tooth
D5640 Replace broken teeth – per tooth Prostho
D5650 Add tooth to existing partial denture Prostho
D5660 Add clasp to existing partial denture – per
Prostho
tooth
D5670 Replace all teeth and acrylic on cast
Prostho X
metal framework (maxillary)

Revised: 01/01/2022
Effective: 01/01/2022
14
HDS PROCEDURE CODE GUIDELINES SUBMISSION REQUIREMENTS

Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

D5671 Replace all teeth and acrylic on cast

Prostho X
metal framework (mandibular)
D5710 Rebase complete maxillary denture Prostho
D5711 Rebase complete mandibular denture Prostho
D5720 Rebase maxillary partial denture Prostho
D5721 Rebase mandibular partial denture Prostho
D5725 Rebase hybrid prosthesis Prostho
D5730 Reline complete maxillary denture
Prostho
(chairside)
D5731 Reline complete mandibular denture
Prostho
(chairside)
D5740 Reline maxillary partial denture
Prostho
(chairside)
D5741 Reline mandibular partial denture
Prostho
(chairside)
D5750 Reline complete maxillary denture
Prostho
(laboratory)
D5751 Reline complete mandibular denture
Prostho
(laboratory)
D5760 Reline maxillary partial denture
Prostho
(laboratory)
D5761 Reline mandibular partial denture
Prostho
(laboratory)
D5765 Soft liner for complete or partial
Prostho
removable denture - indirect
D5810 Interim complete denture (maxillary) Deny
D5811 Interim complete denture (mandibular) Deny
D5820 Interim partial denture – (maxillary) Prostho X
D5821 Interim partial denture – (mandibular) Prostho X
D5850 Tissue conditioning, maxillary Prostho
D5851 Tissue conditioning, mandibular Prostho
D5862 Precision attachment, by report Deny
D5863 Overdenture - complete maxillary Prostho
D5864 Overdenture – partial maxillary Prostho X
D5865 Overdenture – complete mandibular Prostho
D5866 Overdenture – partial mandibular Prostho X
D5867 Replacement of replaceable part of semi-
precision or precision attachment, per Deny
attachment
D5875 Modification of removable prosthesis
Deny
following implant surgery
D5876 Add metal substructure to acrylic full
Deny
denture (per arch)
D5899 Unspecified removable prosthodontic Lab
Alt-By Rpt X
procedure, by report Invoice
D5911 Facial moulage (sectional) Deny
Revised: 01/01/2022
Effective: 01/01/2022
15
HDS PROCEDURE CODE GUIDELINES SUBMISSION REQUIREMENTS

Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

D5912 Facial moulage (complete) Deny

D5913 Nasal prosthesis Deny
D5914 Auricular prosthesis Deny
D5915 Orbital prosthesis Deny
D5916 Ocular prosthesis Deny
D5919 Facial prosthesis Deny
D5922 Nasal septal prosthesis Deny
D5923 Ocular prosthesis, interim Deny
D5924 Cranial prosthesis Deny
D5925 Facial augmentation implant prosthesis Deny
D5926 Nasal prosthesis, replacement Deny
D5927 Auricular prosthesis, replacement Deny
D5928 Orbital prosthesis, replacement Deny
D5929 Facial prosthesis, replacement Deny
D5931 Obturator prosthesis, surgical Deny
D5932 Obturator prosthesis, definitive Deny
D5933 Obturator prosthesis, modification Deny
D5934 Mandibular resection prosthesis with
Deny
guide flange
D5935 Mandibular resection prosthesis without
Deny
guide flange
D5936 Obturator prosthesis, interim Deny
D5937 Trismus appliance (not for TMD
Deny
treatment)
D5951 Feeding aid Deny
D5952 Speech aid prosthesis, pediatric Deny
D5953 Speech aid prosthesis, adult Deny
D5954 Palatal augmentation prosthesis Deny
D5955 Palatal lift prosthesis, definitive Deny
D5958 Palatal lift prosthesis, interim Deny
D5959 Palatal lift prosthesis, modification Deny
D5960 Speech aid prosthesis, modification Deny
D5982 Surgical stent Deny
D5983 Radiation carrier Deny
D5984 Radiation shield Deny
D5985 Radiation cone locator Deny
D5986 Fluoride gel carrier Deny
D5987 Commissure splint Deny
D5988 Surgical splint Deny
D5991 Vesiculobullous disease medicament
Deny
carrier
D5992 Adjust maxillofacial prosthetic appliance,
Deny
by report
D5993 Maintenance and cleaning of a
maxillofacial prosthesis (extra or intraoral)
Deny
other than required adjustments, by
report
D5995 Periodontal medicament carrier with
peripheral seal – laboratory processed – Deny
maxillary

Revised: 01/01/2022
Effective: 01/01/2022
16
HDS PROCEDURE CODE GUIDELINES SUBMISSION REQUIREMENTS

Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

D5996 Periodontal medicament carrier with

peripheral seal – laboratory processed – Deny
mandibular
D5999 Unspecified maxillofacial prosthesis, by Lab
Alt-By Rpt X
report Invoice
IMPLANT SERVICES D6000 – D6199
D6010 Surgical placement of implant body: Implant-Lim,
endosteal implant Implant-Alt or X
Implant
D6011 Surgical access to an implant body
NBP
(second stage implant surgery)
D6012 Surgical placement of interim implant
body for transitional prosthesis: endosteal Deny
implant
D6013 Surgical placement of mini implant Implant-Lim,
Implant-Alt or X
Implant
D6040 Surgical placement: eposteal implant Deny
D6050 Surgical placement: transosteal implant Deny
D6051 Interim implant abutment placement Deny
D6055 Connecting bar – implant supported or
Deny
abutment supported
D6056 Prefabricated abutment – includes
Implant X
modification and placement
D6057 Custom fabricated abutment – includes
Implant X
placement
D6058 Abutment supported porcelain/ceramic Implant-Lim,
crown Implant-Alt or X
Implant
D6059 Abutment supported porcelain fused to Implant-Lim,
metal crown (high noble metal) Implant-Alt or X
Implant
D6060 Abutment supported porcelain fused to Implant-Lim,
metal crown (predominantly base metal) Implant-Alt or X
Implant
D6061 Abutment supported porcelain fused to Implant-Lim,
metal crown (noble metal) Implant-Alt or X
Implant
D6097 Abutment supported crown – porcelain Implant-Lim,
fused to titanium or titanium alloys Implant-Alt or X
Implant
D6062 Abutment supported cast metal crown Implant-Lim,
(high noble metal) Implant-Alt or X
Implant
D6063 Abutment supported cast metal crown Implant-Lim,
(predominantly base metal) Implant-Alt or X
Implant
D6064 Abutment supported cast metal crown Implant-Lim,
(noble metal) Implant-Alt or X
Implant

Revised: 01/01/2022
Effective: 01/01/2022
17
HDS PROCEDURE CODE GUIDELINES SUBMISSION REQUIREMENTS

Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

D6094 Abutment supported crown – titanium and Implant-Lim,

titanium alloys Implant-Alt or X
Implant
D6065 Implant supported porcelain/ceramic Implant-Lim,
crown Implant-Alt or X
Implant
D6066 Implant supported crown-porcelain fused Implant-Lim,
to high noble alloy Implant-Alt or X
Implant
D6082 Implant supported crown-porcelain fused Implant-Lim,
to predominantly base alloys Implant-Alt or X
Implant
D6083 Implant supported crown-porcelain fused Implant-Lim,
to noble alloys Implant-Alt or X
Implant
D6084 Implant supported crown-porcelain fused Implant-Lim,
to titanium or titanium alloys Implant-Alt or X
Implant
D6067 Implant supported crown-high noble Implant-Lim,
alloys Implant-Alt or X
Implant
D6086 Implant supported crown-predominantly Implant-Lim,
base alloys Implant-Alt or X
Implant
D6087 Implant supported crown – noble alloys Implant-Lim,
Implant-Alt or X
Implant
D6088 Implant supported crown – titanium and Implant-Lim,
titanium alloys Implant-Alt or X
Implant
D6068 Abutment supported retainer for Implant-Lim,
porcelain/ceramic FPD Implant-Alt or X
Implant
D6069 Abutment supported retainer for porcelain Implant-Lim,
fused to metal FPD (high noble metal) Implant-Alt or X
Implant
D6070 Abutment supported retainer for porcelain Implant-Lim,
fused to metal FPD (predominantly base Implant-Alt or X
metal) Implant
D6071 Abutment supported retainer for porcelain Implant-Lim,
fused to metal FPD (noble metal) Implant-Alt or X
Implant
D6195 Abutment supported retainer - porcelain Implant-Lim,
fused to titanium and titanium alloys Implant-Alt or X
Implant
D6072 Abutment supported retainer for cast Implant-Lim,
metal FPD (high noble metal) Implant-Alt or X
Implant
D6073 Abutment supported retainer for cast Implant-Lim,
metal FPD (predominantly base metal) Implant-Alt or X
Implant

Revised: 01/01/2022
Effective: 01/01/2022
18
HDS PROCEDURE CODE GUIDELINES SUBMISSION REQUIREMENTS

Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

D6074 Abutment supported retainer for cast Implant-Lim,

metal FPD (noble metal) Implant-Alt or X
Implant
D6194 Abutment supported retainer crown for Implant-Lim,
FPD – titanium and titanium alloys Implant-Alt or X
Implant
D6075 Implant supported retainer for ceramic Implant-Lim,
FPD Implant-Alt or X
Implant
D6076 Implant supported retainer for FPD – Implant-Lim,
porcelain fused to high noble alloys Implant-Alt or X
Implant
D6098 Implant supported retainer – porcelain Implant-Lim,
fused to predominantly base alloys Implant-Alt or X
Implant
D6099 Implant supported retainer – porcelain Implant-Lim,
fused to noble alloys Implant-Alt or X
Implant
D6120 Implant supported retainer for FPD – Implant-Lim,
porcelain fused to titanium and titanium Implant-Alt or X
alloys Implant
D6077 Implant supported retainer for metal Implant-Lim,
FPD - high noble alloys Implant-Alt or X
Implant
D6121 Implant supported retainer for metal Implant-Lim,
FPD- predominantly base alloys Implant-Alt or X
Implant
D6122 Implant supported retainer for metal FPD Implant-Lim,
- noble alloys Implant-Alt or X
Implant
D6123 Implant supported retainer for metal FPD Implant-Lim,
– titanium and titanium alloys Implant-Alt or X
Implant
D6080 Implant maintenance procedures, when
prostheses are removed and reinserted,
Implant
including cleansing of prostheses and
abutments
D6081 Scaling and debridement in the
presence of inflammation or mucositis of
a single implant, including cleaning of Implant X
the implant surfaces, without flap entry
and closure
D6085 Interim implant crown Deny
D6090 Repair implant supported prosthesis by Implant-By Lab
X
report Report invoice
D6091 Replacement of replaceable part of
semi-precision or precision attachment
Deny
of implant/abutment supported
prosthesis, per attachment
D6092 Re-cement or re-bond implant/abutment
Prostho
supported crown

Revised: 01/01/2022
Effective: 01/01/2022
19
HDS PROCEDURE CODE GUIDELINES SUBMISSION REQUIREMENTS

Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

D6093 Re-cement or re-bond implant/abutment

Prostho
supported fixed partial denture
D6095 Repair implant abutment, by report Implant-By Lab
X
Report Invoice
D6096 Remove broken implant retaining screw Implant
D6100 Surgical removal of implant body Group Op
Contract Report
D6101 Debridement of a periimplant defect or
defects surrounding a single implant,
Implant X
and surface cleaning of exposed implant
surfaces, including flap entry and closure
D6102 Debridement and osseous contouring of
a periimplant defect or defects
surrounding a single implant and
Implant X
includes surface cleaning of the exposed
implant surfaces, including flap entry and
closure
D6103 Bone graft for repair of periimplant
defect – does not include flap entry and
closure. Placement of a barrier
Deny
membrane or biologic materials to aid in
osseous regeneration are reported
separately
D6104 Bone graft at time of implant placement Deny
D6110 Implant / abutment supported removable Implant-Lim,
denture for edentulous arch – maxillary Implant-Alt or X
Implant
D6111 Implant / abutment supported removable Implant-Lim,
denture for edentulous arch – Implant-Alt or X
mandibular Implant
D6112 Implant / abutment supported removable Implant-Lim,
denture for partially edentulous arch – Implant-Alt or X
maxillary Implant
D6113 Implant / abutment supported removable Implant-Lim,
denture for partially edentulous arch – Implant-Alt or X
mandibular Implant
D6114 Implant / abutment supported fixed Implant-Lim,
denture for edentulous arch – maxillary Implant-Alt or X
Implant
D6115 Implant / abutment supported fixed Implant-Lim,
denture for edentulous arch – Implant-Alt or X
mandibular Implant
D6116 Implant / abutment supported fixed Implant-Lim,
denture for partially edentulous arch – Implant-Alt or X
maxillary Implant
D6117 Implant / abutment supported fixed Implant-Lim,
denture for partially edentulous arch – Implant-Alt or X
mandibular Implant
D6118 Implant/abutment supported interim fixed
Deny
denture for edentulous arch-mandibular
D6119 Implant/abutment supported interim fixed
Deny
denture for edentulous arch-maxillary
Revised: 01/01/2022
Effective: 01/01/2022
20
HDS PROCEDURE CODE GUIDELINES SUBMISSION REQUIREMENTS

Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

D6190 Radiographic/surgical implant index, by

Deny
report
D6191 Semi-precision abutment- placement Deny
D6192 Semi-precision attachment- placement Deny
D6194 Abutment supported retainer crown for
Implant-Lim,
FPD – (titanium) Implant-Alt or X
Implant
D6198 Remove interim implant component NBP
D6199 Unspecified implant procedure, by report Implant-By
Report
D6205 Pontic – indirect resin-based composite Alt-Prostho
X
(for most plans)
D6210 Pontic – cast high noble metal Prostho X
D6211 Pontic – cast predominantly base metal Prostho X
D6212 Pontic – cast noble metal Prostho X
D6214 Pontic – titanium and titanium alloys Prostho X
D6240 Pontic – porcelain fused to high noble
Prostho X
metal
D6241 Pontic – porcelain fused to predominantly
Prostho X
base metal
D6242 Pontic – porcelain fused to noble metal Prostho X
D6243 Pontic - porcelain fused to titanium and
Prostho X
titanium alloys
D6245 Pontic – porcelain/ceramic Alt-Prostho
X
(for most plans)
D6250 Pontic – resin with high noble metal Prostho X
D6251 Pontic – resin with predominantly base
Prostho X
metal
D6252 Pontic – resin with noble metal Prostho X
D6253 Interim pontic – further treatment or
completion of diagnosis necessary prior Prostho X X
to final impression
D6545 Retainer – cast metal for resin bonded
Prostho X
fixed prosthesis
D6548 Retainer – porcelain/ceramic for resin Alt-Prostho
X
bonded fixed prosthesis (for most plans)
D6549 Resin retainer – for resin bonded fixed Alt-Prostho
prosthesis (for most plans)
D6600 Retainer inlay – porcelain/ceramic, two Alt-Prostho
surfaces (for most plans)
D6601 Retainer inlay – porcelain/ceramic, three Alt-Prostho
or more surfaces (for most plans)
D6602 Retainer inlay – cast high noble metal,
Prostho X
two surfaces
D6603 Retainer inlay – cast high noble metal,
Prostho X
three or more surfaces
D6604 Retainer inlay – cast predominantly base
Prostho X
metal, two surfaces
D6605 Retainer inlay – cast predominantly base
Prostho X
metal, three or more surfaces
D6606 Retainer inlay – cast noble metal, two
Prostho X
surfaces
Revised: 01/01/2022
Effective: 01/01/2022
21
HDS PROCEDURE CODE GUIDELINES SUBMISSION REQUIREMENTS

Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

D6607 Retainer inlay – cast noble metal, three or

Prostho X
more surfaces
D6608 Retainer onlay – porcelain/ceramic, two Alt-Prostho
surfaces (for most plans)
D6609 Retainer onlay – porcelain/ceramic, three Alt-Prostho
or more surfaces (for most plans)
D6610 Retainer onlay – cast high noble metal,
Prostho X
two surfaces
D6611 Retainer onlay – cast high noble metal,
Prostho X
three or more surfaces
D6612 Retainer onlay – cast predominantly base
Prostho X
metal, two surfaces
D6613 Retainer onlay – cast predominantly base
Prostho X
metal, three or more surfaces
D6614 Retainer onlay – cast noble metal, two
Prostho X
surfaces
D6615 Retainer onlay – cast noble metal, three
Prostho X
or more surfaces
D6624 Retainer inlay – titanium Alt-Prostho
X
(for most plans)
D6634 Retainer onlay – titanium Alt-Prostho
X
(for most plans)
D6710 Retainer crown – indirect resin-based Alt-Prostho
composite (for most plans)
D6720 Retainer crown – resin with high noble
Prostho X
metal
D6721 Retainer crown – resin with
Prostho X
predominantly base metal
D6722 Retainer crown – resin with noble metal Prostho X
D6740 Retainer crown – porcelain/ceramic Alt-Prostho
(for most plans)
D6750 Retainer crown – porcelain fused to high
Prostho X
noble metal
D6751 Retainer crown – porcelain fused to
Prostho X
predominantly base metal
D6752 Retainer crown – porcelain fused to noble
Prostho X
metal
D6753 Retainer crown – porcelain fused to
Prostho X
titanium and titanium alloys
D6780 Retainer crown – ¾ cast high noble metal Prostho X
D6781 Retainer crown – ¾ cast predominately
Prostho X
base metal
D6782 Retainer crown – ¾ cast noble metal Prostho X
D6783 Retainer crown – ¾ porcelain/ceramic Alt-Prostho
X
(for most plans)
D6784 Retainer crown – ¾ titanium and titanium
Prostho X
alloys
D6790 Retainer crown – full cast high noble
Prostho X
metal
D6791 Retainer crown – full cast predominantly
Prostho X
base metal
D6792 Retainer crown – full cast noble metal Prostho X
Revised: 01/01/2022
Effective: 01/01/2022
22
HDS PROCEDURE CODE GUIDELINES SUBMISSION REQUIREMENTS

Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

D6793 Interim retainer crown – further treatment

or completion of diagnosis necessary Prostho X X
prior to final impression
D6794 Retainer crown – titanium and titanium Alt-Prostho
X
alloys (for most plans)
D6920 Connector bar Deny
D6930 Re-cement or re-bond fixed partial
Prostho
denture
D6940 Stress breaker Lab
Prostho X
Invoice
D6950 Precision attachment Deny
D6980 Fixed partial denture repair, necessitated Alt-By Rpt Lab
X
by restorative material failure (for most plans) Invoice
D6985 Pediatric partial denture, fixed Deny
D6999 Unspecified, fixed prosthodontic Lab
By Rpt X
procedure, by report Invoice
ORAL AND MAXILLOFACIAL SURGERY D7000 – D7999
D7111 Extraction, coronal remnants – primary
Oral Surgery
tooth
D7140 Extraction, erupted tooth or exposed root
Oral Surgery
(elevation and/or forceps removal)
D7210 Extraction of erupted tooth requiring
removal of bone and/or sectioning of
Oral Surgery X
tooth, and including elevation of
mucoperiosteal flap if indicated
D7220 Removal of impacted tooth  soft tissue Oral Surgery X
D7230 Removal of impacted tooth  partially
Oral Surgery X
bony
D7240 Removal of impacted tooth  completely
Oral Surgery X
bony
D7241 Removal of impacted tooth – completely
Oral Surgery X Op Rpt
bony, with unusual surgical complications
D7250 Removal of residual tooth roots (cutting
Oral Surgery X
procedure)
D7251 Coronectomy – intentional partial tooth
Oral Surgery X
removal
D7260 Oroantral fistula closure Oral Surgery Op Rpt
D7261 Primary closure of a sinus perforation Oral Surgery Op Rpt
D7270 Tooth reimplantation and/or stabilization
of accidentally evulsed or displaced tooth. Oral Surgery X X
D7272 Tooth transplantation (includes
reimplantation from one site to another Deny
and splinting and/or stabilization
D7280 Exposure of an unerupted tooth Oral Surgery X
D7282 Mobilization of erupted or malpositioned
Oral Surgery X
tooth to aid eruption
D7283 Placement of device to facilitate eruption
Ortho X
of impacted tooth
D7285 Incisional biopsy of oral tissue – hard
Oral Surgery Path Rpt
(bone, tooth)

Revised: 01/01/2022
Effective: 01/01/2022
23
HDS PROCEDURE CODE GUIDELINES SUBMISSION REQUIREMENTS

Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

D7286 Incisional biopsy of oral tissue – soft Oral Surgery Path Rpt
D7287 Exfoliative cytological sample collection Deny
D7288 Brush biopsy – transepithelial sample
Deny
collection
D7290 Surgical repositioning of teeth Ortho X
D7291 Transseptal fiberotomy/supra crestal Ortho
Op Rpt
fiberotomy, by report By Rpt
D7292 Placement of temporary anchorage
device (screw retained plate) requiring Deny
flap
D7293 Placement of temporary anchorage
Deny
device requiring flap
D7294 Placement of temporary anchorage
Deny
device without flap
D7295 Harvest of bone for use in autogenous
Deny
grafting procedure
D7296 Corticotomy – one to three teeth or tooth
Deny
bound spaces, per quadrant
D7297 Corticotomy – four or more teeth or tooth
Deny
bound spaces, per quadrant
D7298 Removal of temporary anchorage device
Deny
(screw retained plate), requiring flap
D7299 Removal of temporary anchorage device,
Deny
requiring flap
D7300 Removal of temporary anchorage device
Deny
without flap
D7310 Alveoloplasty in conjunction with
extractions – four or more teeth or tooth Oral Surgery
spaces, per quadrant
D7311 Alveoloplasty in conjunction with
Additional
extractions – one to three teeth or tooth Oral Surgery
Teeth #
spaces, per quadrant
D7320 Alveoloplasty not in conjunction with
extractions – four or more teeth or tooth Oral Surgery
spaces per quadrant
D7321 Alveoloplasty not in conjunction with
Additional
extractions – one to three teeth or tooth Oral Surgery
Teeth #
spaces, per quadrant
D7340 Vestibuloplasty – ridge extension
Deny
(secondary epithelialization)
D7350 Vestibuloplasty – ridge extension
(including soft tissue grafts, muscle
reattachment, revision of soft tissue Deny
attachment and management of
hypertrophied and hyperplastic tissue)
D7410 Excision of benign lesion up to 1.25 cm Med
Oral Surgery EOB
Path Rpt

Revised: 01/01/2022
Effective: 01/01/2022
24
HDS PROCEDURE CODE GUIDELINES SUBMISSION REQUIREMENTS

Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

D7411 Excision of benign lesion greater than Med

1.25 cm Oral Surgery EOB
Path Rpt
D7412 Excision of benign lesion, complicated Deny
D7413 Excision of malignant lesion up to 1.25 Med
cm Oral Surgery EOB
Path Rpt
D7414 Excision of malignant lesion greater than Med
1.25 cm Oral Surgery EOB
Path Rpt
D7415 Excision of malignant lesion, complicated Deny
D7465 Destruction of lesion(s) by physical or
Oral Surgery X
chemical method, by report
D7440 Excision of malignant tumor – lesion Med
diameter up to 1.25 cm Oral Surgery EOB
Path Rpt
D7441 Excision of malignant tumor – lesion Med
diameter greater than 1.25 cm Oral Surgery EOB
Path Rpt
D7450 Removal of benign odontogenic cyst or Med
tumor – lesion diameter up to 1.25 cm Oral Surgery EOB
Path Rpt
D7451 Removal of benign odontogenic cyst or Med
tumor – lesion diameter greater than 1.25 Oral Surgery EOB
cm Path Rpt
D7460 Removal of benign nonodontogenic cyst Med
or tumor – lesion diameter up to 1.25 cm Oral Surgery EOB
Path Rpt
D7461 Removal of benign nonodontogenic cyst Med
or tumor – lesion diameter greater than Oral Surgery EOB
1.25 cm Path Rpt
D7471 Removal of lateral exostosis (maxilla or
Oral Surgery Op Rpt
mandible)
D7472 Removal of torus palatinus Oral Surgery Op Rpt
D7473 Removal of torus mandibularis Oral Surgery Op Rpt
D7485 Reduction of osseous tuberosity Oral Surgery Op Rpt
D7490 Radical resection of maxilla or mandible Oral Surgery Med
EOB
Op Rpt
Path Rpt
D7510 Incision and drainage of abscess –
Oral Surgery Op Rpt
intraoral soft tissue
D7511 Incision and drainage of abscess –
Med
intraoral soft tissue – complicated
Oral Surgery EOB
(includes drainage of multiple fascial
Op Rpt
spaces)
D7520 Incision and drainage of abscess 
Oral Surgery Op Rpt
extraoral soft tissue

Revised: 01/01/2022
Effective: 01/01/2022
25
HDS PROCEDURE CODE GUIDELINES SUBMISSION REQUIREMENTS

Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

D7521 Incision and drainage of abscess –

Med
extraoral soft tissue – complicated
Alt-By Rpt EOB
(includes drainage of multiple fascial
Op Rpt
spaces)
D7530 Removal of foreign body from mucosa, Med
skin, or subcutaneous alveolar tissue Oral Surgery EOB
Op Rpt
D7540 Removal of reaction producing foreign Op Rpt
Oral Surgery
bodies, musculoskeletal system
D7550 Partial ostectomy/sequestrectomy for
Oral Surgery Op Rpt
removal of non-vital bone
D7560 Maxillary sinusotomy for removal of tooth
Oral Surgery Op Rpt
fragment or foreign body
D7610 Maxilla - open reduction (teeth Med
immobilized, if present) Oral Surgery EOB
Op Rpt
D7620 Maxilla - closed reduction (teeth Med
immobilized, if present) Oral Surgery EOB
Op Rpt
D7630 Mandible - open reduction (teeth Med
immobilized, if present) Oral Surgery EOB
Op Rpt
D7640 Mandible-closed reduction (teeth Med
immobilized, if present) Oral Surgery EOB
Op Rpt
D7650 Malar and/or zygomatic arch – open Med
reduction Oral Surgery EOB
Op Rpt
D7660 Malar and/or zygomatic arch – closed Med
reduction Oral Surgery EOB
Op Rpt
D7670 Alveolus – closed reduction, may include Med
stabilization of teeth Oral Surgery X EOB
Op Rpt
D7671 Alveolus – open reduction, may include Med
stabilization of teeth Oral Surgery X EOB
Op Rpt
D7680 Facial bones – complicated reduction
with fixation and multiple surgical Deny
approaches
D7710 Maxilla – open reduction Med
Oral Surgery EOB
Op Rpt
D7720 Maxilla – closed reduction Med
Oral Surgery EOB
Op Rpt
D7730 Mandible – open reduction Med
Oral Surgery EOB
Op Rpt
D7740 Mandible – closed reduction Med
Oral Surgery EOB
Op Rpt
Revised: 01/01/2022
Effective: 01/01/2022
26
HDS PROCEDURE CODE GUIDELINES SUBMISSION REQUIREMENTS

Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

D7750 Malar and/or zygomatic arch – open Med

reduction Oral Surgery EOB
Op Rpt
D7760 Malar and/or zygomatic arch – closed Med
reduction Oral Surgery EOB
Op Rpt
D7770 Alveolus – open reduction stabilization Med
of teeth Oral Surgery EOB
Op Rpt
D7771 Alveolus, closed reduction stabilization Med
of teeth Oral Surgery EOB
Op Rpt
D7780 Facial bones – complicated reduction with
Deny
fixation and multiple surgical approaches
D7810 Open reduction of dislocation Med
TMJ EOB
Op Rpt
D7820 Closed reduction of dislocation Med
TMJ EOB
Op Rpt
D7830 Manipulation under anesthesia Med
TMJ EOB
Op Rep
D7840 Condylectomy Deny
D7850 Surgical discectomy, with/without implant Deny
D7852 Disc repair Deny
D7854 Synovectomy Deny
D7856 Myotomy Deny
D7858 Joint reconstruction Deny
D7860 Arthrotomy Deny
D7865 Arthroplasty Deny
D7870 Arthrocentesis Deny
D7871 Non-arthroscopic lysis and lavage Deny
D7872 Arthroscopy – diagnosis, with or without
Deny
biopsy
D7873 Arthroscopy-lavage and lysis of
Deny
adhesions
D7874 Arthroscopy- disc repositioning and
Deny
stabilization
D7875 Arthroscopy – synovectomy Deny
D7876 Arthroscopy – discectomy Deny
D7877 Arthroscopy – debridement Deny
D7880 Occlusal orthotic device, by report Deny
D7881 Occlusal orthotic device adjustment Deny
D7899 Unspecified TMD therapy, by report Deny
D7910 Suture of recent small wounds up to 5 cm Med
Oral Surgery EOB
Op Rpt
D7911 Complicated suture – greater than 5 cm Deny
D7912 Complicated suture – greater than 5 cm Deny

Revised: 01/01/2022
Effective: 01/01/2022
27
HDS PROCEDURE CODE GUIDELINES SUBMISSION REQUIREMENTS

Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

D7920 Skin graft (identify defect covered,

Deny
location and type of graft)
D7921 Collection and application of autologous
Deny
blood concentrate product
D7922 Placement of intra-socket biological
dressing to aid in hemostasis or clot Deny
stabilization, per site
D7940 Osteoplasty – for orthognathic deformities Deny
D7941 Osteotomy – mandibular rami Deny
D7943 Osteotomy – mandibular rami with bone
Deny
graft; includes obtaining the graft
D7944 Osteotomy – segmented or subapical Deny
D7945 Osteotomy – body of mandible Deny
D7946 LeFort l (maxilla – total) Deny
D7947 LeFort l (maxilla – segmented) Deny
D7948 LeFort II or LeFort lll (osteoplasty of facial
bones for midface hypoplasia or Deny
retrusion) – without bone graft
D7949 LeFort ll or LeFort lll – with bone graft Deny
D7950 Osseous, osteoperiosteal, or cartilage
graft of the mandible or maxilla – Deny
autogenous or nonautogenous, by report
D7951 Sinus augmentation with bone or bone
Deny
substitutes
D7952 Sinus augmentation via a vertical
Deny
approach
D7953 Bone replacement graft for ridge Group
preservation – per site Contract
D7955 Repair of maxillofacial soft and/or hard
Deny
tissue defect
D7961 Buccal/labial frenectomy (frenulectomy) Oral Surgery X
D7962 Lingual frenectomy (frenulectomy) Oral Surgery X
D7963 Lingual frenectomy (frenulectomy) Oral Surgery X
D7970 Excision of hyperplastic tissue  per arch Oral Surgery X
D7971 Excision of pericoronal gingiva Oral Surgery X
D7972 Surgical reduction of fibrous tuberosity Med
Oral Surgery EOB
Op Rpt
D7979 Non- surgical sialolithotomy Oral Surgery X
D7980 Surgical sialolithotomy Med
Oral Surgery EOB
Op Rpt
D7981 Excision of salivary gland, by report Deny
D7982 Sialodochoplasty Deny
D7983 Closure of salivary fistula Med
Oral Surgery EOB
Op Rpt
D7990 Emergency tracheotomy Deny
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Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

D7991 Coronoidectomy Deny

D7993 Surgical placement of craniofacial
Deny
implant-extra oral
D7994 Surgical placement: zygomatic implant Deny
D7995 Synthetic graft – mandible or facial
Deny
bones, by report
D7996 Implant–mandible for augmentation
purposes (excluding alveolar ridge), by Deny
report
D7997 Appliance removal (not by dentist who
placed appliance), includes removal of Deny
archbar
D7998 Intraoral placement of a fixation device
Deny
not in conjunction with a fracture
D7999 Unspecified oral surgery procedure, by
By Rpt Op Rpt
report
ORTHODONTICS D8000 – D8999
D8010 Limited orthodontic treatment of the
Ortho
primary dentition
D8020 Limited orthodontic treatment of the
Ortho
transitional dentition
D8030 Limited orthodontic treatment of the
Ortho
adolescent dentition
D8040 Limited orthodontic treatment of the adult
Ortho
dentition
D8070 Comprehensive orthodontic treatment of
Ortho X
the transitional dentition
D8080 Comprehensive orthodontic treatment of
Ortho X
the adolescent dentition
D8090 Comprehensive orthodontic treatment of
Ortho X
the adult dentition
D8210 Removable appliance therapy Ortho X
D8220 Fixed appliance therapy Ortho X
D8660 Pre-orthodontic treatment examination to NBP
monitor growth and development
D8670 Periodic orthodontic treatment visit NBP
D8680 Orthodontic retention (removal of
appliances, construction and placement Ortho X
of retainer(s))
D8681 Removable orthodontic retainer
Deny
adjustment
D8695 Removal of fixed orthodontic appliances
for reasons other than completion of Deny
treatment
D8696 Repair of orthodontic appliance -
Deny
maxillary
D8697 Repair of orthodontic appliance-
Deny
mandibular
D8698 Re-cement or re-bond fixed retainer -
Ortho
maxillary

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Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

D8699 Re-cement or re-bond fixed retainer -

Ortho
mandibular
D8701 Repair of fixed retainer, includes
Ortho
reattachment - maxillary
D8702 Repair of fixed retainer, includes
Ortho
reattachment - mandibular
D8703 Replacement of lost or broken retainer –
Ortho
maxillary
D8704 Replacement of lost or broken retainer -
Ortho
mandibular
D8999 Unspecific orthodontic procedure, by
Ortho Lab
report X
By Rpt Invoice
ADJUNCTIVE GENERAL SERVICES D9000 – D9999
D9110 Palliative (emergency) treatment of dental
Adjunctive X
pain – minor procedure
D9120 Fixed partial denture sectioning Prostho
D9130 Temporomandibular joint dysfunction-
TMJ
non-invasive physical therapies
D9210 Local anesthesia not in conjunction with
NBP
operative or surgical procedures
D9211 Regional block anesthesia NBP
D9212 Trigeminal division block anesthesia NBP
D9215 Local anesthesia NBP
D9219 Evaluation for moderate sedation, deep
NBP
sedation or general anesthesia
D9222 Deep sedation / general anesthesia – first
Adjunctive
15 minutes
D9223 Deep sedation/general anesthesia – each
Adjunctive
subsequent 15-minute increment
D9230 Inhalation of nitrous oxide /analgesia,
ACA Only
anxiolysis
D9239 Intravenous moderate (conscious)
Adjunctive
sedation/analgesia – first 15 minutes
D9243 Intravenous moderate (conscious)
sedation/analgesia – each subsequent Adjunctive
15-minute increment
D9248 Non-intravenous (conscious) sedation Deny
D9310 Consultation  diagnostic service
provided by dentist or physician other Adjunctive X
than requesting dentist or physician
D9311 Consultation with a medical health
NBP
care professional
D9410 House/extended care facility call Deny
D9420 Hospital or ambulatory surgical center call ACA Only
D9430 Office visit for observation (during
regularly scheduled hours) – no other Adjunctive X
services performed
D9440 Office visit – after regularly scheduled
Adjunctive X
hours
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Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

D9450 Case presentation, detailed and

Deny
extensive treatment planning
D9610 Therapeutic parenteral drug, single Group
administration Contract
D9612 Therapeutic parenteral drugs, two or Group
more administrators, different injections Contract
D9613 Infiltration of sustained release
Deny
therapeutic drug – per quadrant
D9630 Drugs or medicaments dispensed in
Deny
office for home use
D9910 Application of desensitizing medicaments Deny
D9911 Application of desensitizing resin for
Deny
cervical and/or root surface, per tooth
D9912 Pre-visit patient screening NBP
D9920 Behavior management, by report Deny
D9930 Treatment of complications (post–
surgical) – unusual circumstances, by Adjunctive X
report
D9932 Cleaning and inspection of a removable
Deny
complete denture, maxillary
D9933 Cleaning and inspection of a removable
Deny
complete denture, mandibular
D9934 Cleaning and inspection of a removable
Deny
partial denture, maxillary
D9935 Cleaning and inspection of a removable
Deny
partial denture, mandibular
D9941 Fabrication of athletic mouthguard Adjunctive
(for most plans)
D9942 Repair and/or reline of occlusal guard Deny
Occlusal guard adjustment
Deny
D9943
D9944 Occlusal guard - hard appliance, full arch TMJ
D9945 Occlusal guard - soft appliance, full arch TMJ
D9946 Occlusal guard - hard appliance, partial
TMJ
arch
D9947 Custom sleep apnea appliance
Deny
fabrication and placement
D9948 Adjustment of custom sleep apnea
Deny
appliance
D9949 Repair of a custom sleep apnea
Deny
appliance
D9950 Occlusion analysis – mounted case Deny
D9951 Occlusal adjustment – limited Group
Contract
D9952 Occlusal adjustment – complete Deny
D9961 Duplicate/copy patient’s records Deny
D9970 Enamel microabrasion Deny
D9971 Odontoplasty – per tooth Deny
D9972 External bleaching – per arch Deny
D9973 External bleaching – per tooth Deny
D9974 Internal bleaching – per tooth Endo X
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Benefit Tooth
Code Description Category X-Ray Narrative Perio Chart Other

D9975 external bleaching for home application,

per arch; includes materials and Deny
fabrication of custom trays
D9985 Sales tax Deny
D9986 Missed appointment Deny
D9987 Cancelled appointment Deny
D9990 Certified translation or sign language
NBP
services – per visit
D9991 Dental case management-addressing
NBP
appointment compliance barriers
D9992 Dental case management- care
NBP
coordination
D9993 Dental case management-motivational
Deny or NBP
interviewing
D9994 Dental case management-patient
Deny or NBP
education to improve oral health literacy
D9997 Dental case management – patients with
NBP
special health care needs
D9995 Teledentistry – synchronous; real – time
NBP
encounter
D9996 Teledentistry – asynchronous; information
stored and forwarded to dentist for NBP
subsequent review
D9999 Unspecified adjunctive procedure, by
By Rpt X
report

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Code & Nomenclature Submission Requirements Surface

DIAGNOSTIC D0100 - D0999

Clinical Oral Evaluations D0120 - D0180

The codes in this section have been revised to recognize the cognitive skills necessary for patient evaluation.
The collection and recording of some data and components of the dental examination may be delegated;
however, the evaluation, diagnosis and treatment planning are the responsibility of the dentist. As with all ADA
procedure codes, there is no distinction made between the evaluations provided by general practitioners and
specialists. Report additional diagnostic and/or definitive procedures separately.

General Guidelines

1. The number and type of evaluations available for a patient are based on group contract. Any fees in
excess of the approved fees are not billable to the patient.

2. Comprehensive and periodic evaluations include, but are not limited to, evaluations of all hard and soft
tissue of the oral cavity, periodontal charting and oral cancer examination.

3. Multiple oral evaluations by the same dentist/dental office on the same day are not billable to the patient.

D0120
periodic oral evaluation – established patient

An evaluation performed on a patient of record to determine any changes in the patient’s dental
and medical health status since a previous comprehensive or periodic evaluation. This includes
an oral cancer evaluation, periodontal screening where indicated, and may require interpretation
of information acquired through additional diagnostic procedures. The findings are discussed with
the patient. Report additional diagnostic procedures separately.

1. This procedure is applied to the patient’s annual exam benefit.

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D0140
limited oral evaluation – problem focused

An evaluation limited to a specific oral health problem or complaint. This may require
interpretation of information acquired through additional diagnostic procedures. Report additional
diagnostic procedures separately. Definitive procedures may be required on the same date as
the evaluation. Typically, patients receiving this type of evaluation present with a specific
problem and/or dental emergencies, trauma, acute infections, etc.

1. This is a benefit once per patient per dentist/dental office, per 12-month period. If this limit is
exceeded, the benefit will be denied, and the patient is responsible to the Maximum Plan
Allowance.

2. This procedure is not applied to the patient’s annual exam benefit.

3. The benefit for this evaluation is not billable to the patient when performed in conjunction with
a consultation by the same dentist/dental office.

4. Specific government programs (e.g., Supplemental Medicaid, Medicare) have a 1 per

calendar year frequency limit for D0140. Verify if frequency limits apply per dental office in
advance of patient treatment.

D0145
oral evaluation for a patient under three years of age and
counseling with primary caregiver

Diagnostic services performed for a child under the age of three, preferably within the first six
months of the eruption of the first primary tooth, including recording the oral and physical health
history, evaluation of caries susceptibility, development of an appropriate preventive oral health
regimen and communication with and counseling of the child’s parent, legal guardian and/or
primary caregiver.

1. D0145 includes any caries susceptibility tests (D0425) or oral hygiene instructions (D1330)
on the same date. When performed on the same date as D0145, any fees for D0425 and
D1330 are not billable to the patient.

2. When performed on a patient who is three years of age and older, D0145 is not billable to the
patient. The correct evaluation code is required.

3. A comprehensive oral evaluation (D0150) submitted for a patient under three years of age
will be processed as a D0145.

4. This procedure is applied to the patient’s annual exam benefit.

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D0150
comprehensive oral evaluation – new or established
patient

Used by a general dentist and/or a specialist when evaluating a patient comprehensively. This
applies to new patients; established patients who have had a significant change in health
conditions or other unusual circumstances, by report, or established patients who have been
absent from active treatment for three or more years. It is a thorough evaluation and recording of
the extraoral and intraoral hard and soft tissues. It may require interpretation of information
acquired through additional diagnostic procedures. Additional diagnostic procedures should be
reported separately.

This includes an evaluation for oral cancer, the evaluation and recording of the patient’s dental
and medical history and a general health assessment. It may include the evaluation and
recording of dental caries, missing or unerupted teeth, restorations, existing prostheses, occlusal
relationships, periodontal conditions (including periodontal screening and/or charting), hard and
soft tissue anomalies, etc.

1. This procedure is applied to the patient’s annual exam benefit.

2. This procedure is a benefit once per 10 years per patient per dentist/dental office. However,
if the patient has not received any services for 3 years from the same office, a
comprehensive evaluation may be benefited. In all other cases, if the procedure is performed
by the same dentist/dental office in less than 10 years, the benefit is limited to the allowance
of a D0120 and processed to the limitations of a D0120.

3. Benefits for consultation, diagnosis and routine treatment planning are not billable to the
patient as components of the benefits for this evaluation by the same dentist/dental office.

4. If the D0150 is done within 6 months of a D0180, the benefit is limited to the allowance of a
D0120 and processed to the limitations of a D0120.

5. A comprehensive oral evaluation (D0150) submitted for a patient under three years of age
will be processed as a D0145.

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D0160
detailed and extensive oral evaluation – problem
focused, by report

A detailed and extensive problem focused evaluation entails extensive diagnostic and cognitive
modalities based on the findings of a comprehensive oral evaluation. Integration of more
extensive diagnostic modalities to develop a treatment plan for a specific problem is required.
The condition requiring this type of evaluation should be described and documented. Examples
of conditions requiring this type of evaluation may include dentofacial anomalies, complicated
perio-prosthetic conditions, complex temporomandibular dysfunction, facial pain of unknown
origin, conditions requiring multi-disciplinary consultation, etc.

1. The alternate benefit of D0140 is applied, refer to D0140 guidelines for benefit and time
limitations.

D0170
re-evaluation – limited, problem focused (established
patient; not post-operative visit)

Assessing the status of a previously existing condition. For example:

- a traumatic injury where no treatment was rendered but patient needs follow-up
monitoring;
- evaluation for undiagnosed continuing pain;
- soft tissue lesion requiring follow-up evaluation.

1. The alternate benefit of D0140 is applied, refer to D0140 guidelines for benefit and time
limitations.

2. By definition, this procedure code is not to be used for a post operative visit and for follow up
to “nonsurgical” definitive care such as root canal treatment or seating of a crown. It is also
included as part of definitive care that might follow or have preceded the evaluation.

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D0180
comprehensive periodontal evaluation – new or
established patient

This procedure is indicated for patients showing signs or symptoms of periodontal disease and
for patients with risk factors such as smoking or diabetes. It includes evaluation of periodontal
conditions, probing and charting, an evaluation for oral cancer, the evaluation and recording of
the patient’s dental and medical history, and general health assessment. It may include the
evaluation and recording of dental caries, missing or unerupted teeth, restorations, and occlusal
relationships.

1. This procedure is applied to the patient’s annual exam benefit.

2. This procedure is a benefit once per 10 years per patient per dentist/dental office. However,
if the patient has not received any services for 3 years from the same office, a periodontal
evaluation may be benefited. In all other cases, if the procedure is performed by the same
dentist/dental office in less than 10 years, the benefit is limited to the allowance of a D0120
and processed to the limitations of a D0120.

3. This procedure should be used primarily by a periodontist for a referred patient from a
general dentist and should not be reported in addition to a D0150 by the same dentist/dental
office in the same treatment series.

4. Benefits for consultation, diagnosis and routine treatment planning are not billable to the
patient as a component of the benefit for this evaluation by the same dentist/dental office.

5. If the D0180 is done within 6 months of a D0150 by the same dentist/dental office, the benefit
is limited to the allowance of a D0120 and processed to the limitations of D0120.

6. This procedure is not intended for use as a separate code for periodontal charting.

7. A comprehensive periodontal evaluation (D0180) submitted for a patient under three years of
age will be processed as a D0145.

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Diagnostic Imaging D0210 - D0350

Images should be taken only for clinical reasons as determined by the patient's dentist. They should be of
diagnostic quality and properly identified and dated. Images are a part of the patient's clinical record and the
original images should be retained by the dentist. Originals should not be used to fulfill requests made by
patients or third-parties for copies of records.

General Guidelines

1. Must be of diagnostic quality, properly oriented (tooth number, R, L), identified and dated.

2. Diagnostic services such as radiographic images must be necessary for clinical reasons. Radiographic
images are adjunctive to diagnostic services and should be prescribed in accordance with the guidelines
of the American Dental Association. The ADA white paper dictates that these services only be rendered
in cases where they will provide additional information to the dentist/dental office and as such must be
prescriptive rather than routine. (Reference ADA, FDA Dental Radiographic Examinations:
Recommendations for Patient Selection and Limiting Radiation Exposure,
https://www.ada.org/~/media/ADA/Publications/ADA%20News/Files/Dental_Radiographic_Examinations_
2012.pdf?la=en)

3. A panoramic radiographic image D0330 or a panoramic radiographic image with associated periapicals
(D0220/D0230) or bitewings (D0272/D0274) should not be submitted for payment as procedure code
D0210 intra-oral complete series.

4. Any combination of intraoral radiographic images (periapical, occlusal, bitewing) and/or panoramic
images taken by the same dentist/dental office on the same date of service are processed
administratively as a complete series (D0210) when the total cumulative fees equal or exceeds the fee for
a complete series (D0210). These images will be considered the equivalent of a complete series (D0210).
Time and frequency limitations will be applied as determined by the group contract.

5. For oral surgeons and orthodontists, additional radiographic images may be allowed for diagnosis of
specific conditions, pathology, or injury.

6. Radiographic, photographic, and diagnostic images are a part of the patient’s clinical record and the
original images should be retained by the dentist.

7. Charges for duplication (copying) of radiographic images for insurance purposes are not billable to the
patient.

8. Radiographic images used to verify crown seatings are considered a component of the primary procedure
and are not billable to the patient.

9. Poor quality or non-diagnostic radiographic images are not billable to HDS or the patient.

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Image Capture with Interpretation D0210 - D0350

D0210
intraoral – complete series of radiographic images

A radiographic survey of the whole mouth, usually consisting of 14-22 periapical and posterior
bitewing images intended to display the crowns and roots of all teeth, periapical areas and
alveolar bone.

1. Time and frequency limitations for this procedure are determined by the group contract
and are counted per dentist/dental office. The D0210 will be denied if contract imitations
are exceeded.

D0220
intraoral – periapical first radiographic image
D0230
intraoral – periapical each additional radiographic image

1. For endodontic treatment, one pre-operative diagnostic radiograph is benefited.

2. Working and post-operative radiographic images by the same dentist/dental office are
considered a component of the complete treatment procedure and separate benefits are not
billable to the patient.

3. Specific government programs (e.g., Supplemental Medicaid) have a frequency limit of 2 per
calendar year combined for D0220 and D0230 and is not subject to processing as a complete
series. Verify frequency limits in advance of patient treatment.

D0240
intraoral – occlusal radiographic image

1. Occlusal radiographic images taken by the same dentist/ dental office, on the same day as
periapical, panoramic or bitewing radiographic images are processed as a complete series if
the total fee equals or exceeds the complete series D0210 fee. Any fee in excess of a full
mouth series is not billable to the patient. D0210 time and frequency limitations apply.

2. Specific government programs (e.g., Medicare) have a frequency limit of 4 per calendar year
for D0240 and may not be subject to processing as a complete series. Verify frequency limits
in advance of patient treatment.

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D0250
extra-oral – 2D projection radiographic image created
using a stationary radiation source, and detector

These images include, but are not limited to: Lateral Skull; Posterior-Anterior Skull;
Submentovertex; Waters; Reverse Tomes; Oblique Mandibular Body; Lateral Ramus.

1. Specific government programs (e.g., Medicare) have a frequency limit of 5 per date of
service for D0250. Verify frequency limits in advance of patient treatment.

D0270
bitewing – single radiographic image

1. Bitewing radiographic images taken by the same dentist/ dental office, on the same day as
periapical, panoramic, or occlusal radiographic images are processed as a complete series if
the total fee equals or exceeds the complete series D0210 fee. Any fee in excess
of a full mouth series is not billable to the patient. D0210 time and frequency limitations apply.

2. Each D0270, D0272, D0273, D0274, D0277 when performed, are applied to the patient’s
annual bitewing benefit.

3. Specific government programs (e.g., Medicare) have a frequency limit of 1 per date of service
for D0270 and does not count toward the annual bitewing benefit. Verify frequency limits in
advance of patient treatment.

4. A claim consisting of only a bitewing - single radiographic image (D0270) with no other
services are not billable to the patient.

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D0272
bitewings – two radiographic images

D0273
bitewings – three radiographic images

D0274
bitewings – four radiographic images

1. Bitewing radiographic images taken by the same dentist/ dental office, on the same day as
periapical, panoramic, or occlusal radiographic images are processed as a complete series if
the total fee equals or exceeds the complete series D0210 fee. Any fee in excess
of a full mouth series is not billable to the patient. D0210 time and frequency limitations apply.

2. Each D0270, D0272, D0273, D0274, D0277 when performed, is applied to the patient’s annual
bitewing benefit.

3. D0273 or D0274 performed on a patient under age 10 is processed as a D0272; fees in excess
of a D0272 are not billable to the patient.

D0277
vertical bitewings – 7 to 8 radiographic images

This does not constitute a full mouth intraoral radiographic series.

1. Each D0270, D0272, D0273, D0274, D0277 when performed, is applied to the patient’s
annual bitewing benefit.

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D0330
panoramic radiographic image

1. A panoramic radiographic image (D0330) is considered as an intraoral complete series for

benefit, time and frequency limitations. Time and frequency limitations are determined by the
group contract and the D0330 will be denied when the limitations are exceeded.

2. An additional panoramic radiographic image is allowed by an Oral Surgeon or Orthodontist

for diagnosis of specific disease or injury. Specific government programs (e.g., Supplemental
Medicaid) have limitations on the additional panoramic radiographic image performed by an
Oral Surgeon or Orthodontist. Verify limits in advance of patient treatment.

3. Panoramic radiographic images taken by the same dentist/ dental office, on the same day as
periapical, bitewing or occlusal radiographic images are processed as a complete series if
the total fee equals or exceeds the complete series D0210 fee.

D0340
2D cephalometric radiographic image – acquisition,
measurement and analysis

1. Coverage for this procedure is limited to members who have Orthodontic Plan Benefits.

2. Benefits for a cephalometric radiographic image taken in conjunction with services other than
orthodontic treatment are denied.

D0350
2D oral/facial photographic image obtained intra-orally
or extra-orally
This includes photographic images, including those obtained by intraoral and extraoral cameras,
excluding radiographic images. These photographic images should be a part of the patient's
clinical record.

1. Coverage for this procedure is limited to members who have Orthodontic Plan Benefits.

2. Benefits for photographic images taken in conjunction with services other than orthodontic
treatment are denied.

3. Benefit is limited to once per Orthodontic case.

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Surface

Tests and Examinations D0419 - D0470

D0419
assessment of salivary flow by
measurement

This procedure is for identification of low salivary flow in patients at risk for hyposalivation and
xerostomia, as well as effectiveness of pharmacological agents used to stimulate saliva
production.

1. The benefit for assessment of salivary flow may be phased in as employer group
contracts renew. Patient benefits should be verified.

2. Limited to one assessment every three years. Subsequent submissions are not billable to the
patient within 12 months and denied between 12 and 36 months.

D0460
pulp vitality tests

Includes multiple teeth and contra lateral comparison(s), as indicated.

1. Pulp tests are payable per visit not per tooth and only for the diagnosis of emergency
conditions.

2. Benefits for pulp tests are not billable to the patient as part of any other definitive procedure
on the same day, by the same dentist/dental office except X-rays (D0210-D340), limited oral
evaluation-problem focused (D0140), palliative treatment (D9110), pulpal debridement
(D3221) and protective restoration (D2940). The exception also applies to consultation
(D9310) for Individual Dental Plans (IDP).

D0470 Narrative
diagnostic casts

Also known as diagnostic models or study models.

1. Coverage for this procedure is limited to members who have Orthodontic Plan benefits.

2. Diagnostic casts are payable only once per case in conjunction with orthodontic services.
Additional casts taken by the same dentist/dental office during or after orthodontic
treatment are included in the fee for orthodontics and separate benefits are not billable to
the patient.

3. Diagnostic casts are included in the fee for restorations and prosthetic procedures and
therefore are not billable to the patient.

4. Narrative must indicate the purpose for the diagnostic casts.

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Oral Pathology Laboratory D0472 - D0485

These procedures do not include collection of the tissue sample, which is documented separately.

General Guidelines

1. If more than one of these procedures is billed on the same day, same site by the same dentist/dental office,
payment is allowed for the most inclusive procedure and the less inclusive procedure is not billable to the
patient.

2. By definition these procedures include the preparation and transmission of a report.

D0472 .
accession of tissue, gross examination, preparation and
transmission of written report

To be used in reporting architecturally intact tissue obtained by invasive means.

1. Benefits are limited to one D0472, D0473 or D0474 per site on the same date of service by
the same dental office

D0473
accession of tissue, gross and microscopic examination,
preparation and transmission of written report

D0474
accession of tissue, gross and microscopic examination,
including assessment of surgical margins for presence of
disease, preparation and transmission of written report

D0480
accession of exfoliative cytologic smears, microscopic
examination, preparation and transmission of written report

To be used in reporting disaggregated, non-transepithelial cell cytology sample via mild scraping
of the oral mucosa.

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Code & Nomenclature Submission Requirements Surface

D0484
consultation on slides prepared elsewhere

A service provided in which microscopic slides of a biopsy specimen prepared at another

laboratory are evaluated to aid in the diagnosis of a difficult case or to offer a consultative
opinion at the patient's request. The findings are delivered by written report.

1. This benefit is not billable to the patient when billed in conjunction with an evaluation by the
same dentist/dental office.

2. D0484 is benefited as D9310 (diagnostic service provided by dentist or physician other than
practitioner providing treatment).

D0485 Pathology
consultation, including preparation of slides from biopsy Report
material supplied by referring source

A service that requires the consulting pathologist to prepare the slides as well as render a written
report. The slides are evaluated to aid in the diagnosis of a difficult case or to offer a consultative
opinion at the patient's request.

D0999 Narrative
unspecified diagnostic procedure, by report

Used for procedure that is not adequately described by a code. Describe procedure.

1. Provide complete description of services/treatment to allow determination of appropriate

benefit allowance.

2. The narrative should include clinical diagnosis, tooth number, quadrant or arch, intraoral
photographic image when available and X-ray image where appropriate.

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Code & Nomenclature Submission Requirements Surface

PREVENTIVE D1000 - D1999

Dental Prophylaxis D1110 - D1120

General Guidelines

1. Refer to the current group benefit information on HDS Online or DenTel for plans that include
supplemental benefits for certain medical conditions (e.g., Evidence based plans, Total Health Plus.)

2. Local anesthesia is considered an integral part of dental prophylaxis procedures. A separate charge is
not billable to the patient.
D1110
prophylaxis – adult

Removal of plaque, calculus and stains from the tooth structures and implants in the permanent
and transitional dentition. It is intended to control local irritational factors.

1. A prophylaxis performed on the same date by the same dentist/dental office as a Periodontal
Maintenance (D4910), Scaling and Root Planing (D4341/D4342) or Full Mouth Debridement
(D4355) is considered to be part of those procedures and the fee is not billable to the patient.

2. A second prophylaxis treatment will be allowed as a special benefit for under the following
circumstances:

 The two prophylaxis treatments are conducted not more than 21 calendar
days apart and are not performed on the same day.

 The patient has not had a prophylaxis or full mouth debridement (D4355)
performed for at least 24 months.

 The patient must be 14 years or older. Prophylaxis-adult (D1110) submitted for a

patient under age 14 will be processed as a D1120.

 The patient has not had periodontal treatment for at least 36 months.

 Specific government programs (e.g., Supplemental Medicaid) do not benefit the

second prophylaxis treatment. Verify limits in advance of patient treatment.
D1120
prophylaxis – child

Removal of plaque, calculus and stains from the tooth structures and implants in the primary and
transitional dentition. It is intended to control local irritational factors.

1. This is a benefit through age 13.

2. Fees for toothbrush prophylaxis are not billable to the patient.

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Code & Nomenclature Submission Requirements Surface

Topical Fluoride Treatment (Office Procedure) D1206 - D1208

Prescription strength fluoride product designed solely for use in the dental office, delivered to the dentition
under the direct supervision of a dental professional. Fluoride must be applied separately from prophylaxis
paste.

1. Age limitations and benefits for these procedures are determined by the group contract.

2. Fluoride gels, rinses, tablets, or other preparations intended for home application are not a benefit and are
denied.

3. A prophylaxis paste containing fluoride or a fluoride rinse or swish in conjunction with a prophylaxis is
considered a prophylaxis only. A separate fee is not billable to the patient.

4. If a patient is eligible for the HDS fluoride benefit, a D1206 or D1208 will be benefited, depending on the
method used to deliver the fluoride.

5. Refer to the current group benefit information for plans that include supplemental benefits (e.g., Evidence
based plans, Total Health Plus) for certain diseases or medical conditions that places the patient at
elevated risk for caries. Select patients may be eligible for an additional fluoride treatment (D1206, D1208)
if they have specific diseases/conditions that increases the risk for caries. Examples of qualifying medical
diseases/conditions may include: history of head/neck radiation therapy, methamphetamine use,
xerostomia secondary to multiple medications, Sjogren’s syndrome, and special needs patients (nursing
home, dementia, arthritis). This supplemental fluoride benefit is not intended for patients who simply have
poor oral hygiene and/or consume excess dietary sugar/carbohydrates. They must have a documented
medical condition or medical risk factor to be eligible. These specific medical conditions/diseases must
be clearly documented in the patient’s record.

 This benefit is applicable to patients who are currently eligible by contract for the fluoride
benefit or for a patient who is over the contract fluoride age limit.
 Dentists must notify HDS of a patient’s diagnosis of Medical Risk for Caries via HDS Online or
a narrative in order for the patient to take advantage of these benefits.

D1206
topical application of fluoride varnish

D1208
topical application of fluoride – excluding varnish

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Code & Nomenclature Submission Requirements Surface

Other Preventive Services D1351

General Guidelines

1. The preventive resin restoration (PRR) is a procedure (D1352) completed in a moderate to high caries risk
patient. It includes the conservative restoration of an active cavitated lesion in a pit or fissure that does not
extend into dentin; and includes the placement of a sealant in any radiating non-carious fissures or pits. The
PRR involves the mechanical removal of decay with a bur or other instrument and cannot be delegated to a
dental hygienist or auxiliary. The PRR (D1352) is not an HDS benefit and should not be reported as D2391
unless the existing caries extends into dentin.
D1351 1 - 3,
sealant – per tooth 14 - 16,
17 - 19,
30 - 32

Mechanically and/or chemically prepared enamel surface sealed to prevent decay.

1. Sealants are benefits once per tooth on the occlusal surface of permanent molar teeth. The
occlusal surface must be free from overt dentinal caries and restorations. Special
consideration for late eruption can be given by report.

2. Age limitations for this procedure are determined by the group contract.

3. Repair or replacement of a sealant by the same dentist/dental office within 2 years of initial
placement is included in the fee for the initial placement and is not billable to the patient.
Repair or replacement of a sealant by a different dentist/dental office within 2 years of initial
placement is denied and the approved amount is collectable from the patient.

4. Repair or replacement of a sealant after 2 years is denied.

D1354 1-32,
application of caries arresting medicament – per tooth A-T

Conservative treatment of an active, non-symptomatic carious lesion by topical application of a

caries arresting or inhibiting medicament and without mechanical removal of sound tooth
structure.

1. This procedure is covered under plans with a fluoride benefit and is not applied to D1206,
D1208 frequency limits.

2. For coding purposes, this procedure applies to silver diamine fluoride and silver nitrate only.
D1354 should not be submitted if fluoride varnish or topical fluoride was placed.

3. Benefits for silver diamine fluoride application are limited to:

a. Frequency: twice per tooth per 12-month time period. Additional applications on the
same tooth in the 12-month time period are denied.
b. Six teeth per date of service are covered. Additional teeth on the same date of
service are denied.

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Code & Nomenclature Submission Requirements Surface

c. Restorations completed within 30 days of silver diamine fluoride application are

denied.
d. When performed on the same tooth, D1354 is not billable to the patient on the same
date of service as a restoration.

Space Maintenance (Passive Appliances) D1510 - D1558

Passive appliances are designed to prevent tooth movement.

Missing Teeth #
D1510 A - T,
space maintainer – fixed – unilateral 2 - 15,
18 - 31

D1516 A - J,
space maintainer – fixed – bilateral, maxillary 2 -15

K - T,
D1517 18 - 31
space maintainer – fixed – bilateral, mandibular

D1526 A - J,
space maintainer – removable – bilateral, maxillary 2 -15

D1527 K - T,
space maintainer – removable – bilateral, mandibular 18 - 31

1. One replacement per appliance is allowed.

2. Age limitations for this procedure are determined by the group contract.

Missing Teeth #
D1551 A - J,
re-cement or re-bond bilateral 2 -15
space maintainer - maxillary

D1552 K - T,
re-cement or re-bond bilateral 18 - 31
space maintainer - mandibular

1. One recementation and adjustment of a space maintainer by the same dentist/dental office is
allowed after 6 months from initial insertion. Subsequent recementations/rebondings are
denied.

2. One recement by a different dentist/dental office is allowed any time after the insertion.
Limited to one recementation per arch. Subsequent recementations/rebondings are denied.

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Code & Nomenclature Submission Requirements Surface

D1553 UR, UL
re-cement or re-bond unilateral LR, LL
space maintainer - per quadrant

1. One recementation and adjustment of a space maintainer by the same dentist/dental office is
allowed after 6 months from initial insertion. Subsequent recementations/rebondings are
denied.

2. One recement by a different dentist/dental office is allowed any time after the insertion.
Limited to one recementation per arch. Subsequent recementations/rebondings are denied.

D1556 UR, UL
removal of fixed unilateral LR, LL
space maintainer - per quadrant

1. Benefits for removal of fixed space maintainer by the same dentist/dental office who placed
the appliance are not billable to the patient.

2. D1556 is not billable to the patient when submitted with recementation on the same date of
service.

D1557
removal of fixed bilateral space
maintainer – maxillary

D1558
removal of fixed bilateral space
maintainer – mandibular

1. Benefits for removal of fixed space maintainer by the same dentist/dental office who placed
the appliance are not billable to the patient.

2. D1557 and or D1558 is not billable to the patient when submitted with recementation on the
same date of service.

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Code & Nomenclature Submission Requirements Surface

Space Maintainers

D1575 Missing Teeth #

distal shoe space maintainer – fixed – unilateral 3, 14, 19, 30

Fabrication and delivery of fixed appliance extending subgingivally and distally to guide the eruption of
the first permanent molar. Does not include ongoing follow-up or adjustments, or replacement
appliances, once the tooth has erupted.

1. Removal of distal shoe space maintainer by the same dentist/dental office who placed the
appliance is included in the fee for D1575.

2. Limited to children aged 8 and younger.

3. A subsequent space maintainer may be considered on a case-by-case basis.

D1999 Narrative 1-32,

unspecified preventive procedure, by report A-T,
UR, UL,
LR, LL

Used for procedure that is not adequately described by another CDT Code. Describe procedure.

1. Provide complete description of services/treatment to allow determination of appropriate

benefit allowance.

2. The narrative should include clinical diagnosis, tooth number, quadrant or arch,
photographic image when available and X-ray image where appropriate.

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RESTORATIVE D2000 - D2999

Restorative D2140 - D2394

Explanation of Restorations
Number of
Location Characteristics
Surfaces
Placed on one of the following five surface classifications –
1 Mesial, Distal, Incisal, Lingual, or Facial (or Labial).
Placed, without interruption, on two of the five surface
Anterior 2 classifications- e.g., Mesial-Lingual.
Placed, without interruption, on three of the five surface
3 classifications – e.g., Lingual-Mesial-Facial (or Labial).
Placed, without interruption, on four or more of the five surface
4 of more classifications-e.g., Mesial-Incisal-Lingual-Facial (or Labial).
Placed on one of the following five surface classifications –
1 Mesial, Distal, Occlusal, Lingual or Buccal.
Placed, without interruption, on two of the five surface
Posterior 2 classifications- e.g., Mesial-Occlusal.
Placed without interruption, on three of the five surface
3 classifications – e.g., Lingual-Occlusal-Distal
Placed, without interruption, on four or more of the five surface
4 of more classifications-e.g., Mesial-Occlusal-Lingual Distal.
Source: CDT 2022 Dental Procedure Codes, American Dental Association

Note: Tooth surfaces are reported on the HIPAA standard electronic dental transaction and the ADA Dental Claim
Form using the letters in the following table.

Surface Code
Buccal B
Distal D
Facial (or Labial) F
Incisal I
Lingual L
Mesial M
Occlusal O

General Guidelines

1. Restorations for occlusal wear, altering occlusion, vertical dimension, attrition, erosion, abrasion, abfraction,
TMD, periodontal or orthodontic splinting are denied, and the approved amount is collectible from the patient.
See “Definitions” listed on page11 of the Restorative section.

2. A treatment plan with a poor and or uncertain periodontal, restorative, or endodontic outcome may be denied
due to the unfavorable prognosis of the involved tooth/teeth. Special consideration/exception may be made by
submission of a narrative report.

3. By contract, HDS plans benefit restorations due to tooth structure loss from caries or fractured tooth surfaces.
Cosmetic restorations associated with congenital conditions (e.g., peg laterals, enamel hypoplasia) are not
payable by HDS. The patient must be informed and agree to assume the cost of non-benefit procedures.

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4. Restorations are not a benefit in conjunction with overdentures and benefits are denied.

5. The following are non-covered procedures and require the agreement of the patient to assume cost:

 Treatment involving specialized techniques

 Precision attachments for crowns, fixed/removable partial dentures or implants (related procedures
along with any associated appliances)

6. For uniformity of terminology, HDS and DeltaUSA considers a fractured tooth, crazing and crack to be
defined as the following:

 Fractured tooth - a separation in the continuity of tooth structure that results in mobility of one or
both segments.

 Crazing - the appearance of minute cracks on the surface of artificial or natural teeth. (Dorland’s
Illustrated Medical Dictionary)

 Crack - an incomplete split, break or fissure. (Dorland’s Illustrated Medical Dictionary)

7. The replacement of restorations on the same tooth and surface within 24 months is not billable to the patient
if done by the same dentist or dental office and denied if done by a different dentist/dental office. Special
consideration may be given by report. A narrative is required and should indicate the reason for
replacement within 24 months.

The following are exceptions:

 One DO surface restoration and one MO surface restoration are allowed on the same date of
service or within the 24-month period on molar teeth #1-3, 14-19, 30-32.

 Two O surface restorations are allowed on the same date of service or within the 24-month period
for molar teeth #3 and #14.

 Surfaces (DL and ML); (DI and MI); (DF and MF) on anterior teeth 6-11, 22-27, C-H, M-R are
allowed on the same date of service or within the 24-month period.

8. Specific government programs (e.g., Supplemental Medicaid) have combined occurrence limits for
restorative and extraction procedures. Verify limits in advance of patient treatment.

9. For amalgams, composites, inlays and onlays, identify the tooth surface(s) on the claim submission form.
For benefit purposes, the restoration must extend beyond the respective surface line angle.

10. The repair of crown/retainer margins due to caries should be submitted using D2999 unspecified
restorative procedure, by report or the appropriate corresponding restorative procedure code.

11. The fee for a restoration includes services such as, but is not limited to, working films and/or check films,
adhesives, etching, liners, bases, local anesthesia, polishing, occlusal adjustment within 6 months of the
restoration, caries removal, and gingivectomy on the same date of service. Benefits for the procedures
noted above when performed in conjunction with a restoration, are not billable to the patient.

12. If an indirectly fabricated restoration is performed by the same dentist/dental office within 6 months of the
placement of a restoration, the HDS payment for the restoration will be deducted from the indirectly
fabricated restoration benefit.

13. Any restoration performed by the same dentist/dental office on the same tooth within 12 months after crown
insertion is not billable to the patient. Special consideration may be given by report.

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HDS PROCEDURE CODE GUIDELINES RESTORATIVE

14. A narrative is required when a multi-surface restoration is completed 12 months or more after the insertion of
a crown.

 The narrative should confirm that services are performed on a crowned tooth

 When a narrative is not submitted or does not confirm that services were performed on a crowned
tooth, the restoration is not billable to the patient and a narrative to support a restoration on a
crowned tooth is requested.

15. A narrative is required when a multi-surface restoration is completed 12 months or more after the insertion of
a crown.

 The narrative should confirm that services are performed on a crowned tooth

 When a narrative is not submitted or does not confirm that services were performed on a crowned
tooth, the restoration is not billable to the patient and a narrative to support a restoration on a
crowned tooth is requested.

16. There are specific limitations for restorative and extraction procedures for specific government programs
(e.g., Supplemental Medicaid). Refer to general guideline #8 above. Verify limits in advance of patient
treatment.

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

Amalgam Restoration (Including Polishing) D2140 - D2161

Tooth preparation, all adhesives (including amalgam bonding agents), liners and bases are included as part of
the restoration. If pins are used, they should be reported separately (see D2951).

D2140 1 - 32
amalgam – one surface, primary or permanent A-T
Any surface(s)
D2150
amalgam – two surfaces, primary or permanent

D2160
amalgam – three surfaces, primary or permanent

D2161
amalgam – four or more surfaces, primary or permanent

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HDS PROCEDURE CODE GUIDELINES RESTORATIVE

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Code & Nomenclature Submission Requirements Surface

Resin-Based Composite Restorations – Direct D2330 - D2394

Resin-based composite refers to a broad category of materials including but not limited to composites. May include
bonded composite, light-cured composite, etc. Tooth preparation, acid etching, adhesives (including resin bonding
agents), liners and bases and curing are included as part of the restoration. Glass ionomers, when used as
restorations, should be reported with these codes. If pins are used, they should be reported separately (see D2951).

General Guidelines

1. The preventive resin restoration (PRR) is a procedure (D1352) completed in a moderate to high caries risk
patient. It includes the conservative restoration of an active cavitated lesion in a pit or fissure that does not
extend into dentin; and includes the placement of a sealant in any radiating non-carious fissures or pits.
The PRR involves the mechanical removal of decay with a bur and hand piece or other instrument and
cannot be delegated to a dental hygienist or auxiliary. The PRR (D1352) is not an HDS benefit. It should
not be reported as D2391 unless the existing caries extends into dentin.

2. For most plans, composite restorations on posterior teeth (except for the buccal surface composite on
premolars) are not a benefit. HDS will allow the alternate benefit of an amalgam restoration when
performed on posterior teeth. Patients should be informed that they are responsible for the cost difference
if they elect to have the composite restoration done on a posterior tooth. Refer to current group benefit
information for specific restoration coverage.

3. Specific government programs (e.g., Supplemental Medicaid) have combined occurrence limits for
restorative and extraction procedures. Verify limits in advance of patient treatment.

D2330 6 - 11,
resin-based composite – one surface, anterior 22 - 27,
C - H,
D2331 M-R
resin-based composite – two surfaces, anterior Any surface(s)

D2332
resin-based composite – three surfaces, anterior

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Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D2335 6 - 11,
resin-based composite – four or more surfaces or involving 22 - 27,
incisal angle (anterior) C - H,
M-R
Any surface(s)

Incisal angle to be defined as one of the angles formed by the junction of the incisal and the mesial
or distal surface of an anterior tooth.

1. The restoration replaces a proximal incisal angle of an anterior tooth. Benefit of both
angles is allowed within a 24-month period.

D2390 X-ray 6 - 11,

resin-based composite crown, anterior 22 - 27,
C - H,
M-R

Full resin-based composite coverage of tooth.

1. If D2390 is performed by the same dentist/dental office within 6 months of a restoration,

the restoration will be deducted.

2. A D2390 crown placed within 24 months of a stainless steel, resin-based composite, or

resin crown (D2390, D2930, D2932, D2933, D2934) is not billable to the patient for the
same dentist/dental office and denied for different dentist/dental office.

D2391 4, 5
resin-based composite – one surface, posterior 12, 13,
20, 21,
28, 29,
(Surface F)

Used to restore a carious lesion into the dentin or a deeply eroded area into the dentin. Not
a preventive procedure.

1. Only facial (buccal) surface on premolar teeth is benefited.

2. See additional guidelines for D2391 alternate benefit shaded in gray on page 5.

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Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D2391 1-5,
resin-based composite – one surface, posterior 12-21,
28-32,
A-B,
I-L,
S-T
Any surface (excluding buccal
surface on premolar)

D2392 1-5,
resin-based composite – two surfaces, posterior 12-21,
28-32,
D2393 A-B,
resin-based composite – three surfaces, posterior I-L,
S-T
D2394 Any surface(s)
resin-based composite – four or more surfaces,
posterior

1. For most plans, composite restorations on posterior teeth (except for the buccal
surface composite on premolars) are not a benefit. HDS will allow the alternate benefit
of an amalgam restoration when performed on posterior teeth. Patients should be
informed that they are responsible for the cost difference if they elect to have the
composite restoration done on a posterior tooth. Refer to current group benefit
information for specific restorative coverage.

Gold Foil Restorations D2410 – D2430

D2410 1 - 32
gold foil – one surface Any surface(s)

D2420
gold foil – two surfaces

D2430
gold foil – three surfaces

1. For most plans, the alternate benefit of an amalgam or composite restoration will be applied.
Patients should be informed that they are responsible for the cost difference if they
elect to have this service. Refer to current group benefit information for specific
coverage for gold restorations.

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Inlay/Onlay Restorations D2510 - D2664

General Guidelines

1. Restorations for occlusal wear, altering occlusion, vertical dimension, attrition, erosion, abrasion, abfraction,
TMD, periodontal or orthodontic splinting are denied, and the approved amount is collectible from the patient. See
“Definitions” listed on page11 of the Restorative section.

2. The clinical criteria to benefit an inlay or onlay is the same as a crown. The inlay/onlay is a covered benefit only
when required for restorative reasons (decay or fracture) and only when the tooth cannot be restored with a more
conservative restoration. When an inlay or onlay has been requested and the submitted documentation suggests
that the tooth can be more conservatively restored, the alternate benefit of an amalgam or resin-based composite
restoration will be applied.

3. For payment purposes, CEREC or CAD/CAM restorations are held to the same tooth preparation requirements
and outline forms noted in the definitions and references below.

Crown – An artificial replacement that restores missing tooth structure by surrounding the remaining coronal
tooth structure or is placed on a dental implant. It is made of metal or polymer materials or a combination of
such materials. It is retained by luting or mechanical means. (American College of Prosthodontics; The
Glossary of Prosthodontic Terms)

Inlay – An intra-coronal dental restoration, made outside the oral cavity to conform to the prepared cavity,
which does not restore cusp tips. (CDT 2016 Dental Procedure Codes, American Dental Association)

Onlay – A dental restoration made outside the oral cavity that covers one or more cusp tips and adjoining
occlusal surfaces, but not the entire external surface. (CDT 2016 Dental Procedure Codes, American Dental
Association)

Three-quarter crown (partial veneer crown) – a restoration that restores all but one coronal surface of a
tooth or dental implant abutment, usually not covering the facial surface. (Journal of Prosthetic Dentistry;
Glossary of Prosthodontic Terms; July 2005)

4. When an inlay/onlay is being replaced and the X-ray image or attachments submitted do not indicate decay,
fracture and/or the tooth being otherwise compromised, the provider is requested to state the reason(s) for
replacing the inlay/onlay.

5. Replacement of inlays and onlays may be benefited for restorations older than 5 years unless specified under
group contract.

6. Multistage procedures are reported and benefited upon completion. The completion date for crowns, veneers,
onlays and inlays is the cementation date.

7. Porcelain crowns, porcelain-fused to metal or plastic processed to metal type crowns, inlays or onlays are not a
benefit for children under 12 years of age for vital teeth.

8. Regarding Implant-Limited Plans: A crown, inlay or onlay placed adjacent to an implant tooth is subject to the
implant contract time limitation. Implant procedures will be paid as an alternate benefit equivalent to the
payment for two retainers of a 3-unit fixed partial denture. Therefore, the adjacent teeth are subject to treatment
limitations for existing inlays, onlay, crowns, veneers and fixed and removable prosthodontics. Appropriate
processing policies will be applied. As an example, for plans that have a 5-year limitation on crowns; a crown
placed on a tooth adjacent to an implant is not a benefit for 5 years following implant placement. A corresponding
benefit is applied for plans that have a 7-year limitation on crowns.

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Valid Tooth/Quad/Arch/
Code & Nomenclature Submission Requirements Surface

D2510 X-ray 1 - 32,

inlay – metallic – one surface Any surface

1. Benefit only for an occlusal surface to close the RCT access of a pre-existing full gold crown

2. For all other cases, the alternate benefit of an amalgam or composite restoration may be
applied.

D2520 X-ray 1 - 32,

inlay – metallic – two surfaces Any surface

D2530
inlay – metallic – three or more surfaces

1. For most plans, upon review of the X-ray image, the alternate benefit of an amalgam or
composite will be applied if inlay criteria not met.

D2542 X-ray 1 - 32,

onlay – metallic – two surfaces Any surface(s)

D2543
onlay – metallic – three surfaces

D2544
onlay – metallic – four or more surfaces

1. Upon review of the X-ray image, the alternate benefit of an amalgam or composite will be
applied if onlay criteria not met.

D2610 X-ray 1 - 32,

inlay – porcelain/ceramic – one surface Any surface

1. The alternate benefit of a D2510 will be applied only for an occlusal surface to close the
RCT access of a pre-existing porcelain surface. For all other cases, the alternate benefit
of an amalgam or composite restoration may be applied.

2. For most plans, porcelain/ceramic or resin-based composite inlays will be processed as

the alternate benefit of the metallic equivalent when performed on posterior teeth.
Patients should be informed that they are responsible for the cost difference if they elect
to have a porcelain/ceramic or resin-based composite inlay done on a posterior tooth.
Refer to current group benefit information for specific coverage for inlays.

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Valid Tooth/Quad/Arch/
Code & Nomenclature Submission Requirements Surface

D2620 X-ray 1 - 32,

inlay – porcelain/ceramic – two surfaces Any surfaces

D2630
inlay – porcelain/ceramic – three or more surfaces

1. For most plans, porcelain/ceramic or resin-based composite inlays will be processed as

the alternate benefit of the metallic equivalent when performed on posterior teeth.
Patients should be informed that they are responsible for the cost difference if they elect
to have a porcelain/ceramic or resin-based composite inlay done on a posterior tooth.
Refer to current group benefit information for specific coverage for inlays.
D2642 X-ray 1 - 32,
onlay – porcelain/ceramic – two surfaces Any surfaces

D2643
onlay – porcelain/ceramic – three surfaces

D2644
onlay – porcelain/ceramic – four or more surfaces

1. For most plans, porcelain/ceramic or resin-based composite onlays will be processed as

the alternate benefit of the metallic equivalent when performed on posterior teeth.
Patients should be informed that they are responsible for the cost difference if they elect
to have a porcelain/ceramic or resin-based composite inlay done on a posterior tooth.
Refer to current group benefit information for specific coverage for onlays.
D2650 X-ray 1 - 32,
inlay – resin-based composite – one surface Any surface

1. The alternate benefit of a D2510 will be applied only for an occlusal surface to close the
RCT access of a pre-existing resin crown. For all other cases, the alternate benefit of an
amalgam or composite restoration may be applied.

2. For most plans, porcelain/ceramic or resin-based composite onlays will be processed as

the alternate benefit of the metallic equivalent when performed on posterior teeth.
Patients should be informed that they are responsible for the cost difference if they elect
to have a porcelain/ceramic or resin-based composite onlay done on a posterior tooth.
Refer to current group benefit information for specific coverage for inlays.

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Valid Tooth/Quad/Arch/
Code & Nomenclature Submission Requirements Surface

D2651 X-ray 1 - 32,

inlay – resin-based composite – two surfaces Any surface

D2652
inlay – resin-based composite – three or more surfaces

1. For most plans, porcelain/ceramic or resin-based composite inlays will be processed as

the alternate benefit of the metallic equivalent when performed on posterior teeth.
Patients should be informed that they are responsible for the cost difference if they elect
to have a porcelain/ceramic or resin-based composite onlay done on a posterior tooth.
Refer to current group benefit information for specific coverage for inlays.

D2662 X-ray 1 - 32,

onlay – resin-based composite – two surfaces Any surfaces

D2663
onlay – resin-based composite – three surfaces

D2664
onlay – resin-based composite – four or more surfaces

1. For most plans, porcelain/ceramic or resin-based composite onlays will be processed as

the alternate benefit of the metallic equivalent when performed on posterior teeth.
Patients should be informed that they are responsible for the cost difference if they elect
to have a porcelain/ceramic or resin-based composite inlay done on a posterior tooth.
Refer to current group benefit information for specific coverage for onlays.

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HDS PROCEDURE CODE GUIDELINES RESTORATIVE

Crowns-Single Restorations Only D2710 – D2799

General Guidelines

1. Restorations for occlusal wear, altering occlusion, vertical dimension, attrition, erosion, abrasion,
abfraction, TMD, periodontal or orthodontic splinting are denied, and the approved amount is collectible
from the patient. See definitions below.

Definitions:

 Abfraction - the pathological loss of hard tooth substance caused by biomechanical

loading forces. Such loss is thought to be due to flexure and chemical fatigue
degradation of enamel and/or dentin at some location distant from the actual point of
loading.

 Abrasion - The wearing away of a substance or structure (such as the skin or

teeth) through some unusual or abnormal mechanical process. An abnormal
wearing away of the tooth substance by causes other than mastication.

 Attrition - The act of wearing or grinding down by friction. The mechanical wear
resulting from mastication or parafunction, limited to contacting surfaces of the teeth.

 Erosion - the progressive loss of tooth substance by chemical processes that do not
involve bacterial action producing defects that are sharply defined, wedge shaped
depressions often in facial and cervical areas.

(Reference: Journal of Prosthetic Dentistry, Vol 94, No. 1, The Glossary of Prosthodontic Terms, 8th Edition
2005, pp-10-81)

2. By contract, HDS plans benefit restorations of tooth structure loss from caries or fractured tooth surfaces.
Restorations provided for cosmetic purposes, congenital malformations (e.g., peg lateral incisors, enamel
hypoplasia) are non-payable by HDS. The patient must be informed and agree to assume the cost of non-
benefit procedures.

For uniformity in terminology, HDS and Delta USA considers a fractured tooth, crazing and crack to be
defined as the following:

Fractured tooth - a separation in the continuity of tooth structure that results in mobility of one or
both segments.

Crazing - the appearance of minute cracks on the surface of artificial or natural teeth.

Crack - an incomplete split, break or fissure.

3. A treatment plan with a poor and or uncertain periodontal, restorative or endodontic outcome may be
denied due to the unfavorable prognosis of the involved tooth/teeth. Special consideration/exception may
be made by submission of a narrative report.

4. A crown (resin, ceramic or metal) is a covered benefit only when required for missing tooth structure
(decay or fracture) and only when the tooth cannot be restored with a more conservative restoration. The
patient must be informed that the crown is an elective procedure when the tooth can be restored with a
more conservative restoration.

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HDS PROCEDURE CODE GUIDELINES RESTORATIVE

5. When a crown is planned for replacement and the X-ray image or other documentation does not
demonstrate decay, fracture and or the tooth being otherwise compromised, a narrative stating the clinical
reason(s) for replacement should be provided.

6. For most plans, porcelain/ceramic, porcelain-fused to metal, and resin-based composite crowns placed
on molar teeth will be processed as the alternate benefit of the metallic equivalent crown. Patients should
be informed that they are responsible for the cost difference if they elect to have a porcelain/ceramic,
porcelain-fused to metal or resin-based composite processed to metal type crown on a molar tooth. Refer
to current group benefit information for specific coverage for crowns.

7. If an indirectly fabricated restoration is performed by the same dentist/dental office within 6 months of the
placement of an amalgam or resin-based composite restoration, the HDS payment for the amalgam or
resin-based composite restoration will be deducted from the indirectly fabricated restoration benefit.

8. The fee for a restoration includes services such as, but not limited to:

 crown removal  laboratory fees

 tooth preparation  laser technology
 diagnostic wax-up,  occlusal adjustment within 6 months after the restoration
 electro surgery  post-operative visits within 6 months after the restoration
 temporary restorations  local anesthesia
 liners and cement bases  crown lengthening and gingivectomy on the same date of
 impressions service

These procedures/services are not billable to the patient when submitted as a separate charge.

9. Replacement of partial coverage restorations, veneers, ceramic, porcelain fused to metal and resin based
composite crowns due to defective margins, recurrent decay, restorative material failure or fractured tooth
surfaces may be a benefit as specified under group contract.

10. Ceramic crowns, porcelain-fused to metal or resin based composite crowns processed to metal type
crowns, inlays or onlays are not a benefit for children under 12 years of age for vital teeth.

11. Multistage procedures are reported and benefited upon completion. Claims should be submitted with the
cementation date of the crown. For patients whose dental coverage has been terminated; indicate the
preparation date in a narrative. If the preparation was done prior to the patient’s termination date, the
crown will be benefited if inserted within 30 days of the termination and if no other dental coverage exists.

12. When submitting for crowns, core buildup or post and core, an X-ray image may not be required for molar
and premolar teeth with an HDS history of endodontic treatment.

13. Radiographic images used to verify crown seatings are considered working images and are not billable to
the patient.

14. The repair of crown/retainer margins due to caries should be submitted using D2999 unspecified
restorative procedure, by report or the appropriate corresponding restorative procedure code.

15. Regarding Cosmetic Services and Patient-Elected Services:

Services elected by the patient for cosmetic reasons or for restoring/altering vertical dimension are not
covered benefits. The dentist must explain that the services may be denied.

 HDS plans provide benefits for restoration of tooth structure loss from caries and or fractured/missing
tooth surfaces. Restorations provided for cosmetic purposes are considered elective services.

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HDS PROCEDURE CODE GUIDELINES RESTORATIVE

 Replacement of cosmetic crowns and veneers is denied. Patient must be informed and agree to
assume the cost of non-benefit procedures.

 Even when a crown is elected by the patient for cosmetic reasons, there is still the possibility that the
service may be benefited by HDS if there is clinical justification for the restoration. Therefore, the
dentist must submit the service to HDS with the required attachments (if any). HDS will review the
submission and determine if the service is covered. If the crown is benefited, the dentist is held to
the Maximum Plan Allowance for the service.

 When reviewing the treatment plan for a cosmetic service with the patient, the dentist should explain
that the service may not be a benefit. It is recommended that the dentist obtain the patient’s written
consent on a form that clearly explains the charges that will be incurred.

16. When closing or restoring the endodontic access opening through an existing crown that will not be
replaced, the following appropriate coding options will apply:

 D2140 amalgam one surface

 D2330 resin one surface anterior
 D2391 resin one surface posterior
 D2999 unspecified restorative procedure, by report

17. Regarding Implant-Limited Plans: A crown, inlay or onlay placed adjacent to an implant tooth is subject
to the implant contract time limitation. Implant procedures will be paid as an alternate benefit equivalent
to the payment for two retainers of a 3-unit fixed partial denture. Therefore, the adjacent teeth are subject
to treatment limitations for existing inlays, onlays, crowns, veneers and fixed and removable
prosthodontics. Appropriate processing policies will be applied. As an example, for plans that have a 5-
year limitation on crowns, a crown placed on a tooth adjacent to an implant is not a benefit for 5 years
following implant placement. A corresponding benefit is applied for plans that have a 7-year limitation on
crowns.

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

Crowns – Single Restorations Only D2710 – D2799

D2710 X-ray 4 - 13,

crown – resin-based composite (indirect) 20 - 29

1. See additional guidelines for D2710 alternate benefit shaded in gray.

D2710 X-ray 1 - 3,
crown – resin-based composite (indirect) 14 -19,
30 - 32
1. For most plans, porcelain/ceramic, porcelain-fused to metal, and resin-based composite
crowns placed on molar teeth will be processed as the alternate benefit of the metallic
equivalent crown. Patients should be informed that they are responsible for the cost
difference if they elect to have a porcelain/ ceramic, porcelain-fused to metal, resin-
based composite crown completed on a molar tooth. Refer to current group benefit
information for specific coverage for crowns.

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Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D2712 X-ray 4 - 13,

crown –¾ resin-based composite (indirect) 20 - 29

This procedure does not include facial veneers.

1. See additional guidelines for D2712 alternate benefit shaded in gray.

D2712 X-ray 1 - 3,
crown –¾ resin-based composite (indirect) 14 -19,
30 - 32
This procedure does not include facial veneers.

1. For most plans, porcelain/ceramic, porcelain-fused to metal, and resin-based composite

crowns placed on molar teeth will be processed as the alternate benefit of the metallic
equivalent crown. Patients should be informed that they are responsible for the cost
difference if they elect to have a porcelain/ ceramic, porcelain-fused to metal, resin-
based composite crown completed on a molar tooth. Refer to current group benefit
information for specific coverage for crowns.

D2720 X-ray 4 - 13,

crown – resin with high noble metal 20 - 29

D2721
crown – resin with predominantly base metal

D2722
crown – resin with noble metal

1. See additional guidelines for D2720, D2721 and D2722 alternate benefits shaded in
gray.

D2720 X-ray 1 - 3,
crown – resin with high noble metal 14 -19,
30 - 32
D2721
crown – resin with predominantly base metal

D2722
crown – resin with noble metal

1. For most plans, porcelain/ceramic, porcelain-fused to metal, and resin-based composite

crowns placed on molar teeth will be processed as the alternate benefit of the metallic
equivalent crown. Patients should be informed that they are responsible for the cost
difference if they elect to have a porcelain/ ceramic, porcelain-fused to metal, resin-
based composite crown completed on a molar tooth. Refer to current group benefit
information for specific coverage for crowns.

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HDS PROCEDURE CODE GUIDELINES RESTORATIVE

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D2740 X-ray 4 - 13,

crown – porcelain/ceramic 20 - 29

Porcelain margin charges associated with this procedure are not billable to the patient.

1. See additional guidelines for D2740 alternate benefit shaded in gray.

D2740 X-ray 1 - 3,
crown – porcelain/ceramic 14 -19,
30 - 32
1. For most plans, porcelain/ceramic, porcelain-fused to metal, and resin-based composite
crowns placed on molar teeth will be processed as the alternate benefit of the metallic
equivalent crown. Patients should be informed that they are responsible for the cost
difference if they elect to have a porcelain/ ceramic, porcelain-fused to metal, resin-
based composite crown completed on a molar tooth. Refer to current group benefit
information for specific coverage for crowns.

2. Porcelain margin charges associated with this procedure are not billable to the patient.

D2750 X-ray 4 - 13,

crown – porcelain fused to high noble metal 20 - 29

D2751
crown – porcelain fused to predominantly base metal

D2752
crown – porcelain fused to noble metal

D2753
crown - porcelain fused to titanium or titanium alloy

1. The additional lab cost for porcelain gingival margin on anterior and premolar crowns may
be charged to the patient when the following conditions are met:

 Submit as code D2999 or D6999 (Miscellaneous by report codes) describing

the service, including a narrative stating, “Service elected by patient for
cosmetic reasons”.

 Lab invoice showing the additional amount charged for porcelain margin.

2. See additional guidelines for D2750, D2751, D2752 and D2753 alternate benefit shaded in
gray.

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Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D2750 X-ray 1 - 3,
crown – porcelain fused to high noble metal 14 -19,
30 - 32
D2751
crown – porcelain fused to predominantly base metal

D2752
crown – porcelain fused to noble metal

D2753
crown - porcelain fused to titanium or titanium alloy

1. For most plans, porcelain/ceramic, porcelain-fused to metal, and resin-based composite

crowns placed on molar teeth will be processed as the alternate benefit of the metallic
equivalent crown. Patients should be informed that they are responsible for the cost
difference if they elect to have a porcelain/ ceramic, porcelain-fused to metal, resin-based
composite crown completed on a molar tooth. Refer to current group benefit information for
specific coverage for crowns.

D2780 X-ray 1 - 32
crown – 3⁄4 cast high noble metal

D2781
crown – 3⁄4 cast predominantly base metal

D2782
crown – 3⁄4 cast noble metal

D2783 X-ray 4 -13,

crown – 3⁄4 porcelain/ceramic 20 - 29

This procedure does not include facial veneers.

1. See additional guidelines for D2783 alternate benefit shaded in gray.

D2783 X-ray 1 - 3,
crown – 3⁄4 porcelain/ceramic 14 -19,
30 - 32
This procedure does not include facial veneers.

1. For most plans, porcelain/ceramic, porcelain-fused to metal, and resin-based composite

crowns placed on molar teeth will be processed as the alternate benefit of the metallic
equivalent crown. Patients should be informed that they are responsible for the cost
difference if they elect to have a porcelain/ ceramic, porcelain-fused to metal, resin-based
composite crown completed on a molar tooth. Refer to current group benefit information for
specific coverage for crowns.

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Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D2790 X-ray 1 - 32
crown – full cast high noble metal

D2791 X-ray 1 - 32
crown – full cast predominantly base metal

D2792
crown – full cast noble metal

D2794 X-ray 1 - 32
crown – titanium and titanium alloys

1. For most plans, upon review of the X-ray images, the alternate benefit of a D2790
will be applied. Patients should be informed that they are responsible for the cost
difference. Refer to current group benefit information for specific coverage for
crowns.

D2799 X-ray, 1 - 32
interim crown – further treatment or completion of diagnosis Narrative
necessary prior to final impression

Not to be used as a temporary crown for a routine prosthetic restoration.

1. Covered as a benefit only in the event of an injury/trauma. Narrative must detail the
cause and nature of the injury/trauma. The presence of caries is not considered an injury
or trauma.

2. Temporary, interim or provisional restorations are not separate benefits and are included
in the fee for the permanent restoration. Benefits are not billable to the patient.

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HDS PROCEDURE CODE GUIDELINES RESTORATIVE

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

Other Restorative Services D2910 - D2999

D2910 1 - 32
re-cement or re-bond inlay, onlay, veneer or partial coverage
restoration

D2915
re-cement or re-bond indirectly fabricated or prefabricated
post and core

D2920
re-cement or re-bond crown 1 - 32
A-T
1. Benefit for recementation within 6 months of the initial placement is not billable to the
patient when performed by the same dentist or dental office.

2. Recementation by a different provider (within 6 months of initial placement) is a benefit

once.

3. Benefits are allowed for one recementation after 6 months have elapsed since initial
placement. Subsequent requests for recementation are allowed every 12 months
thereafter.

4. D2920 and D2915 are not benefited on the same tooth on the same service date by the
same dentist or dental office. If submitted, D2915 is not billable to the patient.

D2921 1 - 32
reattachment of tooth fragment, incisal edge or cusp

1. The replacement of a D2921 performed within 24 months by the same dentist/dental office is
not billable to the patient.

2. Benefits are allowed for permanent teeth. Reattachment of a tooth fragment on a primary
tooth is denied.

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HDS PROCEDURE CODE GUIDELINES RESTORATIVE

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D2928 1 - 32
prefabricated porcelain/ceramic crown – permanent
tooth

1. If D2928 is performed by same dentist/dental office within 6 months of an amalgam or resin-

based composite restoration, the restoration will be deducted.

2. A D2928 placed within 24 months of a crown is not billable to the patient by same
dentist/dental office and denied by different dentist/dental office.

3. For most plans, the alternate benefit allowance of D2931 is applied. Patients should be
informed that they are responsible for the cost difference. Refer to current group benefit
information for specific restorative coverage.

D2929 A-T
prefabricated porcelain/ceramic crown – primary tooth

1. If D2929 is performed by same dentist/dental office within 6 months of an amalgam or resin-

based composite restoration, the restoration will be deducted.

2. A D2929 placed within 24 months of a crown is not billable to the patient by same
dentist/dental office and denied by different dentist/dental office.

3. For most plans, if submitted for a posterior primary tooth the alternate benefit allowance of
D2930 is applied. If submitted for an anterior primary tooth, the alternate benefit allowance of
D2934 is applied. Patients should be informed that they are responsible for the cost
difference. Refer to current group benefit information for specific restorative coverage.

D2930 A-T
prefabricated stainless steel crown – primary tooth

1. If D2930 is performed by same dentist/dental office within 6 months of an amalgam or resin-

based composite restoration, the restoration will be deducted.

2. A D2930 placed within 24 months of a crown is not billable to the patient by same
dentist/dental office and denied by different dentist/dental office.

D2931 1 - 32
prefabricated stainless steel crown – permanent tooth

1. If D2931 is performed by same dentist/dental office within 6 months of an amalgam or resin-

based composite restoration, the restoration will be deducted.

2. A D2931placed within 24 months of a stainless steel, resin-based or resin crown

(D2390, D2930, D2932, D2933, D2934) is not billable to the patient by same
dentist/dental office and denied by different dentist/dental office.

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HDS PROCEDURE CODE GUIDELINES RESTORATIVE

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D2932 C - H,
prefabricated resin crown M-R

1. If D2932 is performed by same dentist/dental office within 6 months of an amalgam or resin-

based composite restoration, the restoration will be deducted.

2. A D2932 placed within 24 months of a crown is not billable to the patient by same
dentist/dental office and denied by different dentist/dental office.

3. See additional guidelines for D2932 alternate benefit shaded in gray.

D2932 A-B,
prefabricated resin crown I-L,
S-T

1. If D2932 is performed by same dentist/dental office within 6 months of an amalgam or resin-

based composite restoration, the restoration will be deducted.

2. A D2932 placed within 24 months of a crown is not billable to the patient by same
dentist/dental office and denied by different dentist/dental office.

3. For most plans, if submitted for a posterior primary tooth or permanent tooth, the alternate
benefit allowance of D2930 or D2931 is applied. Patients should be informed that they are
responsible for the cost difference. Refer to current group benefit information for specific
coverage for restorative coverage.

D2933 C - H,
prefabricated stainless steel crown with resin window M-R

Open-face stainless steel crown with aesthetic resin facing or veneer.

1. If D2933 is performed by same dentist/dental office within 6 months of an amalgam or

resin-based composite restoration, the restoration will be deducted.

2. A D2933 placed within 24 months of a crown is not billable to the patient by same
dentist/dental office and denied by different dentist/dental office.

3. If submitted for a posterior primary tooth or a permanent tooth, the alternate benefit
D2930 or D2931 is applied.

4. See additional guidelines for D2933 alternate benefit shaded in gray.

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HDS PROCEDURE CODE GUIDELINES RESTORATIVE

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D2933 A-B,
prefabricated stainless steel crown with resin window I-L,
S-T

Open-face stainless steel crown with aesthetic resin facing or veneer.

1. If D2933 is performed by same dentist/dental office within 6 months of an amalgam or

resin-based composite restoration, the restoration will be deducted.

2. A D2933 placed within 24 months of a crown is not billable to the patient by same
dentist/dental office and denied by different dentist/dental office.

3. For most plans, if submitted for a posterior primary tooth or a permanent tooth, the
alternate benefit D2930 or D2931 is applied. Patients should be informed that they are
responsible for the cost difference. Refer to current group benefit information for specific
restorative coverage.

D2934 C - H,
prefabricated esthetic coated stainless steel crown – M-R
primary tooth

1. If D2934 is performed by same dentist/dental office within 6 months of an amalgam or

resin-based restoration, the restoration will be deducted.

2. A D2934 placed within 24 months of a crown is not billable to the patient for same
dentist/dental office and denied for different dentist/dental office.

3. See additional guidelines for D2394 alternate benefit shaded in gray.

D2934 A-B,
prefabricated esthetic coated stainless steel crown – I-L,
primary tooth S-T

1. If D2934 is performed by same dentist/dental office within 6 months of an amalgam or

resin-based composite restoration, the restoration will be deducted.

2. A D2934 placed within 24 months of a crown is not billable to the patient for same
dentist/dental office and denied for different dentist/dental office.

3. For most plans, if submitted for a posterior primary tooth, the alternate benefit of D2930 is
applied. Patients should be informed that they are responsible for the cost difference.
Refer to current group benefit information for specific restorative coverage.

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HDS PROCEDURE CODE GUIDELINES RESTORATIVE

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D2940 A - T,
protective restoration 1 - 32

Direct placement of a restorative material to protect tooth and/or tissue form. This procedure
may be used to relieve pain, promote healing, or prevent further deterioration. Not to be
used for endodontic access closure, or as a base or liner under a restoration.

1. Allowed once per tooth, per dentist/dental office, per 24 months. D2940 is not billable to
the patient for same dentist/dental office and denied for different dentist/dental office
when performed within 24 months of the initial placement.

2. Benefits for a protective restoration are not billable to the patient when performed in
conjunction with a definitive service and/or palliative treatment (D9110) on the same
tooth.

D2950 X-ray 1 - 32
core buildup, including any pins when required

Refers to building up of coronal structure when there is insufficient retention for a separate
extracoronal restorative procedure. A core buildup is not a filler to eliminate any undercut, box
form, or concave irregularity in a preparation.

1. A core buildup is a benefit only when there is insufficient sound tooth structure (less than
50% remaining tooth structure) to support and retain a crown or retainer.

2. A core buildup is not billable to the patient when the radiographic image and other
supporting documents indicate that sufficient tooth structure remains to support and
retain a crown or retainer.

3. An X-ray image may not be required for molar and premolar teeth with an HDS history of
endodontic treatment.

4. Do not submit this code for the closure of an endodontic access through an existing
crown unless a new crown will be fabricated.

5. A core buildup is not billable to the patient when performed in conjunction with inlay and
onlay procedures.

D2951 1 - 32
pin retention – per tooth, in addition to restoration

1. Only allowed for amalgam and composite restorations.

2. Fees for additional pins on the same tooth are not billable to the patient as a component
of the initial pin placement.

3. A fee for pin retention when billed in conjunction with a buildup is not billable to the
patient.

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Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D2952 X-ray 1 - 32
post and core in addition to crown, indirectly fabricated

Post and core are custom fabricated as a single unit.

1. Post and cores (D2952 and D2954) are benefits only when insufficient crown retention
exists due to extensive caries and/or tooth fracture. Post and cores will be denied when
the x-ray documentation shows a minimal loss of tooth structure due to the endodontic
access opening, caries and/or fracture.

2. Benefits for post and core are not billable to the patient when radiographs indicate an
absence of endodontic treatment, incompletely filled canal space or unresolved
pathology associated with the involved tooth.

3. An X-ray image may not be required for molar and premolar teeth with an HDS history of
endodontic treatment.

4. Restorations are not a benefit in conjunction with overdentures and benefits are denied as an
elective technique.

D2954 X-ray 1 - 32
prefabricated post and core in addition to crown

Core is built around a prefabricated post. This procedure includes the core material.

1. Post and cores (D2952 and D2954) are benefits only when insufficient crown retention
exists due to extensive caries and/or tooth fracture. Post and cores will be denied when
the x-ray documentation shows a minimal loss of tooth structure due to the endodontic
access opening, caries and/or fracture.

2. Benefits for post and core are not billable to the patient when radiographs indicate an
absence of endodontic treatment, incompletely filled canal space or unresolved
pathology associated with the involved tooth.

3. An X-ray image may not be required for molar and premolar teeth with an HDS history of
endodontic treatment.

4. Restorations are not a benefit in conjunction with overdentures and benefits are denied as an
elective technique.

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D2955 X-ray, 1 - 32
post removal Narrative

1. Post removal is considered an integral component of endodontic retreatment procedure

codes D3346, D3347, D3348. Post removal associated with endodontic retreatment
performed by the same dentist/dental office is not billable to the patient.

2. A benefit allowance may be made based on the submitted X-ray image and narrative (i.e.
removal of a broken/fractured post when endodontic treatment is not anticipated or
planned).
D2960 4 - 13,
labial veneer (resin laminate) – direct 20 - 29

Refers to labial/facial direct resin bonded veneers.

1. Veneers to treat caries and incisal fractures are considered covered benefits if the tooth
qualifies for a crown and patient payments are limited to co-payments of the HDS eligible
amount.

2. The placement or replacement of veneers on permanent anterior teeth and premolar s for
cosmetic purposes are considered non-covered benefits and the patient must be informed
and agree to assume the cost up to the submitted charge amount.

3. Benefit limit is determined by the group contract.

4. Replacement of veneers should be accompanied by a narrative explaining the need to replace

the veneer. While not routinely required, photographic images may be beneficial to support
the claim submission.

5. See the General Guidelines, page 11 for services provided for cosmetic reasons.
D2961 X-ray 4 - 13,
labial veneer (resin laminate) – indirect 20 - 29

Refers to labial/facial indirect resin bonded veneers.

1. Veneers to treat caries and incisal fractures are considered covered benefits if the tooth
qualifies for a crown and patient payments are limited to co-payments of the HDS eligible
amount.

2. The placement or replacement of veneers on permanent anterior teeth and premolars for
cosmetic purposes are considered non-covered benefits and the patient must be informed
and agree to assume the cost up to the submitted charge amount.

3. Benefit limit is determined by the group contract.

4. Replacement of veneers should be accompanied by a narrative explaining the need to replace

the veneer. While not routinely required, photographic images may be beneficial to support
the claim submission.

5. See the General Guidelines, page 11 for services provided for cosmetic reasons.
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D2962 X-ray 4 - 13,

labial veneer (porcelain laminate) – indirect 20 - 29

Refers also to facial veneers that extend interproximally and/or cover the incisal edge.
Porcelain/ceramic veneers presently include all ceramic and porcelain veneers.

1. Veneers to treat caries and incisal fractures are considered covered benefits if the tooth
qualifies for a crown and patient payments are limited to co-payments of the HDS eligible
amount.

2. The placement or replacement of veneers on permanent anterior teeth and premolars for
cosmetic purposes are considered non-covered benefits, and the patient must be informed
and agree to assume the cost up to the submitted charge amount.

3. Benefit limit is determined by the group contract.

4. Replacement of veneers should be accompanied by a narrative explaining the need to replace

the veneer. While not routinely required, photographic images may be beneficial to support the
claim submission.

5. See the General Guidelines, page 11 for services provided for cosmetic reasons.

D2971 1 - 32
additional procedures to customize a crown to fit under an
existing partial denture framework

This procedure is in addition to the separate crown procedure documented with its own code.

1. This procedure must be submitted with a crown procedure.

2. Patient history of partial denture (D5213, D5214) is required for benefit of this procedure.

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D2980 Narrative, 1 - 32
crown repair necessitated by restorative material failure Lab Invoice

D2981
inlay repair necessitated by restorative material failure

D2982
onlay repair necessitated by restorative material failure

D2983
veneer repair necessitated by restorative material failure

1. Includes removal of prosthesis, if necessary.

2. The repair of crown/retainer margins due to caries should be submitted using D2999
unspecified restorative procedure, by report or the appropriate corresponding
restorative procedure code.

3. For most plans, ceramic repairs on molars are not benefits and the patient is responsible
for the cost. Refer to current group benefit information for specific coverage for
porcelain/ceramic repairs on molars.

4. Repair is a benefit 6 months after the initial insertion and then only a benefit once every
12 months.

5. Any restoration performed by the same dentist on the same tooth within 12 months after
crown insertion is not billable to the patient. Special consideration may be given by
report.

6. The submitted information should include:

 Clinical diagnosis
 The tooth surfaces involved in the repair
 Type of restorative materials used for the repair (composite, amalgam, etc.)
 Tooth number
 Chair time
 Laboratory invoice when appropriate
 X-ray or photographic image(s)when available
 Additional other supporting information

7. Upon review of the submitted narrative and other documentation, an appropriate benefit
allowance will be applied.

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D2999 Narrative, A-T,

unspecified restorative procedure, by report Lab Invoice 1-32

Use for procedure that is not adequately described by a code. Describe procedure (e.g., rigid
splinting of crowns).

1. Narrative should include the clinical diagnosis, restorative materials used, tooth number and
surfaces, chair time. Intraoral photographic images (when available), x-ray images when
appropriate or additional supporting information may be requested.

2. Upon review of documentation, the appropriate benefit allowance will be applied.

3. The repair of crown/retainer margins due to caries should be submitted using D2999
unspecified restorative procedure, by report or the appropriate corresponding
restorative procedure code.

4. The additional lab cost for porcelain gingival margin on anterior and premolar crowns
may be charged to the patient when the following conditions are met:

 Submit as code D2999 or D6999 (Miscellaneous by report codes) describing the

service, including a narrative stating, “service elected by patient for cosmetic
reasons”.
 Lab invoice showing the additional amount charged for porcelain margin.

5. For most plans, additional cost for porcelain gingival margin on molar crowns are not
benefits and the patient is responsible for the cost. Refer to current group benefit
information for specific coverage for porcelain services performed on molar crowns

6. When closing or restoring the endodontic access opening through an existing crown that
will not be replaced, the appropriate coding options are:

 D2140 amalgam one surface

 D2330 resin one surface anterior
 D2391 resin one surface posterior
 D2999 unspecified restorative procedure, by report

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ENDODONTICS D3000 - D3999

Local anesthesia is usually considered to be part of Endodontic procedures.

General Guidelines

1. A treatment plan with a poor and or uncertain periodontal, restorative or endodontic outcome may be denied due to
the unfavorable prognosis of the involved tooth/teeth. Special consideration/exception may be made by submission
of a narrative report.

2. Endodontic exploratory surgery is denied.

3. Incomplete obturation and treatment of the root canal system is not payable by HDS or patient.

Pulp Capping D3110 - D3120

D3110 X-ray 1 - 32,

pulp cap – direct (excluding final restoration) A-T

Procedure in which the exposed pulp is covered with a dressing or cement that protects the pulp
and promotes healing and repair.

1. Calcium Hydroxide or Mineral Trioxide Aggregate (MTA) is considered the material of choice for
direct and indirect pulp cap.

2. A separate benefit for a pulp cap by the same dentist/dental office is not billable to the patient as
a component of a protective restoration (D2940).

D3120 X-ray 1 - 32,

pulp cap – indirect (excluding final restoration) A-T

Procedure in which the nearly exposed pulp is covered with a protective dressing to protect the
pulp from additional injury and to promote healing and repair via formation of secondary dentin.
This code is not to be used for bases and liners when all caries have been removed.

1. Calcium hydroxide or Mineral Trioxide Aggregate (MTA) is considered the material of choice for
direct and indirect pulp cap.

2. A separate benefit for a pulp cap by the same dentist/dental office is not billable to the patient as
a component of a protective restoration (D2940).

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Pulpotomy D3220 - D3222

D3220 1 - 32,
therapeutic pulpotomy (excluding final restoration) – removal A-T
of pulp coronal to the dentinocemental junction and
application of medicament

Pulpotomy is the surgical removal of a portion of the pulp with the aim of maintaining the vitality of
the remaining portion by means of an adequate dressing.

- To be performed on primary or permanent teeth.

- This is not to be construed as the first stage of root canal therapy.
- Not to be used for Apexogenesis.

1. This benefit is allowed once per tooth per lifetime.

D3221 1 - 32,
pulpal debridement, primary and permanent teeth A-T

Pulpal debridement for the relief of acute pain prior to conventional root canal therapy. This
procedure is not to be used when endodontic treatment is completed on the same day.

1. The benefit for D3221 is not billable to the patient when performed by the same dentist/dental
office on the same day as endodontic therapy (D3230-D3333).

2. This benefit (D3221) is allowed once per tooth per lifetime. Additional D3221 on the same
tooth by the same dentist is not billable to the patient.

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D3222 X-ray 2 - 15,

partial pulpotomy for apexogenesis - permanent tooth with 18 - 31
incomplete root development

Removal of a portion of the pulp and application of a medicament with the aim of maintaining the
vitality of the remaining portion to encourage continued physiological development and formation
of the root. This procedure is not to be construed as the first stage of root canal therapy.

1. The benefit for partial pulpotomy is not billable to the patient when performed in conjunction
with root canal therapy (D3230–D3333) or procedures D3351-D3353 by the same
dentist/dental office.

2. This is a benefit only for teeth with incomplete root development.

Endodontic Therapy on Primary Teeth D3230 - D3299

Endodontic therapy on primary teeth with succedaneous teeth and placement of resorbable filling. This includes
pulpectomy, cleaning, and filling of canals with resorbable material.

D3230 X-ray C - H,
pulpal therapy (resorbable filling) - anterior, primary tooth M-R
(excluding final restoration)

Primary incisors and cuspids.

1. Pulpal therapy is only benefited when performed on a non-vital primary tooth that has a
successor.

2. If submitted for a non-vital primary tooth with no successor, benefit is limited to a D3310
(anterior) root canal.

3. Pulpal therapy submitted for a permanent tooth is not billable to the patient. Please resubmit
with proper coding.

4. This benefit is allowed once per tooth per lifetime.

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D3240 X-ray A, B,
pulpal therapy (resorbable filling) – posterior, primary tooth I - L,
(excluding final restoration) S, T

Primary first and second molars.

1. Pulpal therapy is only benefited when performed on a non-vital primary tooth that has a
successor.

2. If submitted for a non-vital primary tooth with no successor, benefit is limited to a D3320
(premolar) root canal.

3. Pulpal therapy submitted for a permanent tooth is not billable to the patient. Please resubmit
with proper coding.

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Endodontic Therapy (Including Treatment Plan, Clinical Procedures and Follow-up Care) D3310 - D3333

Includes primary teeth without succedaneous teeth and permanent teeth. Complete root canal therapy; pulpectomy is
part of root canal therapy.

Includes all appointments necessary to complete treatment; also includes intra-operative radiographs. Does not
include diagnostic evaluation and necessary radiographs/diagnostic images.

1. Administrative Criteria:

 Always submit a labeled and dated X-ray image that is diagnostic and clearly demonstrates the
periapical region 2-3 millimeters beyond the radiographic apex. The image should clearly demonstrate
the entire obturation of the root canal system and be free of positional errors and artifacts.
 In the case of endodontic retreatment or treatment of obstructions, clearly label or indicate if the image is
a pre-operative or post-operative image.
 When submitting a narrative to support a claim, ensure that a valid AAE (American Association of
Endodontists) pulpal and apical diagnosis is included. (Source: https://www.aae.org/specialty/wp-
content/uploads/sites/2/2017/07/endodonticdiagnosisfall2013.pdf)
 The narrative should contain a clear, concise description of the procedure, patient symptoms, and any
other pertinent information related to the claim.
 Interim working films should not be submitted for payment.
 A final obturation that is greater than 2.0 millimeters short of the apex or overextended more than 1.5
millimeters past the apex should have an accompanying narrative that details the clinical circumstances
as well as the current and long-term prognosis. This is not a guarantee of payment or benefit.

2. Clinical Criteria:
The clinical criteria listed below are utilized by HDS dental consultants when reviewing endodontic treatment
claims.

 The tooth should not be perforated.

 The tooth should be restorable.
 The final obturation should be complete, within the confines of the root canal system and ideally
positioned ½ to 1.5 millimeters from the radiographic apex. (See Pathways of the Pulp 10th edition).
 The gutta percha obturation should be solid and free of significant voids.
 The final obturation should not be significantly over-extended (> 1.5 millimeters).
 Extrusion of sealer may be unavoidable, but it should not be excessive.

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D3310 Post-op X-ray 6 - 11,

endodontic therapy, anterior tooth (excluding final 22 - 27
restoration)

D3320 4, 5,
endodontic therapy, premolar tooth (excluding final 12, 13,
restoration) 20, 21,
28, 29
D3330
endodontic therapy, molar tooth (excluding final restoration)
1 - 3,
14 - 19,
30 – 32

1. A separate fee for palliative treatment is not billable to the patient when done in conjunction
with root canal therapy by the same dentist/dental office on the same date of service.

2. One diagnostic radiographic image is allowed per tooth. Additional films are considered as
part of the root canal treatment and are not billable to the patient.

3. When a radiograph indicates obturation of an endodontically treated tooth has been

performed without the use of a biologically acceptable nonresorbable semisolid or solid core
material, benefit is not billable to the patient.

4. When a root canal is left unfinished, an allowance may be made for pulpal debridement
(D3221) and fees in excess of a D3221 are not billable to the patient.

5. When a root canal is completed and filled with biologically acceptable material on a retained
primary tooth, whose permanent successor is missing, indicate the primary tooth number and
include a narrative stating that there is no permanent successor.

6. Root canal therapy is not a benefit in conjunction with overdentures and benefits are denied
as an elective technique.

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D3331 Pre-op X-ray, 1 - 32

treatment of root canal obstruction; non-surgical access Post-op X-ray

In lieu of surgery, for the formation of a pathway to achieve an apical seal without surgical
intervention because of a non-negotiable root canal blocked by foreign bodies, including but not
limited to separated instruments, broken posts or calcification of 50% or more of the length of the
tooth root.

1. Post removal is not included in this procedure.

D3332 Narrative 1 - 32
incomplete endodontic therapy; inoperable, unrestorable
or fractured tooth

Considerable time is necessary to determine diagnosis and/or provide initial treatment before the
fracture makes the tooth unretainable.

1. Benefit is limited to once per tooth. Subsequent endodontic therapy is not billable to the
patient when performed by the same dentist/dental office.

2. The narrative should indicate the pre-operative diagnosis and treatment performed.

D3333 X-ray, 1 - 32
internal root repair of perforation defects Narrative

Non-surgical seal of perforation caused by resorption and/or decay but not iatrogenic by provider
filing claim.

1. Benefit is limited to once per tooth. Subsequent internal root repair of perforation defects is not
billable to the patient when performed by the same dentist/dental office. Special consideration
may be given by report.

2. The narrative should indicate the pre-operative diagnosis and treatment performed.

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Endodontic Retreatment D3340 - D3349

General Guidelines

1. This procedure includes the removal of a post, pin(s), old root canal filling material, and the procedures necessary
to prepare the canals and place the canal filling. Separate fees for these procedures are not billable to the
patient.

2. Multiple visits to complete the endodontic retreatment are considered a component of the primary procedure and
are not billable to the patient.

D3346 Narrative, 6 - 11,

retreatment of previous root canal therapy – anterior Pre-op X-ray, 22 - 27
Post-op X-ray
D3347 4, 5, 12, 13,
retreatment of previous root canal therapy – premolar 20, 21, 28, 29

D3348 1 - 3,
retreatment of previous root canal therapy – molar 14 - 19,
30 - 32

1. Retreatment of root canal therapy or retreatment of apical surgery by the same dentist/dental
office within 24 months is considered part of the original procedure. Benefits are denied when
performed by a different dentist within 24 months. Special consideration for exceptional
circumstances are reviewed on a per case basis.

2. When radiographs indicate obturation of an endodontically treated tooth has been performed
without the use of a solid core material, benefits for the endodontic therapy and/or restoration
of the tooth are not billable to the patient.

3. The narrative should indicate the pre-operative diagnosis and treatment performed.

Apexification/Recalcification and Pulpal Regeneration Procedures D3351-D3357

D3351 X-ray 1 - 32
apexification/recalcification – initial visit (apical
closure/calcific repair of perforations, root resorption, etc.)

Includes opening tooth, pulpectomy, preparation of canal spaces, first placement of medication
and necessary radiographs. (This procedure includes first phase of complete root canal therapy.)

1. Apexification is only benefited on permanent teeth with incomplete root development or for
repair of a perforation.

2. Benefit is limited to once per tooth. Subsequent visits are benefited as recalcification –
interim medication replacement (D3352).

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D3352 Post-op X-ray 1 - 32

apexification/recalcification – interim medication replacement

For visits in which the intra-canal medication is replaced with new medication. Includes any
necessary radiographs.

1. Apexification is only allowable on permanent teeth with incomplete root development or for
repair of a perforation.

2. A prior apexification/recalcification- initial visit (D3351) performed on the same tooth is

required.

D3353 Post-op X-ray 1 - 32

apexification/recalcification – final visit (includes completed
root canal therapy – apical closure/calcific repair of
perforations, root resorption, etc.)

Includes removal of intra-canal medication and procedures necessary to place final root canal
filling material including necessary radiographs. (This procedure includes last phase of complete
root canal therapy.)

1. Apexification is allowable only on permanent teeth with incomplete root development or for
repair of a perforation.

2. A prior apexification/recalcification- initial visit (D3351) performed on the same tooth is

required.

3. Benefit is limited to once per tooth. Subsequent submissions are not billable to the patient by
same dentist/dental office.

D3355 X-ray 1 - 32
pulpal regeneration – initial visit

Includes opening tooth, preparation of canal spaces, and placement of medication.

1. One diagnostic radiographic image is allowed per tooth. Additional radiographic images are
considered part of the pulpal regeneration treatment and are not billable to the patient.

2. Benefit is limited to once per tooth per lifetime. Subsequent submissions of this code are not
billable to the patient by the same dentist/dental office.

3. Pulpal regeneration is only a benefit on permanent teeth with incomplete development of

the root and an open apex (blunderbuss canal).

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D3356 Post-op X-ray 1 - 32

pulpal regeneration – interim medication replacement

1. Includes all necessary radiographic images. All radiographic images are considered part of the
initial pulpal regeneration procedure and are not billable to the patient.

2. Patient history of a previous pulpal regeneration – initial visit (D3355) performed on the same
tooth is required.

3. This procedure code is only submitted for visits in which the initial intra-canal medication is
replaced with new intra-canal medication.

D3357 Post-op X-ray 1 - 32

pulpal regeneration – completion of treatment

Does not include final restoration.

1. Benefit is limited to once per tooth per lifetime.

2. One post-operative radiographic image is allowed. Additional radiographic images are considered
part of the pulpal regeneration treatment and are not billable to the patient.

3. Patient history of a previous pulpal regeneration – initial visit (D3355) performed on the same
tooth is required.

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APICOECTOMY/PERIRADICULAR SERVICES D3410 - D3470

Periradicular surgery is a term used to describe surgery to the root surface (e.g., apicoectomy), repair of a root
perforation or resorptive defect, exploratory curettage to look for root fractures, removal of extruded filling materials or
instruments, removal of broken root fragments, sealing of accessory canals, etc. This does not include retrograde
filling material placement.

General Guidelines

1. Endodontic exploratory surgery is denied.

D3410 Pre-op X-ray, 6 - 11,
apicoectomy – anterior Post-op X-ray 22 - 27

For surgery on root of anterior tooth. Does not include placement of retrograde filling material.

1. The benefit for a biopsy of oral tissue is not billable to the patient as included in the fee for an
apicoectomy when performed in the same location and on the same date of service by the
same dentist/dental office.

2. Retreatment of an apicoectomy is not billable to the patient within 24 months of the initial
treatment by the same dentist/dental office.

D3421 Pre-op X-ray, 4, 5, 12, 13,

apicoectomy - premolar (first root) Post-op X-ray 20, 21, 28, 29

For surgery on one root of a premolar. Does not include placement of retrograde filling material. If
more than one root is treated, see D3426.

1. The benefit for a biopsy of oral tissue is not billable to the patient as included in the fee for an
apicoectomy when performed in the same location and on the same date of service by the
same dentist/dental office.

2. Retreatment of an apicoectomy is not billable to the patient within 24 months of the initial
treatment by the same dentist/dental office.

D3425 Pre-op X-ray, 1 - 3,

apicoectomy – molar (first root) Post-op X-ray 14 - 19,
30 - 32

For surgery on one root of a molar tooth. Does not include placement of retrograde filling material.
If more than one root is treated, see D3426.

1. The benefit for a biopsy of oral tissue is as included in the fee for an apicoectomy when
performed in the same location and on the same date of service by the same dentist/dental
office.

2. Retreatment of an apicoectomy is not within 24 months of the initial treatment by

the same dentist/dental office.

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D3426 Pre-op X-ray, 1 - 32

apicoectomy (each additional root) Post-op X-ray

Typically used for premolar and molar surgeries when more than one root is treated during the
same procedure. This does not include retrograde filling material placement.

1. The benefit for a biopsy of oral tissue is not billable to the patient as included in the fee for an
apicoectomy when performed in the same location and on the same date of service by the
same dentist/dental office.

2. Retreatment of an apicoectomy is not billable to the patient within 24 months of the initial
treatment by the same dentist/dental office.

D3430 Post-op X-ray 1 - 32

retrograde filling – per root

For placement of retrograde filling material during periradicular surgery procedures. If more than
one filling is placed in one root report as D3999 and describe.

1. Service is limited to once per 24 months.

2. Retrograde filling includes all retrograde procedures per root.

D3450 X-ray 1 - 5,
root amputation – per root 12 - 21,
28 – 32

Root resection of a multi-rooted tooth while leaving the crown. If the crown is sectioned, see
D3920.

D3471 Operative Report 6-11, 22-27

surgical repair of root resorption – anterior

For surgery on root of anterior tooth. Does not include placement of restoration.

1. The benefit is not billable to the patient when performed on the same tooth by the same
dentist/dental office on the same date as internal root repair of perforation defects D3333,
apicoectomy (D3410-D3426), retrograde filling (D3430) and root amputation (D3450).

2. The repair of iatrogenic perforations occurring during periodontal procedures: D4210 - D4212,
D4231, D4240, D4241, D4245, D4249, D4260, D4261, D4268, D4270, D4273 - D4278,
D4283, and D4285 are not billable to the patient.

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D3472 Operative Report 4-5,12-13,

surgical repair of root resorption – premolar 20-21, 28-29

For surgery on root of premolar tooth. Does not include placement of restoration.

1. The benefit is not billable to the patient when performed on the same tooth by the same
dentist/dental office on the same date as apicoectomy (D3410-D3426), retrograde filling
(D3430) and root amputation (D3450).

2. The repair of iatrogenic perforations occurring during periodontal procedures: D4210 - D4212,
D4231, D4240, D4241, D4245, D4249, D4260, D4261, D4268, D4270, D4273 - D4278,
D4283, and D4285.are not billable to the patient.

D3473 Operative Report 1-3, 14-16,

surgical repair of root resorption – molar 17-19, 30-32

For surgery on root of molar tooth. Does not include placement of restoration.

1. The benefit is not billable to the patient when performed on the same tooth by the same
dentist/dental office on the same date as apicoectomy (D3410-D3426), retrograde filling
(D3430) and root amputation (D3450).

2. Retreatment of periradicular surgery without apicoectomy is not billable to the patient within 24
months of the initial treatment by the same dentist/dental office.

D3501 Operative Report 6-11, 22-27

surgical exposure of root surface without apicoectomy or
repair of root resorption – anterior

Exposure of root surface followed by observation and surgical closure of

the exposed area. Not to be used for or in conjunction with apicoectomy or
repair of root resorption.

1. Fees for surgical exposure of root surface are not billable to the patient when performed
on the same tooth by the same dentist/dental office on the same date of service as
D3333, D3410 - D3426, D3430, D3450, D3471, D4210 - D4212, D4231, D4240, D4241,
D4245, D4249, D4260, D4261, D4268, D4270, D4273 - D4278, D4283, and D4285.

2. When performed on the same tooth by the same dentist/dental office as D4341 or D4342 the
fees for scaling and root planing are not billable to the patient.

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HDS PROCEDURE CODE GUIDELINES ENDODONTICS

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D3502 Operative Report 4-5,12-13,

surgical exposure of root surface without apicoectomy or 20-21, 28-29
repair of root resorption – premolar

Exposure of root surface followed by observation and surgical closure of

the exposed area. Not to be used for or in conjunction with apicoectomy or
repair of root resorption.

1. Fees for surgical exposure of root surface are not billable to the patient when performed
on the same tooth by the same dentist/dental office on the same date of service as
D3333, D3410 - D3426, D3430, D3450, D3471, D4210 - D4212, D4231, D4240, D4241,
D4245, D4249, D4260, D4261, D4268, D4270, D4273 - D4278, D4283, and D4285.

2. When performed on the same tooth by the same dentist/dental office as D4341 or D4342 the
fees for scaling and root planing are not billable to the patient.

D3503 Operative Report 1-3, 14-16,

surgical exposure of root surface without apicoectomy or 17-19, 30-32
repair of root resorption – molar

Exposure of root surface followed by observation and surgical closure of

the exposed area. Not to be used for or in conjunction with apicoectomy or
repair of root resorption.

1. Fees for surgical exposure of root surface are not billable to the patient when performed
on the same tooth by the same dentist/dental office on the same date of service as
D3333, D3410 - D3426, D3430, D3450, D3471, D4210 - D4212, D4231, D4240, D4241,
D4245, D4249, D4260, D4261, D4268, D4270, D4273 - D4278, D4283, and D4285.

2. When performed on the same tooth by the same dentist/dental office as D4341 or D4342 the
fees for scaling and root planing are not billable to the patient.

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HDS PROCEDURE CODE GUIDELINES ENDODONTICS

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

Other Endodontic Procedures D3920 - D3999

D3920 X-ray 1 - 3,
hemisection (including any root removal), not including root 14 -19,
canal therapy 30 -32

Includes separation of a multi-rooted tooth into separate sections containing the root and the
overlying portion of the crown. It may also include the removal of one or more of those sections.

1. No benefit is allowed for the replacement of the missing portion of existing tooth.

D3921 Operative Report 1 -32

decoronation or submergence of an erupted tooth

Intentional removal of coronal tooth structure for preservation of root and surrounding bone.

1. Sealing of the remaining root with glass ionomer, amalgam, composite is considered a
component of the primary D3921 procedure.

D3999 Narrative A - T,
unspecified endodontic procedure, by report 1 - 32

Used for procedure that is not adequately described by a code. Describe procedure.

1. Provide a complete description of services and treatment including tooth number.

2. Upon review the appropriate benefit allowance will be applied.

3. Narrative should include the pre-operative diagnosis, treatment performed,

restorative materials used, tooth number and surfaces, chair time and laboratory invoices
(when applicable).

4. When available, intraoral photographic images may be requested to support the claim
submission.

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 HDS PROCEDURE CODE GUIDELINES PERIODONTICS

PERIODONTICS D4000 - D4999

Local anesthesia is usually considered to be part of Periodontal procedures.

General Guidelines

1. Periodontal services are only benefited when performed on natural teeth for treatment of
periodontal disease. Unless otherwise specified by contract, benefits for these procedures when
billed in conjunction with implants, ridge augmentation, extraction sites and/or periradicular surgery
are denied and the approved amount is collectable from the patient.

2. Periodontal benefits are based on the following hierarchy:

When more than one surgical procedure involves the same teeth or area on the same date of
service, benefits will be based on the most inclusive procedure.

Certain procedures are interrelated by sequence and timing. Fees for the services involved in the
relationships listed below may not be billable to the patient in the absence of extraordinary
circumstances.

These inter-related services include, but are not limited to, the following hierarchy:
D4260 most inclusive
D4261
D4249
D4240
D4241
D4210
D4211
D4341
D4342
D4355
D4910
D1110
D1120

3. When two or more different 1-3 teeth services are performed in the same quadrant on the same
service date, payment of the 1-3 teeth procedures will be made, not to exceed the quadrant fee of
the highest hierarchy service performed.

4. A treatment plan with a poor and or uncertain periodontal, restorative or endodontic outcome may
be denied due to the unfavorable prognosis of the involved tooth/teeth. Special
consideration/exception may be made by submission of a narrative report.

5. Prophylaxis is not payable as a separate benefit when provided on the same date as periodontal
scaling and root planing, or periodontal maintenance.

6. The following categorizes procedures for reporting and adjudicating by quadrant, site or individual
tooth.

Quadrant: D4210, D4341: Four or more diseased teeth/periodontium distal to the midline are
considered a quadrant. Bounded tooth spaces are not counted in making this determination.
When these periodontal procedures do not meet all of these criteria use codes D4211 and
D4342 respectively.

D4240, D4260: Four or more diseased teeth/periodontium or bounded tooth spaces distal to the
midline are considered a quadrant. A bounded tooth space counts as one space irrespective of the
number of teeth that would normally exist in the space. When these procedures do not meet all of
these criteria, use codes D4241 and D4261 respectively.
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HDS PROCEDURE CODE GUIDELINES PERIODONTICS

Site: A term used to describe a single area, position, or locus. The word "site" is frequently used to indicate an area
of soft tissue recession on a single tooth or an osseous defect adjacent to a single tooth; also used to indicate soft
tissue defects and/or osseous defects in endentulous tooth positions.

- If two contiguous teeth have areas of soft tissue recession, each tooth is a single site.

- If two contiguous teeth have adjacent but separate osseous defects, each defect is a single site.

- If two contiguous teeth have a communicating interproximal osseous defect, it should be considered a single
site.

- All non-communicating osseous defects are single sites.

- All edentulous non-contiguous tooth positions are single sites.

- Up to two contiguous edentulous tooth positions may be considered a single site.

Tooth Bounded Space: space created by one or more missing teeth that has a tooth on each side.

7. Once the quadrant fee is paid within the service time limitation, subsequent episodes of the same procedure
will be denied.

8. Delta Dental Plans and HDS consider the use of a laser (e.g., laser disinfection, bacteria reduction,
debridement) or perioscopy in conjunction with periodontal services or dental prophylaxis (D1110) to be a
component of the primary procedure. Additional charges exceeding the Maximum Plan Allowance are
not billable to the patient.

9. When laser disinfection and or perioscopy is performed as a stand-alone procedure with no other
periodontal services or prophylaxis on that same date of service, submit charges as D4999 unspecified
periodontal procedure, by report. In this situation, HDS will DENY these fees and the patient is responsible
for the cost.

10. Gingival irrigation is considered part of any periodontal procedure when performed on the same day and is not
billable to the patient. When completed on the same day as periodontal scaling and root planing, gingival irrigation is
not billable to the patient.

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 HDS PROCEDURE CODE GUIDELINES PERIODONTICS

Surgical Services (Including Usual Post-Operative Care) D4210 - D4278

General Guidelines

1. Periodontal surgical procedures include all necessary postoperative care, finishing procedures,
evaluations (D9430, D9110, D0140) for three months. Surgical re-entry is not billable to the patient
when performed within three years. When a surgical procedure is billed in the same site within three
months of the initial procedure, a separate benefit for the surgery is not billable to the patient.

2. If periodontal surgery is performed in less than 30 days after scaling and root planing, the benefit for
scaling and root planing will be deducted from the surgery.

3. The benefits for biopsy (D7285, D7286), frenectomy (D7961, D7962), frenuloplasty (D7963) and
excision of hard and soft tissue lesions (D7410, D7411, D7450, D7451) are not billable to the patient
when the procedures are performed on the same date, same surgical site/area by the same
dentist/dental office as the codes D4210 – D4275.

4. Diseased teeth/periodontium: For payment and processing purposes periodontically involved teeth
that would qualify for surgical pocket reduction benefits under procedure codes D4210, D4211,
D4240, D4241, D4260 and D4261 must be documented to have at least 5 mm pocket depths. If
pocket depths are under 5 mm the surgical procedure is denied and the approved amount is
chargeable to the patient.

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 HDS PROCEDURE CODE GUIDELINES PERIODONTICS

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D4210 Perio Chart UR, UL

gingivectomy or gingivoplasty – four or more contiguous LR, LL
teeth or tooth bounded spaces per quadrant

D4211 Perio Chart 1 - 32

gingivectomy or gingivoplasty – one to three contiguous
teeth or tooth bounded spaces per quadrant

It is performed to eliminate suprabony pockets or to restore normal architecture when gingival

enlargements or asymmetrical or unaesthetic topography is evident with normal bony
configuration.

1. Procedure is a benefit once every three years.

2. Procedure is a benefit if the pocket depth is greater than or equal to 5mm.

3. For D4211, if more than one tooth; indicate additional teeth numbers in narrative.

4. A separate benefit for gingivectomy or gingivoplasty per tooth is not billable to the patient when
performed in conjunction with the preparation of a crown or other restoration by the same
dentist/dental office. A separate benefit for D4210/4211 will be denied if performed for
“cosmetic reasons”.

5. Bounded tooth spaces are not counted as the procedure does not require a flap extension.

D4212 Perio Chart, 1 - 32

gingivectomy or gingivoplasty to allow access for restorative X-ray
procedure, per tooth

1. A separate benefit for gingivectomy or gingivoplasty per tooth is not billable to the patient
when performed in conjunction with the preparation of a crown or other restoration by the
same dentist/dental office. Individual consideration may be allowed based on dental
consultant review.

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 HDS PROCEDURE CODE GUIDELINES PERIODONTICS

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D4240 Perio Chart UR, UL

gingival flap procedure, including root planing – four or more LR, LL
contiguous teeth or tooth bounded spaces per quadrant

D4241 Perio Chart 1 - 32

gingival flap procedure, including root planing – one to three
contiguous teeth or tooth bounded spaces per quadrant

A soft tissue flap is reflected or resected to allow debridement of the root surface and the removal
of granulation tissue. Osseous recontouring is not accomplished in conjunction with this
procedure. May include open flap curettage, reverse bevel flap surgery, modified Kirkland flap
procedure, and modified Widman surgery. This procedure is performed in the presence of
moderate to deep probing depths, loss of attachment, need to maintain esthetics, need for
increased access to the root surface and alveolar bone, or to determine the presence of a cracked
tooth, fractured root, or external root resorption. Other procedures may be required concurrent to
D4240 and should be reported separately using their own unique codes.

1. Procedure D4240 includes root planing (D4341/4342) and the benefit for root planing will be
not billable to the patient when performed in conjunction with D4240/4241.

2. Procedure is a benefit once every three years.

3. Procedure is a benefit if the pocket is greater than or equal to 5mm.

4. For D4241, if more than one tooth; indicate additional teeth numbers in narrative.

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 HDS PROCEDURE CODE GUIDELINES PERIODONTICS

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D4249 X-ray 1 - 32
clinical crown lengthening – hard tissue

This procedure is employed to allow a restorative procedure on a tooth with little or no tooth
structure exposed to the oral cavity. Crown lengthening requires reflection of a full thickness flap
and removal of bone, altering the crown to root ratio. It is performed in a healthy periodontal
environment, as opposed to osseous surgery, which is performed in the presence of periodontal
disease.

Definition: A surgical procedure exposing more tooth for restorative purposes by apically
positioning the gingival margin and removing supporting bone. (American College of
Prosthodontics; The Glossary of Prosthodontic Terms)

1. Crown lengthening is a benefit only when subgingival caries or fracture requires removal
of soft and hard tissue to enable restoration of the tooth or when less than 3 mm of tooth
structure remain between the restorative margin and alveolar crest. Crown lengthening
for cosmetic purposes or to correct congenital or developmental defects is denied.

2. This code should not be submitted when only gingival soft tissue has been removed via a
laser or electrosurgery.

3. Crown lengthening (D4249) is benefited only when bone is removed and sufficient time is
allowed for healing.

4. Benefits for crown lengthening are not billable to the patient when performed on the same day
as crown preparations or restorations.

5. A separate fee for crown lengthening is not billable to the patient when performed in
conjunction with osseous surgery on the same teeth.

6. The fee for multiple crown lengthening sites within a single quadrant will not exceed the
benefit for D4260.

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 HDS PROCEDURE CODE GUIDELINES PERIODONTICS

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D4260 Perio Chart UR, UL,

osseous surgery (including elevation of a full thickness flap LR, LL
and closure) – four or more contiguous teeth or tooth
bounded spaces per quadrant

D4261 Perio Chart 1 - 32

osseous surgery (including elevation of a full thickness flap
and closure) – one to three contiguous teeth or tooth
bounded spaces per quadrant

This procedure modifies the bony support of the teeth by reshaping the alveolar process to
achieve a more physiologic form during the surgical procedure. This must include the removal of
supporting bone (ostectomy) and/or non-supporting bone (osteoplasty). Other procedures may be
required concurrent to D4260, D4261 and should be reported using their own unique codes.

1. Osseous surgery is a benefit on the same tooth once every three years.
2. This procedure is a benefit if the pocket depth is greater than or equal to 5mm.
3. Usually only two full quadrants of osseous surgery are allowed on the same date of service.
Benefits in excess of two full osseous surgeries on the same date of service are denied unless
a narrative is supplied to explain exceptional circumstances.
4. If periodontal surgery is performed less than 30 days after scaling and root planing, the benefit
for the scaling and root planing will be deducted from the surgery.
5. For one to three teeth, when subsequent treatment of the same procedure is required within
the same quadrant, the total benefit is limited to the allowance of the quadrant fee.
6. This code should not be submitted for laser-assisted new attachment procedure (LANAP).
Refer to D4999.
7. The fee for osseous surgery includes:
 Osseous contouring
 Distal or proximal wedge surgery
 Scaling and root planing (D4341, D4342)
 Gingivectomy (D4210, D4211)
 Flap procedures (D4240, D4241)
 Frenectomy (Frenulectomy D7961, D7962), Frenuloplasty (D7963)
8. The following procedures may be benefited separately on the same day:
 Bone replacement graft (D4263, D4264)
 Soft tissue grafts (D4273, D4275, D4277, D4278)
 Guided tissue regeneration (D4266)
 Biologic materials with demonstrated efficacy in aiding periodontal tissue regeneration
(D4265)
 Exotosis removal (D7471)
 Hemisection (D3920)
 Extraction (D7140)
 Apicoectomy (D3410)
 Root amputation (D3450)
9. For D4261, if more than one tooth, indicate teeth numbers in narrative.
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 HDS PROCEDURE CODE GUIDELINES PERIODONTICS

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D4263 1 - 32
bone replacement graft –retained natural tooth- first site in
quadrant

This procedure involves the use of grafts to stimulate periodontal regeneration when the
disease process has led to a deformity of the bone. This procedure does not include flap
entry and closure, wound debridement, osseous contouring, or the placement of biologic
materials to aid in osseous tissue regeneration or barrier membranes. Other separate
procedures delivered concurrently are documented with their own codes. Not to be reported
for an edentulous space or an extraction site.

1. Benefits for bone grafting are available only when performed on retained natural teeth and
must be submitted with a gingival flap (D4240/D4241) or osseous surgery (D4260/D4261)
entry procedure.

2. Bone grafting is denied when billed in conjunction with implants, ridge augmentation,
periradicular surgery or extraction sites – refer to D7950, D7951 and D7953.

3. This procedure is a benefit if the pocket depth is greater than or equal to 5 mm.

4. Maximum benefit for bone replacement grafts is two sites per quadrant. Bone graft for
the second site in the same quadrant will be processed as D4264.
D4264 1 - 32
bone replacement graft – retained natural tooth-each
additional site in quadrant

This procedure involves the use of grafts to stimulate periodontal regeneration when the
disease process has led to a deformity of the bone. This procedure does not include flap
entry and closure, wound debridement, osseous contouring, or the placement of biologic
materials to aid in osseous tissue regeneration or barrier membranes. This procedure is
performed concurrently with one or more bone replacement grafts to document the number
of sites involved. Not to be reported for an edentulous space or an extraction site.

1. Benefits for bone grafting are available only when billed for natural teeth and performed for
periodontal purposes.

2. Bone grafting is denied as a specialized or elective technique when billed in conjunction

with implants, ridge augmentation, extraction sites, periradicular surgery, etc. – refer to
D7950, D7951 and D7953.

3. This procedure must be submitted with a gingival flap (D4240/D4241) or osseous surgery
(D4260/D4261) entry procedure.

4. This procedure is a benefit if the pocket depth is greater than or equal to 5 mm.

5. Maximum benefit for bone replacement grafts is two sites per quadrant. Bone graft for
the second site in the same quadrant will be processed as D4264.

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 HDS PROCEDURE CODE GUIDELINES PERIODONTICS

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D4265 1 - 32
biologic materials to aid in soft and osseous tissue
regeneration, per site

Biologic materials may be used alone or with other regenerative substrates such as bone and
barrier membranes, depending upon their formulation and the presentation of the periodontal
defect. This procedure does not include surgical entry and closure, wound debridement, osseous
contouring, or the placement of graft materials and /or barrier membranes. Other separate
procedures may be required concurrent to D4265 and should be reported using their own unique
codes.

1. Benefits are available once per site every three years when reported with periodontal flap
surgery (D4240, D4241, D4260, and D4261).

2. Benefits are available only when billed for natural teeth. Benefits are denied when billed in
conjunction with implants, ridge augmentation, extraction sites and periradicular surgery as a
specialized or elective technique.

3. When performed on the same day as D4263, D4264, D4266, D4267, D4273, D4275,
D4277, D4278, D4283, D4285 in the same surgical site, the benefit for D4265 is denied.

D4266 1 - 5,
guided tissue regeneration – resorbable barrier, per site 12 - 16,
17 - 21,
28 - 32

This procedure does not include flap entry and closure, or, when indicated, wound debridement,
osseous contouring, bone replacement grafts, and placement of biologic materials to aid in
osseous regeneration. This procedure can be used for periodontal and peri-implant defects.

1. Benefits for guided tissue regeneration are denied in conjunction with soft tissue grafts
(D4273, D4275, D4277, D4278, D4283 and D4285) in the same surgical area.

2. A bone graft is required in order to benefit the guided tissue regeneration.

3. Benefits are available only when billed for natural teeth. Benefits for these procedures when
billed in conjunction with implants, ridge augmentation, extraction sites, periradicular surgery,
etc. are denied as a specialized or elective technique.

4. Maximum benefit for guided tissue regeneration is two sites per quadrant. GTR for more
than two sites will be denied to the Maximum Plan Allowance.

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HDS PROCEDURE CODE GUIDELINES PERIODONTICS

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D4267 1 - 5,
guided tissue regeneration – nonresorbable barrier, per site 12 - 16,
(includes membrane removal) 17 - 21,
28 - 32

This procedure does not include flap entry and closure, or, when indicated, wound debridement,
osseous contouring, bone replacement grafts, and placement of biologic materials to aid in
osseous regeneration. This procedure can be used for periodontal and peri-implant defects.

1. For most plans, upon review of the documentation, the alternate benefit of a D4266 (guided
tissue regeneration) may be applied. Patients should be informed that they are responsible for
the cost difference if they elect to have this service. Refer to current group benefit information
for specific coverage.

2. A bone graft is required in order to benefit the guided tissue regeneration.

3. Benefits are available only when billed for natural teeth. Benefits for these procedures when
billed in conjunction with implants, ridge augmentation, extraction sites, periradicular surgery,
etc. are denied as a specialized or elective technique.

4. Benefits for guided tissue regeneration are denied in conjunction with soft tissue grafts
(D4273, D4275, D4277, D4278, D4283 and D4285) in the same surgical area.

5. Maximum benefit for guided tissue regeneration is two sites per quadrant. GTR for more than
two sites within a quadrant will be denied to the Maximum Plan Allowance.

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HDS PROCEDURE CODE GUIDELINES PERIODONTICS

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

Periodontal Grafts D4273 - D4278

General Guidelines

1. A periodontal graft is a benefit once every three years per tooth unless otherwise specified in the group
contract.

2. Benefits for guided tissue regeneration (D4266) are denied in conjunction with soft tissue grafts in the same
surgical area.

3. Benefits for frenectomy (frenulectomy D7962, D7963) or frenuloplasty (D7963) are not billable to the patient in
conjunction with soft tissue graft (D4273, D4275, D4277, D4278, D4283 and D4285) when performed in the
same surgical site.

4. Maximum benefit for periodontal graft procedures is two teeth per quadrant. Periodontal graft procedures
exceeding two teeth within a quadrant will be denied to the Maximum Plan Allowance.

5. This is a benefit only for natural teeth. Grafting of an edentulous site or any implant site is denied.

6. Periodontal grafts are not a benefit when performed for cosmetic purposes.

7. Narrative should specify the clinical diagnosis and the indications/reason for the graft procedure. Clinical
photos, if available are encouraged to enhance the supporting documentation.

D4273 Narrative 1 - 32
autogenous connective tissue graft procedure (including
donor and recipient surgical sites) first tooth, implant, or
edentulous tooth position in graft

There are two surgical sites. The recipient site utilizes a split thickness incision, retaining the
overlapping flap of gingiva and/or mucosa. The connective tissue is dissected from a separate
donor site leaving an epithelialized flap for closure.

D4283 Narrative 1 - 32
autogenous connective tissue graft procedure (including
donor and recipient surgical sites) – each additional
contiguous tooth, implant, or edentulous tooth position in
same graft site
Used in conjunction with D4273.

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HDS PROCEDURE CODE GUIDELINES PERIODONTICS

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D4275 Narrative 1 - 32
non-autogenous connective tissue graft (including recipient
site and donor material) first tooth, implant, or edentulous
tooth position in graft

There is only a recipient surgical site utilizing split thickness incision, retaining the overlaying flap of
gingiva and/or mucosa. A donor surgical site is not present.

D4285 Narrative 1 - 32
non-autogenous connective tissue graft procedure (including
recipient surgical site and donor material) – each additional
contiguous tooth, implant, or edentulous tooth position in
same graft site

Used in conjunction with D4275.

D4277 Narrative 1 - 32
free soft tissue graft procedure (including recipient and
donor surgical sites) first tooth, implant, or edentulous tooth
position in graft

D4278 Narrative 1 - 32
free soft tissue graft procedure (including recipient and
donor surgical sites) each additional contiguous tooth,
implant or edentulous tooth position in same graft site

Used in conjunction with D4277.

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Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

Non-Surgical Periodontal Service D4341 - D4355

D4341 Perio Chart UR, UL,

periodontal scaling and root planing – four or more teeth per LR, LL
quadrant

D4342 Perio Chart 1-32

periodontal scaling and root planing – one to three teeth per
quadrant

This procedure involves instrumentation of the crown and root surfaces of the teeth to remove
plaque and calculus from these surfaces. It is indicated for patients with periodontal disease
and is therapeutic, not prophylactic, in nature. Root planing is the definitive procedure
designed for the removal of cementum and dentin that is rough, and/or permeated by calculus
or contaminated with toxins or microorganisms. Some soft tissue removal occurs. This
procedure may be used as a definitive treatment in some stages of periodontal disease and/or
as a part of pre-surgical procedures in others.

1. Periodontal scaling and root planing per quadrant are covered benefits once every 2 years.

2. Scaling and root planing (D4341, D4342) is considered an integral component of the
osseous surgery (D4260, D4261) and is not billable to the patient when submitted on the
same date of service and performed on the same teeth.

3. Scaling and root planing is a benefit when the clinical attachment loss is greater than or
equal to 4 mm. When there is no evident alveolar bone loss or attachment loss, D4341 or
D4342 is denied.

4. If periodontal surgery is performed less than 30 days after scaling and root planing, the
benefit for the scaling and root planing will be deducted from the surgery.

5. Prophylaxis (D1110) is not billable to the patient if performed on the same day as D4341 or
D4342.

6. When 3 or 4 quadrants of periodontal scaling and root planing are completed on the same
day, the following is required for claim submission:

a. X-ray image(s) of the treated teeth to verify alveolar bone loss and attachment loss.
b. Periodontal charting to include pocket depth (PD) and gingival margin (GM)
measurements of the treated teeth to identify clinical attachment loss (CAL).
c. Periodontal diagnosis.

When documentation does not support alveolar bone loss or attachment loss, D4341 or
D4342 is denied.

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HDS PROCEDURE CODE GUIDELINES PERIODONTICS

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

7. For D4342, if more than one tooth, indicate teeth numbers in narrative.
8. Delta Dental Plans and HDS consider the use of a laser (e.g. laser disinfection, bacteria
reduction, debridement) in conjunction with periodontal services or dental prophylaxis
(D1110) to be a component of the primary procedure. Additional charges exceeding the
Maximum Plan Allowance are not billable to the patient.

9. Gingival irrigation is considered part of any periodontal procedure when performed on the same
day and is not billable to the patient. When completed on the same day as periodontal scaling
and root planing, gingival irrigation is not billable to the patient.

D4346
scaling in presence of generalized moderate or severe
gingival inflammation – full mouth, after oral evaluation

The removal of plaque, calculus, and stains from supra- and sub-gingival tooth surfaces when there is
generalized moderate or severe gingival inflammation in the absence of periodontitis. It is indicated for
patients who have swollen, inflamed gingiva, generalized suprabony pockets, and moderate to severe
bleeding on probing. Should not be reported in conjunction with prophylaxis, scaling and root planing,
or debridement procedures.

1. This procedure is applied to the patient’s annual prophylaxis benefit and benefited at the
preventive co-pay percentage.

2. Benefits for D4346 include prophylaxis fees for D1110, D1120, D4341, D4342, D4355 or
D4910 and are not billable to the patient when submitted by the same dentist/dental office
on the same day.

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HDS PROCEDURE CODE GUIDELINES PERIODONTICS

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D4355
full mouth debridement to enable a comprehensive oral
evaluation and diagnosis on a subsequent visit

Full mouth debridement involves the preliminary removal of plaque and calculus that interferes with
the ability of the dentist to perform a comprehensive oral evaluation. Not to be completed on the same
day as D0150, D0160, or D0180.

1. A D4355 is a benefit when the dentist is unable to accomplish an accurate comprehensive

evaluation (D0150) and periodontal probing/screening due to heavy plaque, calculus etc.

2. A D4355 is not billable to the patient when performed by the same dentist/dental office on the
same day as D0150, D0160, or D0180.

3. This procedure is allowed as a benefit under the following circumstances:

 The patient has not had a prophylaxis or debridement for at least 24 months.

 The patient must be 14 years or older.

 The patient has not had periodontal treatment for at least 36 months.

4. This procedure is applied to the prophylaxis benefit and benefited at the preventive co-pay
percentage.

5. When benefit criteria are not met, this procedure is limited to and processed as a
prophylaxis (D1110).

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HDS PROCEDURE CODE GUIDELINES PERIODONTICS

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

Other Periodontal Services D4910 - D4999

D4910
periodontal maintenance

This procedure is instituted following periodontal therapy and continues at varying intervals,
determined by the clinical evaluation of the dentist, for the life of the dentition or any implant
replacements. It includes removal of the bacterial plaque and calculus from supragingival
and subgingival regions, site specific scaling and root planing where indicated, and polishing
the teeth. If new or recurring periodontal disease appears, additional diagnostic and
treatment procedures must be considered.

1. D4910 benefits are available to members who are currently in a periodontal maintenance
program or who have a history of periodontal treatment (D4210, D4211, D4240, D4241,
D4260, D4261, D4341, and D4342). Contract may specify different limits or submission
requirements for specific medical conditions.

2. D4910 is a benefit twice per calendar year following active periodontal treatment for the
next 18 months.

3. An extension of this benefit may be considered for continuing periodontal disease. A

current periodontal chart (recorded within 6 months of the date of service) must be
submitted with the D4910.

 The periodontal chart should document the patient's on-going periodontal status.

 Benefits for D4910 are denied when the documentation submitted does not indicate
active periodontal disease.

 Current patient periodontal maintenance limits can be viewed on HDSOnline and the
DenTel faxback.

4. Benefits for D4910 include prophylaxis and scaling and root planing procedures.

D4920
unscheduled dressing change (by someone other than
treating dentist or their staff)

1. Unscheduled dressing changes by the treating dentist are not billable to the patient.

2. This benefit is limited to once per dentist/dental office per patient and subsequent
treatment is not billable to the patient when performed by same dentist/dental office.

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Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D4999 Narrative 1 - 32,

unspecified periodontal procedure, by report LL, LR,
UL, UR,
UA, LA

Use for this procedure that is not adequately described by a code. Describe procedure.

1. Provide complete description of services/treatment to allow determination of appropriate

benefit allowance.

2. Indicate tooth number as needed.

3. Narrative should include the clinical diagnosis, restorative materials used, tooth number and
surfaces, chair time, laboratory invoices, intraoral photographic images when available, X-ray
images when appropriate or additional supporting information.

4. Delta Dental Plans and HDS consider the use of a laser (e.g., laser disinfection, bacteria
reduction, debridement) in conjunction with periodontal services or dental prophylaxis
(D1110) to be a component of the primary procedure. Additional charges exceeding the
Maximum Plan Allowance are not billable to the patient.

5. When submitting for laser-assisted new attachment procedure (LANAP):

 Maintain an appropriate Patient Consent Form on file documenting that the

LANAP procedure was explained to the patient and alternatives to the LANAP
procedure were also explained.

 Inform the patient of the cost difference if they elect LANAP and that they will be
responsible for the difference between the HDS payment and the submitted fee
for LANAP.
 Submit CDT procedure code D4999 for each quadrant or tooth (when only 1 to 3
teeth involved).
 Indicate LANAP in the narrative along with the quadrant or tooth number.
 Submit a copy of the patient’s periodontal chart.

 HDS will process the submission as an alternate benefit of a gingival flap

procedure, D4240/D4241 if the pocket depth is greater than or equal to 5mm.

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HDS PROCEDURE CODE GUIDELINES PROSTHODONTICS
(REMOVABLE)

PROSTHODONTICS (REMOVABLE) D5000 - D5899

General Guidelines

1. A treatment plan with a poor and or uncertain prosthodontic, periodontal, restorative, or endodontic
outcome may be denied due to the unfavorable prognosis of the involved tooth/teeth. Special
consideration/exception may be made by submission of a narrative report.

2. HDS provides for replacement of missing teeth with complete or partial dentures. Treatment involving
specialized techniques, precious metals for removable appliances, precision attachments for partial
dentures or fixed partial dentures, implants, and related procedures along with any associated
appliances are not covered and any additional fee is the patient’s responsibility.

3. Restorations and associated services are not a benefit for overdentures and benefits are denied.

4. The replacement of replaceable part of semi-precision or precision attachment, per attachment (D5867)
or semi-precision attachments (D5862, D5867) for partial dentures are not a benefit and are denied.

5. Fixed partial dentures, resin based partial dentures and removable cast partials are not a benefit for
patients under age 16.

6. The fabrication, repair, adjustment, reline/rebase of an extra (“spare”) denture/partial are not benefits
and are denied.

7. Replacement of Removable Prosthodontic appliances, one per edentulous space, may be benefited
for appliances older than 5 years unless specified under group contract. This includes complete
dentures, immediate dentures, partial dentures, or fixed partial dentures.

8. The fees for prosthetic procedures include services such as, but not limited to, tooth preparation,
impressions, all models, guide planes, diagnostic wax-up, laboratory fees, occlusal adjustment within 6
months after the insertion and other associated procedures. These services are not billable to the
patient when performed in conjunction with the Removable Prosthodontic procedure.

9. Complete or partial dentures, except in the case of immediate dentures, include any reline/rebase,
adjustment or repair required within 6 months of insertion date; reline/rebase is denied if performed
after 6 months and prior to two years following insertion date. Thereafter, reline/rebase is allowed once
every two years.

10. In the case of immediate dentures, reline is allowed any time following the insertion and thereafter once
every two years. The rebase allowance includes the allowance for reline and a separate charge cannot
be made to the patient.

11. Indicate the insertion date of the prosthesis when submitting for payment. For patients whose coverage
has terminated, also include the preparation date in the narrative.

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HDS PROCEDURE CODE GUIDELINES PROSTHODONTICS
(REMOVABLE)

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

Complete Dentures (Including Routine Post-Delivery Care) D5110 – D5140

D5110
complete denture – maxillary

D5120
complete denture – mandibular

1. Includes any reline/rebase, adjustment or repair required within six months of insertion
date by the same dentist/dental office, except in the case of immediate dentures.

D5130
immediate denture – maxillary

D5140
immediate denture – mandibular

1. Includes limited follow-up care only; does not include future rebasing / relining procedure(s).

Partial Dentures (Including Routine Post-Delivery Care) D5211 - D5283

General Guidelines

1. A posterior fixed partial denture and removable partial denture are not a benefit in the same arch in the
same treatment plan. An anterior fixed partial denture with no more than 4 pontics is allowed in
the same arch with a posterior removable partial denture.

2. Indicate missing teeth in tooth chart.

D5211 Tooth Chart

maxillary partial denture – resin base (including,
retentive/clasping materials, rests, and teeth)

D5212
mandibular partial denture – resin base (including,
retentive/clasping materials, rests, and teeth)

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HDS PROCEDURE CODE GUIDELINES PROSTHODONTICS
(REMOVABLE)

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D5213 Tooth Chart

maxillary partial denture – cast metal framework with
resin denture bases (including retentive/clasping
materials, rests and teeth)

D5214
mandibular partial denture – cast metal framework with
resin denture bases (including retentive/clasping
materials, rests and teeth)

D5225
maxillary partial denture – flexible base (including
retentive/clasping materials, rests, and teeth)

D5226
mandibular partial denture – flexible base (including
retentive/clasping materials, rests, and teeth)

D5221 Tooth Chart

immediate maxillary partial denture – resin base
(including retentive/clasping materials, rests and teeth)

D5222
immediate mandibular partial denture – resin base
(including retentive/clasping materials, rests and teeth)

D5223
immediate maxillary partial denture – cast metal framework
with resin denture bases (including retentive/clasping
materials, rests and teeth)

D5224
immediate mandibular partial denture – cast metal
framework with resin denture bases (including
retentive/clasping materials, rests and teeth)

D5227
immediate maxillary partial denture – flexible base (including
any clasps, rests and teeth)

D5228
immediate mandibular partial denture – flexible base
(including any clasps, rests and teeth)

1. Includes limited follow-up care only; does not include future rebasing / relining
procedure(s).

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HDS PROCEDURE CODE GUIDELINES PROSTHODONTICS
(REMOVABLE)

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D5282 Tooth Chart UR, UL,

removable unilateral partial denture – one piece cast metal 1-16
(including retentive/clasping materials, rests and teeth),
maxillary

D5283 Tooth Chart LR, LL

removable unilateral partial denture – one piece cast metal 17-32
(including retentive/clasping materials, rests, and teeth),
mandibular

D5284 Tooth Chart UR, UL, LR, LL,

removable unilateral partial denture - one piece flexible
base (including retentive/clasping materials, rests, and
teeth)- per quadrant

D5286 Tooth Chart UR, UL, LR, LL,

removable unilateral partial denture - one piece resin
(including retentive/clasping materials, rests, and teeth)
- per quadrant

General Guidelines

1. The benefit for complete dentures includes any adjustments or repairs required within 6 months of insertion
date, except in the case of immediate dentures. The adjustment or repair of dentures is not billable to the
patient when performed by the same dentist/ dental office or denied when performed by different dentist
within six months of initial placement.

D5410
adjust complete denture – maxillary

D5411
adjust complete denture – mandibular

D5421
adjust partial denture – maxillary

D5422
adjust partial denture – mandibular

1. Adjustments to complete or partial dentures are limited to once every six months (after
six months have elapsed since initial placement).

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HDS PROCEDURE CODE GUIDELINES PROSTHODONTICS
(REMOVABLE)

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

Repairs to Complete Dentures D5511 - D5520

General Guidelines

1. The benefit for complete dentures includes any adjustments or repairs required within 6 months of insertion
date, except in the case of immediate dentures. The adjustment or repair of dentures is not billable to the
patient when performed by the same dentist/ dental office or denied when performed by different dentist
within six months of initial placement.

D5511
repair broken complete denture base, mandibular

D5512
repair broken complete denture base, maxillary

1. Benefit allowance for this service is limited to once every 6 months.

D5520 1 - 32
replace missing or broken teeth - complete denture (each
tooth)

1. Benefit allowance for this service is limited to once every 6 months.

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HDS PROCEDURE CODE GUIDELINES PROSTHODONTICS
(REMOVABLE)

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

Repairs to Partial Dentures D5611 - D5671

General Guidelines

1. Benefit allowance for this service is limited to once every 6 months. The repair of dentures is not billable to
the patient if performed by the same dentist/dental office or denied when performed by a different dentist
within 6 months of initial insertion date.

2. The HDS benefit for combined repairs, rebase and reline will not exceed the allowable benefit of a
removable prosthesis.

3. The benefit for partial dentures includes any adjustments or repairs required within six months of insertion
date, except in the case of immediate dentures. If performed by the same dentist/dental office within 6
months of initial placement, fees for the adjustments or repairs are not billable to the patient.

D5611
repair resin partial denture base, mandibular

D5612
repair resin partial denture base, maxillary

D5621
repair cast partial framework, mandibular

D5622
repair cast partial framework, maxillary

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HDS PROCEDURE CODE GUIDELINES PROSTHODONTICS
(REMOVABLE)

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D5630 1 - 32
repair or replace broken clasp – per tooth

D5640
replace broken teeth – per tooth

D5650
add tooth to existing partial denture

D5660
add clasp to existing partial denture – per tooth

D5670 Tooth Chart

replace all teeth and acrylic on cast metal framework
(maxillary)

D5671
replace all teeth and acrylic on cast metal framework
(mandibular)

1. Benefit is allowed once per partial denture.

2. Benefit is allowed two years following date of partial denture insertion.

3. The allowance for this benefit includes reline and rebase and a separate charge cannot
be made to the patient.

4. These procedures only apply to partials with four or more teeth. For situations involving
fewer than four teeth, the per tooth repair codes (D5640/D5650) should be used.

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HDS PROCEDURE CODE GUIDELINES PROSTHODONTICS
(REMOVABLE)

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

Denture Rebase Procedures D5710 - D5721

Rebase - process of refitting a denture by replacing the base material.

General Guidelines

1. The benefit for the rebase includes the fee for relining. The benefit for a reline procedure performed in
conjunction with (within 6 months of) a rebase by the same dentist/dental office is not billable to the patient.

2. Complete or partial dentures, except in the case of immediate dentures, include any reline/rebase,
adjustment or repair required within 6 months of insertion date; reline/rebase is denied if performed after 6
months and prior to two years following insertion date. Thereafter, reline/rebase is a benefit once every two
years.

3. If a new denture is placed within 24 months of a rebase, HDS payment for the rebase will be deducted from
the allowance for the new denture.

D5710
rebase complete maxillary denture

D5711
rebase complete mandibular denture

D5720
rebase maxillary partial denture

D5721
rebase mandibular partial denture

D5725
rebase hybrid prosthesis

Replacing the base material connected to the framework.

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HDS PROCEDURE CODE GUIDELINES PROSTHODONTICS
(REMOVABLE)

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

Denture Reline Procedures D5730 - D5761

Reline is the process of resurfacing the tissue side of a denture with new base material.

General Guidelines

1. Complete or partial dentures, except in the case of immediate dentures, include any reline/rebase,
adjustment or repair required within 6 months of insertion date; reline/rebase is denied if performed after 6
months and prior to two years following insertion date. Thereafter, reline/rebase is a benefit once every two
years.

2. In the case of immediate dentures, reline is allowed any time following the insertion and thereafter once
every two years.

D5730
reline complete maxillary denture (chairside)

D5731
reline complete mandibular denture (chairside)

D5740
reline maxillary partial denture (chairside)

D5741
reline mandibular partial denture (chairside)

1. If a new denture is placed within 6 months of a chairside reline, the reline will be
deducted.

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HDS PROCEDURE CODE GUIDELINES PROSTHODONTICS
(REMOVABLE)

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D5750
reline complete maxillary denture (laboratory)

D5751
reline complete mandibular denture (laboratory)

D5760
reline maxillary partial denture (laboratory)

D5761
reline mandibular partial denture (laboratory)

1. If a new denture is placed within 12 months of a laboratory reline, the reline will
be deducted.

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

Interim Prosthesis D5810 - D5821

A prosthesis designed for use over a limited period of time, after which it is to be replaced by a definitive
restoration.

D5820 Narrative 5 - 12
interim partial denture (including retentive/clasping materials,
rests, and teeth), maxillary

D5821 Narrative 22 - 27
interim partial denture (including retentive/clasping materials,
rests, and teeth), mandibular

1. Patients are allowed one interim partial denture to replace an extracted or lost permanent
tooth if provided within 21 days of the extraction or when the tooth was lost.

2. Interim partial denture is denied and chargeable to the patient if submitted for other than
replacement of a recently extracted or lost tooth within 21 days.

3. Indicate recently extracted tooth number and date of extraction. Benefit of D5820 is
available for anterior and 1st premolar teeth. Benefit of D5821 is available only for
anterior teeth.

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HDS PROCEDURE CODE GUIDELINES PROSTHODONTICS
(REMOVABLE)

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

Other Removable Prosthetic Services D5765, D5850 - D5899

D5765
soft liner for complete or partial removable denture –
indirect
A discrete procedure provided when the dentist determines placement of the soft liner is clinically
indicated.

1. If a new denture is placed within 12 months of a laboratory reline, the reline will
be deducted.

D5850
tissue conditioning, maxillary

D5851
tissue conditioning, mandibular

Treatment reline using materials designed to heal unhealthy ridges prior to more definitive
final restoration.

1. A maximum of two tissue conditioning treatments per denture is allowed prior to

impressions for reline, rebase or denture prostheses. The patient is responsible for the
cost of additional treatments.

2. Tissue conditioning is a benefit if done prior to insertion, but not on the same day as
insertion.

D5863
overdenture – complete maxillary

D5864 Tooth Chart

overdenture – partial maxillary

D5865
overdenture – complete mandibular

D5866 Tooth Chart

overdenture – partial mandibular

1. Restorations and associated services are not a benefit for overdentures and benefits are
denied.

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HDS PROCEDURE CODE GUIDELINES PROSTHODONTICS
(REMOVABLE)

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D5899 Narrative,
unspecified removable prosthodontic procedure, Lab Invoice
by report

Use for a procedure that is not adequately described by a code. Describe procedure.

1. Documentation should include materials used, tooth number, arch, quadrant, or area of
the mouth, chair time, laboratory invoices, X-ray images or any other supporting
information.

2. Restorations and associated services are not a benefit for overdentures and benefits are
denied.

3. Upon review of documentation, the appropriate benefit allowance will be applied.

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HDS PROCEDURE CODE GUIDELINES MAXILLOFACIAL PROSTHETICS

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

Maxillofacial Prosthetics D5900 - D5999

D5999 Narrative,
unspecified maxillofacial prosthesis, Lab Invoice
by report

Used for a procedure that is not adequately described by a code. Describe procedure.

1. Narrative should include the restorative materials used, tooth number, arch, quadrant, or
area of the mouth, chair time. Laboratory invoices, intraoral photographic images when
available, X-ray images or additional supporting information may be requested.

2. Upon review of documentation, the appropriate benefit allowance will be applied.

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HDS PROCEDURE CODE GUIDELINES IMPLANT SERVICES

IMPLANT SERVICES D6000 - D6199

Implant services are not benefits of all HDS plans. Some plans may have contracted to provide different
benefits / limitations. Please refer to the current Group Benefits or Patient Eligibility Verification (available on
HDS Online or DenTel) for specific group coverage.

General Guidelines

1. Implant fees and benefits are defined by the group contract.

2. A treatment plan with a poor and or uncertain implant outcome may be denied due to the unfavorable
prognosis of the involved tooth/teeth. Special consideration/exception may be made by submission of a
narrative report.

3. Implants are denied when a treatment plan for a fixed partial denture includes retainers on natural teeth and
implants.

4. The following are non-covered procedures and require the agreement of the patient to assume cost:

 Treatment involving specialized techniques

 Locators for implants
 Precision attachments for crowns, fixed/removable partial dentures or implants (related
procedures along with any associated appliances)

5. Separate charges are not allowed for preparation, models, temporary restorations, impressions, laboratory
fees, laser technology, local anesthesia, occlusal adjustments within six months after the insertion, and
other associated procedures as these services are components of a complete procedure for which a single
charge is made. If submitted as a separate charge(s) the fees for these procedures, unless otherwise
specified are not billable to the patient.

6. Oral Surgery benefits do not apply to Implant surgical services.

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HDS PROCEDURE CODE GUIDELINES IMPLANT SERVICES

Surgical Services D6010, D6013, D6101 - D6102

An implant body and mini implant are not covered by all HDS plans. Please refer to current group benefit
information for specific coverage. Three options for implant benefits are available to HDS groups:

 “Implant-Limited” allows an alternate benefit only if replacing one missing permanent tooth between two
natural teeth in lieu of a 3-unit fixed partial denture.
 “Implant-Alternate Benefit” allows an alternate benefit for all clinically acceptable treatment plans.
 “Implant” allows a benefit for all clinically acceptable treatment plans. The dentist is held to the
Maximum Plan Allowance.

A comparison of the three plans is provided on pages 4 and 5 of Implant Services.

General Guidelines

1. The time limitation for the replacement of a surgical placement of implant body: endosteal implant (D6010)
or surgical placement of mini implant (D6013) follows the same replacement time limitation for
Prosthodontics (Fixed) restorations as specified in the group contract.

2. Implants and implant/abutment supported prosthetics are denied for patients under age 19 or as specified
in the group contract.

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D6010 X-ray 2 - 15
surgical placement of implant body: endosteal implant 18 - 31

D6013
surgical placement of mini implant

Implant-Limited Implant-Alternate Benefit Implant

Alternate benefit available only if replacing one Alternate benefit available for Benefit is available for all clinically
missing permanent tooth between two natural all clinically acceptable acceptable treatment plans. The
teeth. treatment plans. dentist is held to the Maximum Plan
Allowance.
Adjacent teeth are subject to time limitations for Time limitations apply only for Time limitations apply only for tooth
existing crowns, removable prosthodontics, inlays, tooth replaced with an implant. replaced with an implant. The
onlays and veneers. (Rationale: By contract, dentist is held to the Maximum Plan
implant is paid as an alternate benefit equivalent to Allowance.
the payment for two retainers of a 3-unit fixed
partial denture. Appropriate treatment limitations
and processing policies are applied.)

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HDS PROCEDURE CODE GUIDELINES IMPLANT SERVICES

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D6100 Operative Report

surgical removal of implant body

1. Surgical removal of implant body is not a benefit unless it is a group contract specific
benefit.

2. Surgical removal of implant body is denied when performed after 3 months of

D6010/D6013 on the same tooth.

D6101 Narrative 2 - 15
debridement of a peri-implant defect or defects 18 - 31
surrounding a single implant, and surface
cleaning of the exposed implant surfaces,
including flap entry and closure

1. This procedure is denied when implants are not a benefit of the plan.

2. Narrative should include the clinical diagnosis.

3. D6101 is not billable to the patient when performed in the same surgical site by the same
dentist/dental office on the same day as D6102.

Implant-Limited and Implant-Alternate

Implant
Benefit
1. Denied. 1. Benefit is subject to the review of the narrative.

D6102 Narrative 2 - 15
debridement and osseous contouring of a peri- 18 - 31
implant defect or defects surrounding a single
implant, and surface cleaning of the exposed
implant surfaces, including flap entry and
closure

1. This procedure is denied when implants are not a benefit of the plan.

2. Narrative should include the clinical diagnosis.

3. This procedure is not billable to the patient when billed separately in conjunction with D4260 or
D4261 or D6101.

Implant-Limited and Implant-Alternate

Implant
Benefit
1. Denied. 1. Benefit is subject to the review of the narrative.

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 HDS PROCEDURE CODE GUIDELINES IMPLANT SERVICES

Implant Supported Prosthetics D6055 - D6077, D6094, D6110 - 6117, D6194

General Guidelines
1. Implant supported prosthetic benefits are determined by the employer group implant contract.
2. Implants and implant/abutment supported prosthetics are denied for patients under age 19 or as specified in the group contract.

3. The submitted X-ray image must show the implant body. When submitting for preauthorization, attach the most current X-ray image for tentative approval.
The X-ray image demonstrating the implant body is required when submitting for payment on a previously approved preauthorization.
4. An implant treatment plan with a poor and or uncertain outcome may be denied due to the unfavorable prognosis of the involved tooth/teeth.
5. A fixed partial denture between an implant tooth and a natural tooth is denied.
Clinical Scenario Implant-Limited Implant-Alternate Benefit Implant
Anterior Teeth: Replacing 1 to 4 Benefited as the alternate benefit up to
missing teeth with an implant 4 pontics in the anterior segment, only
supported prosthesis. when there are teeth present
anterior and posterior to the
implants.
Posterior Teeth: Replacing 1 to 3 Benefited as the alternate benefit up to Benefited as the alternate benefit of Benefited procedure. Subject to the
missing teeth with an implant 3 pontics in the posterior segment, the appropriate pontic procedure current group benefit and time
supported prosthesis. only when there are teeth present code(s). Subject to the current group limitations of previous prosthodontic/
anterior and posterior to the benefit and time limitations of restorative services performed. The
implants. previous prosthodontic /restorative dentist is held to the Maximum Plan
services performed. Allowance.
Anterior fixed partial denture spanning Processed as the alternate benefit of a
more than 4 pontics or posterior fixed removable partial denture. Special
partial denture spanning more than 3 consideration/exception may be made
pontics by submission of a narrative report.

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HDS PROCEDURE CODE GUIDELINES IMPLANT SERVICES

When a distal extension edentulous space is involved, the appropriate benefit will be applied as follows:

Clinical Scenario Implant-Limited Implant-Alternate Benefit Implant

If the implant crown is for one tooth, The alternate benefit of one pontic will be applied. This
and it is adjacent to a natural tooth benefit is allowed twice per arch (once on the left side and
once on the right side) within a 5-year period unless Benefited procedure.
specified by group contract. Benefited as the alternate Subject to the current
benefit of the appropriate group benefit and time
If adjacent implant crowns are for The alternate benefit of a removable partial denture will be pontic procedure code(s). limitations of previous
more than one tooth applied. This benefit is allowed once per arch per 5-year Subject to the current group prosthodontic/restorative
period (unless specified by group contract) on the left or benefit and time limitations services performed. The
right side. If an implant crown is placed on the opposite of previous prosthodontic/ dentist is held to the
side within the time limitation, the combined benefit (of the restorative services Maximum Plan
implant crowns on both sides) will not exceed the benefit performed. Allowance.
of two pontics.

Revised: 01/01/2022
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HDS PROCEDURE CODE GUIDELINES IMPLANT SERVICES

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

Supporting Structures D6056 - D6057

D6056 X-ray 2-15, 18-31

prefabricated abutment – includes modification and
placement

Modification of a prefabricated abutment may be necessary.

Implant-Limited and Implant-Alternate Benefit Implant

1. Denied. 1. The X-ray image must show the implant body.

D6057 X-ray 2-15, 18-31

custom fabricated abutment – includes placement

Created by a laboratory process, specific for an individual application.

Implant-Limited and Implant-Alternate Benefit Implant

1. Denied. 1. The X-ray image must show the implant body.

Implant/Abutment Supported Removable Dentures D6110 - D6113

D6110 X-ray
Implant/abutment supported removable
denture for edentulous arch – maxillary

D6111
Implant/abutment supported removable
denture for edentulous arch – mandibular

1. For most plans, upon review, the alternate benefit of D5110/D5120 will be applied. Patients should be
informed that they are responsible for the cost difference. Refer to current group benefit information for
specific coverage for implant services.

2. The X-ray image must show the implant body.

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HDS PROCEDURE CODE GUIDELINES IMPLANT SERVICES

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D6112 X-ray
Implant/abutment supported removable
denture for partially edentulous arch –
maxillary

D6113
Implant/abutment supported removable
denture for partially edentulous arch –
mandibular

1. For most plans, upon review, the alternate benefit of D5213/D5214 will be applied. Patients should be
informed that they are responsible for the cost difference. Refer to current group benefit information
for specific coverage for implant services.

2. The X-ray image must show the implant body.

Implant/Abutment Supported Fixed Dentures (Hybrid Prosthesis) D6114 - D6117

D6114 X-ray
Implant/abutment supported fixed denture
for edentulous arch – maxillary

D6115
Implant/abutment supported fixed denture
for edentulous arch – mandibular

1. For most plans, upon review, the alternate benefit of D5110/D5120 will be applied. Patients should be
informed that they are responsible for the cost difference. Refer to current group benefit information
for specific coverage for implant services.

2. The X-ray image must show the implant body.

D6116 X-ray
Implant/abutment supported fixed denture
for partially edentulous arch – maxillary

D6117
Implant/abutment supported fixed denture
for partially edentulous arch – mandibular

1. For most plans, upon review, the alternate benefit of 5213/D5214 will be applied. Patients should be
informed that they are responsible for the cost difference. Refer to current group benefit information
for specific coverage for implant services.

2. The X-ray image must show the implant body.

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HDS PROCEDURE CODE GUIDELINES IMPLANT SERVICES

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

Single Crowns, Abutment Supported D6058 - D6064, D6094

D6058 X-ray 2-15, 18-31

abutment supported porcelain/ceramic crown

A single crown restoration that is retained, supported and stabilized by an abutment on an implant.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit of D6210, 1. The X-ray image must show the implant body.
D6240, will be applied.

2. The X-ray image must show the implant body.

D6059 X-ray 2-15, 18-31

abutment supported porcelain fused to metal
crown (high noble metal)

A single metal-ceramic crown restoration that is retained, supported and stabilized by an abutment
on an implant.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit of D6210, 1. The X-ray image must show the implant body.
D6240, will be applied.

2. The X-ray image must show the implant body.

D6060 X-ray 2-15, 18-31

abutment supported porcelain fused to metal
crown (predominantly base metal)

A single metal-ceramic crown restoration that is retained, supported and stabilized by an abutment
on an implant.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit of D6211, 1. The X-ray image must show the implant body.
D6241 will be applied.

2. The X-ray image must show the implant body.

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HDS PROCEDURE CODE GUIDELINES IMPLANT SERVICES

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D6061 X-ray 2-15, 18-31

abutment supported porcelain fused
to metal crown (noble metal)

A single metal-ceramic crown restoration that is retained, supported and stabilized by an abutment
on an implant.

Implant-Limited and Implant-Alternate

Implant
Benefit
1. Upon review, the alternate benefit 1. The X-ray image must show the implant body.
D6212/D6242 will be applied.

2. The X-ray image must show the implant

body.

D6097 X-ray 2-15, 18-31

abutment supported crown -
porcelain fused to titanium and
titanium alloys

A single metal-ceramic crown restoration that is retained, supported, and stabilized by an abutment
on an implant.

Implant-Limited and Implant-Alternate

Implant
Benefit
1. Upon review, the alternate benefit 1. The X-ray image must show the implant body.
D6210/D6240 will be applied.

2. The X-ray image must show the implant

body.

D6062 X-ray 2-15, 18-31

abutment supported cast metal crown
(high noble metal)

A single metal-ceramic crown restoration that is retained, supported and stabilized by an abutment
on an implant.

Implant-Limited and Implant-Alternate

Implant
Benefit
1. Upon review, the alternate benefit D6210 1. The X-ray image must show the implant body.
will be applied.

2. The X-ray image must show the implant

body.
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HDS PROCEDURE CODE GUIDELINES IMPLANT SERVICES

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D6063 X-ray 2-15, 18-31

abutment supported cast metal crown
(predominantly base metal)

A single cast metal crown restoration that is retained, supported and stabilized by an abutment on
an implant.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit D6211 will be 1. The X-ray image must show the implant body.
applied.

2. The X-ray image must show the implant body.

D6064 X-ray 2-15, 18-31

abutment supported cast metal crown
(noble metal)

A single cast metal crown restoration that is retained, supported and stabilized by an
abutment on an implant.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit D6212 will be 1. The X-ray image must show the implant body.
applied.

2. The X-ray image must show the implant body.

D6094 X-ray 2-15, 18-31

Abutment supported crown-titanium and
titanium alloys

A single cast metal crown restoration that is retained, supported and stabilized by an
abutment on an implant.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit of D6210 will be 2. The X-ray image must show the implant body.
applied.

2. The X-ray image must show the implant body.

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HDS PROCEDURE CODE GUIDELINES IMPLANT SERVICES

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

Single Crowns, Implant Supported D6065 - D6067

D6065 X-ray 2-15, 18-31

implant supported porcelain/ceramic
crown

A single crown restoration that is retained, supported and stabilized by an implant.

1. This procedure code should not be submitted to report an abutment supported implant crown; refer to
D6058, D6059, D6060, D6061, D6062, D6063, D6064 and D6094.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit D6210/D6240 1. The X-ray image must show the implant body.
will be applied.

2. The X-ray image must show the implant body.

D6066 X-ray 2-15, 18-31

implant supported crown - porcelain
fused to high noble alloys

A single crown restoration that is retained, supported and stabilized by an implant.

1. This procedure code should not be submitted to report an abutment supported implant crown; refer to
D6058, D6059, D6060, D6061, D6062, D6063, D6064 and D6094.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit of D6210, 1. The X-ray image must show the implant body.
D6240 may be applied.

2. The X-ray image must show the implant body.

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HDS PROCEDURE CODE GUIDELINES IMPLANT SERVICES

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D6082 X-ray 2-15, 18-31

implant supported crown - porcelain fused
to predominantly base alloys

A single metal-ceramic crown restoration that is retained, supported and stabilized by an

implant.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit of D6211 will be 1. The X-ray image must show the implant body.
applied.

2. The X-ray image must show the implant body.

2.
D6083 X-ray 2-15, 18-31
implant supported crown - porcelain fused
to noble alloys

A single metal-ceramic crown restoration that is retained, supported and stabilized by an

implant.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit of D6210 will be 3. The X-ray image must show the implant body.
applied.

2. The X-ray image must show the implant body.

4.
D6084 X-ray 2-15, 18-31
implant supported crown - porcelain fused
to titanium and titanium alloys

A single metal-ceramic crown restoration that is retained, supported and stabilized by an

implant.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit of D6210 will be 5. The X-ray image must show the implant body.
applied.

2. The X-ray image must show the implant body.

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HDS PROCEDURE CODE GUIDELINES IMPLANT SERVICES

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D6067 X-ray 2-15, 18-31

implant supported crown - high noble
alloys

A single metal-ceramic crown restoration that is retained, supported and stabilized by an implant.

1. This procedure code should not be submitted to report an abutment supported implant crown; refer to
D6058, D6059, D6060, D6061, D6062, D6063, D6064 and D6120.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit D6210 will be 1. The X-ray image must show the implant body.
applied.

2. The X-ray image must show the implant body.

D6086 X-ray 2-15, 18-31

implant supported crown - predominantly
base alloys

A single metal crown restoration that is retained, supported and stabilized by an implant.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit D6211 will be 1. The X-ray image must show the implant body.
applied.

2. The X-ray image must show the implant body.

D6087 X-ray 2-15, 18-31

implant supported crown - noble alloys

A single metal crown restoration that is retained, supported and stabilized by an implant.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit D6210 will be 1. The X-ray image must show the implant body.
applied.

2. The X-ray image must show the implant body.

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HDS PROCEDURE CODE GUIDELINES IMPLANT SERVICES

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D6088 X-ray 2-15, 18-31

implant supported crown - titanium and
titanium alloys

A single metal crown restoration that is retained, supported and stabilized by an implant.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit D6210 will be 1. The X-ray image must show the implant body.
applied.
2. The X-ray image must show the implant body.

Fixed Partial Denture Retainer, Abutment Supported D6068 - D6194

D6068 X-ray 2-15, 18-31

abutment supported retainer for porcelain/
ceramic FPD

A ceramic retainer for a fixed partial denture that gains retention, support and stability from an
abutment on an implant.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit D6210/D6240 1. The X-ray image must show the implant body.
will be applied.

2. The X-ray image must show the implant body.

D6069 X-ray 2-15, 18-31

abutment supported retainer for porcelain
fused to metal FPD (high noble metal)

A metal-ceramic retainer for a fixed partial denture that gains retention, support and stability
from an abutment on an implant.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit D6210/D6240 will 1. The X-ray image must show the implant body.
be applied.

2. The X-ray image must show the implant body.

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HDS PROCEDURE CODE GUIDELINES IMPLANT SERVICES

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D6070 X-ray 2-15, 18-31

abutment supported retainer for porcelain
fused to metal FPD (predominantly base
metal)

A metal-ceramic retainer for a fixed partial denture that gains retention, support and stability
from an abutment on an implant.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit of D6211/D6241 will 1. The X-ray image must show the implant body.
be applied.

2. The X-ray image must show the implant body.

D6071 X-ray 2-15, 18-31

abutment supported retainer for porcelain
fused to metal FPD (noble metal)

A metal-ceramic retainer for a fixed partial denture that gains retention, support and stability
from an abutment on an implant.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit of D6212/D6242 1. The X-ray image must show the implant body.
will be applied.

2. The X-ray image must show the implant body.

D6195 X-ray 2-15, 18-31

abutment supported retainer - porcelain
fused to titanium and titanium alloys

A metal-ceramic retainer for a fixed partial denture that gains retention, support, and stability
from an abutment on an implant.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit of D6212/D6242 1. The X-ray image must show the implant body.
will be applied.

2. The X-ray image must show the implant body.

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HDS PROCEDURE CODE GUIDELINES IMPLANT SERVICES

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D6072 X-ray 2-15, 18-31

abutment supported retainer for cast
metal FPD (high noble metal)

A cast metal retainer for a fixed partial denture that gains retention, support and stability from an
abutment on an implant.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit of D6210 will be 1. The X-ray image must show the implant body.
applied.

2. The X-ray image must show the implant body.

D6073 X-ray 2-15, 18-31

abutment supported retainer for cast
metal FPD (predominantly base metal)

A cast metal retainer for a fixed partial denture that gains retention, support and stability from an
abutment on an implant.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit of D6211 will be 1. The X-ray image must show the implant body.
applied.

2. The X-ray image must show the implant body.

D6074 X-ray 2-15, 18-31

abutment supported retainer for cast metal
FPD (noble metal)

A cast metal retainer for a fixed partial denture that gains retention, support and stability from an
abutment on an implant.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit of D6212 will be 1. The X-ray image must show the implant body.
applied.

2. The X-ray image must show the implant body.

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HDS PROCEDURE CODE GUIDELINES IMPLANT SERVICES

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D6194 X-ray 2-15, 18-31

abutment supported retainer crown for
FPD – titanium and titanium alloys

A retainer for a fixed partial denture that gains retention, support and stability from an abutment on
an implant.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit of D6210 will be 1. The X-ray image must show the implant body.
applied.

2. The X-ray image must show the implant body.

Fixed Partial Denture Retainer, Implant Supported D6075 - D6077

D6075 X-ray 2-15, 18-31

implant supported retainer for ceramic FPD

A ceramic retainer for a fixed partial denture that gains retention, support and stability from an
implant.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit of D6210/D6240 1. The X-ray image must show the implant body.
will be applied.

2. The X-ray image must show the implant body.

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HDS PROCEDURE CODE GUIDELINES IMPLANT SERVICES

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D6076 X-ray 2-15, 18-31

implant supported retainer for FPD -
porcelain fused to high noble alloys

A metal-ceramic retainer for a fixed partial denture that gains retention, support and stability
from an implant.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit of D6210/D6240 1. The X-ray image must show the implant body.
will be applied.

2. The X-ray image must show the implant body.

D6098 X-ray 2-15, 18-31

implant supported retainer - porcelain
fused to predominantly base alloys

A metal-ceramic retainer for a fixed partial denture that gains retention, support, and stability
from an implant.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit of D6211, D6241 1. The X-ray image must show the implant body.
will be applied.

2. The X-ray image must show the implant body.

D6099 X-ray 2-15, 18-31

implant supported retainer for FPD -
porcelain fused to noble alloys

A metal-ceramic retainer for a fixed partial denture that gains retention, support, and stability
from an implant.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit of D6210/D6240 1. The X-ray image must show the implant body.
will be applied.

2. The X-ray image must show the implant body.

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HDS PROCEDURE CODE GUIDELINES IMPLANT SERVICES

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D6120 X-ray 2-15, 18-31

implant supported retainer – porcelain
fused to titanium and titanium alloys

A metal-ceramic retainer for a fixed partial denture that gains retention, support, and stability
from an implant.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit of D6210/D6240 1. The X-ray image must show the implant body.
will be applied.

2. The X-ray image must show the implant body.

D6077 X-ray 2-15, 18-31

implant supported retainer for cast metal
FPD - high noble alloys

A metal retainer for a fixed partial denture that gains retention, support and stability from an
implant.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit of D6210 will be 1. The X-ray image must show the implant body.
applied.

2. The X-ray image must show the implant body.

D6121 X-ray 2-15, 18-31

implant supported retainer for metal FPD –
predominantly base alloys

A metal retainer for a fixed partial denture that gains retention, support, and stability from an
implant.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit of D6211 will be 1. The X-ray image must show the implant body.
applied.

2. The X-ray image must show the implant body.

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HDS PROCEDURE CODE GUIDELINES IMPLANT SERVICES

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D6122 X-ray 2-15, 18-31

implant supported retainer for metal FPD –
noble alloys

A metal retainer for a fixed partial denture that gains retention, support, and stability from an
implant.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit of D6210 will be 1. The X-ray image must show the implant body.
applied.

2. The X-ray image must show the implant body.

D6123 X-ray 2-15, 18-31

implant supported retainer for metal FPD –
titanium and titanium alloys

A metal retainer for a fixed partial denture that gains retention, support, and stability from an
implant.

Implant-Limited and Implant-Alternate Benefit Implant

1. Upon review, the alternate benefit of D6210 will be 1. The X-ray image must show the implant body.
applied.

2. The X-ray image must show the implant body.

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HDS PROCEDURE CODE GUIDELINES IMPLANT SERVICES

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

Other Implant Services D6080 - D6095

D6080 2-15, 18-31

implant maintenance procedures when
prostheses are removed and reinserted,
including cleansing of prostheses and
abutments

This procedure includes active debriding of the implant(s) and examination of all aspects of the
implant system(s), including the occlusion and stability of the superstructure. The patient is also
instructed in thorough daily cleansing of the implant(s). This is not a per implant code and is
indicated for implant supported fixed prostheses.

Implant-Limited and Implant-Alternate Benefit Implant

1. Denied. 1. Patient history of an implant performed on the
same tooth is required.
2. This benefit is allowed once every 3 years.

D6081 Narrative 2-15, 18-31

scaling and debridement in the presence of inflammation or
mucositis of a single implant, including cleaning of the
implant surfaces, without flap entry and closure

This procedure is not performed in conjunction with D1110, D4910, or D4346.

1. Narrative should include the clinical diagnosis.

2. Benefit is allowed once per tooth per 24 months. Retreatment by the same dentist/dental office within 24 months is
considered part of the original procedure and is not billable to the patient.

3. D6081 is not billable to the patient when performed in the same surgical site by the same dentist/dental office on
the same day as D4341/D4342 or D4240/D4241, D4260/D4261 or D6101/ D6102.

4. D6081 is not billable to the patient when performed in conjunction with D1110, D4346 or D4910.

5. D6081 is not billable to the patient when performed within 12 months of restoration placement (D6058-D6077,
D6120 and D6194) on the same tooth by the same dentist/dental office.

Implant-Limited and Implant-Alternate Benefit Implant

1. Denied. 1. The X-ray image must show the implant body.

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Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D6090 Narrative, 2-15, 18-31

repair implant supported prosthesis, by Lab Invoice
report

This procedure involves the repair or replacement of any part of the implant supported
prosthesis.

1. Narrative should include the clinical diagnosis, restorative materials used, tooth number and surfaces, chair time,
laboratory invoices, intraoral photographic images when available, X-ray images when appropriate or any other
supporting information.

2. Upon review of documentation, the appropriate benefit allowance will be applied.

Implant-Limited and Implant-Alternate Benefit Implant

1. Denied. 1. Upon review of documentation, the appropriate
benefit allowance will be applied.

D6092 2-15, 18-31

re-cement or re-bond implant/abutment
supported crown

D6093
re-cement or re-bond implant/abutment
supported fixed partial denture

1. Benefit for recementation within 6 months of the initial placement is not billable to the patient if performed by
the same dentist or dental office.

2. Recementation by a different dentist (within 6 months of initial placement) is a benefit once.

3. Benefits are allowed for one recementation after 6 months have elapsed since initial placement.
Subsequent requests for recementation are allowed every 12 months thereafter.

D6095 Narrative, 2-15, 18-31

repair implant abutment, by report Lab Invoice

This procedure involves the repair or replacement of any part of the implant abutment.

1. Narrative should include the clinical diagnosis, restorative materials used, tooth number and surfaces, chair time,
laboratory invoices, intraoral photographic images when available, X-ray images when appropriate or any other
supporting information.

Implant-Limited and Implant-Alternate Benefit Implant

1. Denied. 1. Upon review of documentation, the appropriate
benefit allowance will be applied.

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Code & Nomenclature Submission Requirements Surface

D6096 2-15, 18-31

remove broken implant retaining screw

1. The code is submitted to report the removal of a broken implant retaining screw.

2. This code should not be submitted to report the tightening of an intact implant retaining screw.

Implant-Limited and Implant-Alternate Benefit Implant

1. Denied. 1. Benefit is limited to once every 12 months beginning
6 months after the initial placement.

D6199 Narrative 2-15, 18-31

Unspecified implant procedure, by report

Used for procedure that is not adequately described by a code. Describe procedure.

1. Narrative should include the clinical diagnosis, restorative materials used, tooth number and surfaces, chair time.
Laboratory invoices and intraoral photographic images when available, X-ray images when appropriate or additional
supporting information may be requested.

2. Upon review of documentation, the appropriate benefit allowance will be applied.

Implant-Limited and Implant-Alternate Benefit Implant

1. Denied. 1. Upon review of documentation, the appropriate
benefit allowance will be applied.

2. Benefit is limited to once every 12 months beginning

6 months after the initial placement.

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HDS PROCEDURE CODE GUIDELINES PROSTHODONTICS (FIXED)

PROSTHODONICS, FIXED D6200 - D6999

Each retainer and each pontic constitutes a unit in a fixed partial denture.

Local anesthesia is usually considered to be part of Fixed Prosthodontic procedures.

The term “fixed partial denture” or FPD is synonymous with fixed bridge or bridgework.

Fixed partial denture prosthetic procedures include routine temporary prosthetics. When indicated, interim or
provisional codes should be reported separately.

General Guidelines

1. The fee for a restoration includes services such as, but not limited to:

 crown removal  laboratory fees

 tooth preparation  laser technology
 diagnostic wax-up  occlusal adjustment within 6 months after the restoration
 electro surgery  post-operative visits within 6 months after the restoration
 temporary restorations  local anesthesia
 liners and cement bases  crown lengthening and gingivectomy on the same date of
 impressions service

These procedures are not billable to the patient when submitted as a separate charge.

2. The following are not covered benefits and require the agreement of the patient to assume the
cost:

 Treatment involving specialized techniques

 Precision attachment (D5862, D6950) for crowns, fixed/removable partial dentures or
implants (related procedures along with any associated appliances)
 Additional abutments needed because of congenital or unusual conditions
 Additional pontics needed to restore a space beyond the normal complement of natural
teeth
 Restorations performed for the following reasons (see “Definitions” listed on page 9 of the
Restorative section):
 Altering occlusion, involving vertical dimension
 Replacing tooth structure lost by attrition, erosion, abrasion, abfraction, occlusal
wear or for periodontal, orthodontic or other splinting

3. A treatment plan with a poor and or uncertain periodontal, restorative or endodontic outcome may be
denied due to the unfavorable prognosis of the involved tooth/teeth. Special consideration/exception
may be made by submission of a narrative report.

4. Cantilever fixed partial dentures are limited to only one pontic. Additional pontics are denied.

5. When a fixed partial denture (bridge) is planned for replacement and the X-ray images and other
submitted attachments do not indicate decay, fracture and/or the tooth being otherwise compromised,
the provider should provide a narrative to state the clinical reason(s) for replacement.

6. A posterior fixed partial denture and removable partial denture are not a benefit in the same arch in
the same treatment plan. An anterior fixed partial denture with not more than 4 pontics is allowed in
the same arch with a posterior removable partial denture.

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HDS PROCEDURE CODE GUIDELINES PROSTHODONTICS (FIXED)

7. Replacement of prosthodontic fixed restorations due to defective marginal integrity, recurrent decay
and fracture of tooth structure may be a benefit when older than 5 years or as specified under
group contract.

8. If any unit or tooth within a new fixed partial denture has had a prior fixed (indirect) restoration still
subject to the time limitations, that unit of the fixed partial denture will be denied and the patient is
responsible for the cost.

9. Fixed partial dentures and removable cast partials are not benefits for patients under age 16.

10. For most plans, porcelain/ceramic, porcelain-fused to metal, and resin-based composite crowns
placed on molar teeth will be processed as the alternate benefit of the metallic equivalent crown.
Patients should be informed that they are responsible for the cost difference if they elect to have a
porcelain/ceramic, porcelain-fused to metal or resin-based composite processed to metal type
crown on a molar tooth. Refer to current group benefit information for specific coverage for crowns.

11. Porcelain/ceramic/resin retainers and pontics will be processed as the conventional fixed
prosthetics with the patient responsible for the difference to the submitted amount.

12. Always indicate the insertion date of the appliance when submitting for payment. For patients
whose coverage has terminated, also indicate the date of preparation.

13. Use a separate line on the claim for each tooth involved in the fixed partial denture and indicate a
separate fee for each tooth.

14. Anterior fixed partial dentures spanning more than 4 pontics or posterior fixed partial dentures
spanning more than 3 pontics will be processed as the alternate benefit of a removable partial
denture.

15. When rebonding or recementing a Maryland Bridge, submit procedure code D6930.

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HDS PROCEDURE CODE GUIDELINES PROSTHODONTICS (FIXED)

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Code & Nomenclature Submission Requirements Surface

Fixed Partial Denture Pontics D6205 - D6253

D6205 X-ray 1 - 32
pontic – indirect resin based composite
1. For most plans, porcelain/ceramic, porcelain-fused to metal, and resin-based composite
crowns placed on molar teeth will be processed as the alternate benefit of the metallic
equivalent crown. Patients should be informed that they are responsible for the cost
difference if they elect to have a porcelain/ceramic, porcelain-fused to metal or resin-
based composite processed to metal type crown on a molar tooth. Refer to current group
benefit information for specific coverage for crowns.

D6210 X-ray 1 - 32
pontic – cast high noble metal

D6211
pontic – cast predominantly base metal

D6212
pontic – cast noble metal
D6214 X-ray 1 - 32
pontic - titanium and titanium alloys

1. The alternate benefit of D6210 will be applied. Patients should be informed that they are
responsible for the cost difference if they elect to have this service. Refer to current
group benefit information for specific coverage for crowns.
D6240 X-ray 4 - 13
pontic – porcelain fused to high noble metal 20 - 29

D6241
pontic – porcelain fused to predominantly base metal

D6242
pontic – porcelain fused to noble metal

D6243
pontic - porcelain fused to titanium and titanium alloys

1. See additional guidelines for D6240, D6241, D6242 and D6243 alternate benefits
shaded in gray.

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Code & Nomenclature Submission Requirements Surface

D6240 X-ray 1 -3, 14 -16,

pontic – porcelain fused to high noble metal 17-19, 30-32

D6241
pontic – porcelain fused to predominantly base metal

D6242
pontic – porcelain fused to noble metal

D6243
pontic – porcelain fused to titanium and titanium alloys

1. For most plans, porcelain/ceramic, porcelain-fused to metal, and resin-based composite

crowns placed on molar teeth will be processed as the alternate benefit of the metallic
equivalent crown. Patients should be informed that they are responsible for the cost
difference if they elect to have a porcelain/ceramic, porcelain-fused to metal or resin-
based composite processed to metal type crown on a molar tooth. Refer to current group
benefit information for specific coverage for crowns.

D6245 X-ray 1 - 32
pontic– porcelain/ceramic

1. For most plans, upon review- the alternate benefit D6240/D6210 will be applied.
Patients should be informed that they are responsible for the cost difference if they elect
this service. Refer to current group benefit information for specific coverage for crowns.

D6250 X-ray 4 - 13,

pontic – resin with high noble metal 20 - 29

D6251
pontic – resin with predominantly base metal

D6252
pontic – resin with noble metal
1. See additional guidelines for D6250, D6251 and D6252 alternate benefits shaded in
gray.

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Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D6250 X-ray 1 -3, 14 -16,

pontic – resin with high noble metal 17-19, 30-32

D6251
pontic – resin with predominantly base metal

D6252
pontic – resin with noble metal
1. For most plans, porcelain/ceramic, porcelain-fused to metal, and resin-based composite
crowns placed on molar teeth will be processed as the alternate benefit of the metallic
equivalent crown. Patients should be informed that they are responsible for the cost
difference if they elect to have a porcelain/ceramic, porcelain-fused to metal or resin-
based composite processed to metal type crown on a molar tooth. Refer to current group
benefit information for specific coverage for crowns.

D6253 X-ray, Narrative 1 - 32

Interim pontic – further treatment or completion of
diagnosis necessary prior to final impression

Not to be used as a temporary pontic for routine prosthetic fixed partial dentures.

1. Covered as a benefit only in the event of an injury/trauma. Narrative must detail the cause and
nature of the injury/trauma.

2. D6253 when used as a temporary, interim or provisional fixed prostheses for routine
prosthetic fixed partial denture, is not billable to the patient.

3.Temporary, interim or provisional fixed prostheses are not separate benefits and are
considered an integral component of the permanent prosthesis. As such, is not billable to
the patient.

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HDS PROCEDURE CODE GUIDELINES PROSTHODONTICS (FIXED)

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

Fixed Partial Denture Retainers – Inlays/Onlays D6545 - D6634

D6545 X-ray 1 - 32
retainer – cast metal for resin bonded fixed prosthesis

1. Limited to two retainers, one on each side of space.

D6548 X-ray 1 - 32
retainer – porcelain/
ceramic for resin bonded fixed prosthesis
D6549
resin retainer – for resin bonded fixed prosthesis

1. Generally used for Maryland Bridge retainer.

2. For most plans, upon review- the alternate benefit D6545 will be applied. Patients should
be informed that they are responsible for the cost difference if they elect to have this
service. Refer to current group benefit information for specific coverage for crowns.

D6600 X-ray 1 - 32
retainer inlay – porcelain/ Any surfaces
ceramic, two surfaces

D6601
retainer inlay – porcelain/
ceramic, three or more surfaces

1. For most plans, upon review- the alternate benefit D6602 (2 surface) or D6603 (3
surface) will be applied. Patients should be informed that they are responsible for the
cost difference if they elect to have this service. Refer to current group benefit
information for specific coverage for crowns.

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Code & Nomenclature Submission Requirements Surface

D6602 X-ray 1 - 32
retainer inlay – cast high noble metal, two surfaces Any surfaces

D6603
retainer inlay – cast high noble metal, three or more surfaces

D6604
retainer inlay – cast predominantly base metal, two surfaces

D6605
retainer inlay – cast predominantly base metal, three or more
surfaces

D6606
retainer inlay – cast noble metal, two surfaces

D6607
retainer inlay – cast noble metal, three or more surfaces
D6608 X-ray 1 - 32
retainer onlay – porcelain/ceramic, two surfaces Any surfaces
D6609
retainer onlay – porcelain/ceramic, three or more
surfaces
1. For most plans, upon review- the alternate benefit D6610 (2 surface) or D6611 (3
surface) will be applied. Patients should be informed that they are responsible for the
cost difference if they elect to have this service. Refer to current group benefit
information for specific coverage for crowns.

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Code & Nomenclature Submission Requirements Surface

D6610 X-ray 1 - 32
retainer onlay – cast high noble metal, two surfaces Any surfaces

D6611
retainer onlay – cast high noble metal, three or more
surfaces

D6612
retainer onlay – cast predominantly base metal, two
surfaces

D6613
retainer onlay – cast predominantly base metal, three or
more surfaces

D6614
retainer onlay – cast noble metal, two surfaces

D6615
retainer onlay – cast noble metal, three or more surfaces

D6624 X-ray 1 - 32
retainer inlay – titanium
1. For most plans, upon review the alternate benefit D6602/D6603 will be applied.
Patients should be informed that they are responsible for the cost difference if they elect
this service. Refer to current group benefit information for specific coverage for crowns.

D6634 X-ray 1 - 32
retainer onlay – titanium
1. For most plans, upon review- the alternate benefit D6610/D6611 will be applied.
Patients should be informed that they are responsible for the cost difference if they elect
this service. Refer to current group benefit information for specific coverage for crowns.

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Code & Nomenclature Submission Requirements Surface

Fixed Partial Denture Retainers – Crowns D6710 - D6793

D6710 X-ray 1 - 32
retainer crown – indirect resin based composite

1. For most plans, upon review- the alternate benefit D6721/D6791 will be applied.
Patients should be informed that they are responsible for the cost difference if they elect
to have this service. Refer to current group benefit information for specific coverage for
crowns.

D6720 X-ray 4 - 13,

retainer crown – resin with high noble metal 20 - 29

D6721
retainer crown – resin with predominantly base metal

D6722
retainer crown – resin with noble metal
1. See additional guidelines for D6720, D6721 and D6722 alternate benefits shaded in
gray.

D6720 X-ray 1 -3, 14 -16,

retainer crown – resin with high noble metal 17-19, 30-32

D6721
retainer crown – resin with predominantly base metal

D6722
retainer crown – resin with noble metal
1. For most plans, porcelain/ceramic, porcelain-fused to metal, and resin-based composite
crowns placed on molar teeth will be processed as the alternate benefit of the metallic
equivalent crown. Patients should be informed that they are responsible for the cost
difference if they elect to have a porcelain/ceramic, porcelain-fused to metal or resin-
based composite processed to metal type crown on a molar tooth. Refer to current group
benefit information for specific coverage for crowns.

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Code & Nomenclature Submission Requirements Surface

D6740 X-ray 1 - 32
retainer crown – porcelain/ceramic

1. For most plans, upon review- the alternate benefit D6750/D6790 will be applied.
Patients should be informed that they are responsible for the cost difference if they elect
to have a ceramic crown, porcelain-fused to metal, resin-based processed to metal type
crown done on a posterior tooth. Refer to current group benefit information for specific
coverage for crowns.

D6750 X-ray 4 - 13,

retainer crown – porcelain fused to high noble metal 20 - 29

1. See additional guidelines for D6750 alternate benefits shaded in gray.

D6750 X-ray 1 -3, 14 -16,
retainer crown – porcelain fused to high noble metal 17-19, 30-32

1. For most plans, porcelain/ceramic, porcelain-fused to metal, and resin-based composite

crowns placed on molar teeth will be processed as the alternate benefit of the metallic
equivalent crown. Patients should be informed that they are responsible for the cost
difference if they elect to have a porcelain/ceramic, porcelain-fused to metal or resin-
based composite processed to metal type crown on a molar tooth. Refer to current group
benefit information for specific coverage for crowns.

D6751 X-ray 4 - 13,

retainer crown – porcelain fused to predominantly base metal 20 – 29

1. See additional guidelines for D6751 alternate benefits shaded in gray.

D6751 X-ray 1 -3, 14 -16,

retainer crown – porcelain fused to predominantly base metal 17-19, 30-32

1. For most plans, porcelain/ceramic, porcelain-fused to metal, and resin-based composite

crowns placed on molar teeth will be processed as the alternate benefit of the metallic
equivalent crown. Patients should be informed that they are responsible for the cost
difference if they elect to have a porcelain/ceramic, porcelain-fused to metal or resin-
based composite processed to metal type crown on a molar tooth. Refer to current
group benefit information for specific coverage for crowns.

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Code & Nomenclature Submission Requirements Surface

D6752 X-ray 4 - 13,

retainer crown – porcelain fused to noble metal 20 - 29

1. See additional guidelines for D6752 alternate benefits shaded in gray.

D6752 X-ray 1 -3, 14 -16,

retainer crown – porcelain fused to noble metal 17-19, 30-32

1. For most plans, porcelain/ceramic, porcelain-fused to metal, and resin-based composite

crowns placed on molar teeth will be processed as the alternate benefit of the metallic
equivalent crown. Patients should be informed that they are responsible for the cost
difference if they elect to have a porcelain/ceramic, porcelain-fused to metal or resin-
based composite processed to metal type crown on a molar tooth. Refer to current group
benefit information for specific coverage for crowns.

D6753 X-ray 4 - 13,

retainer crown - porcelain fused to titanium and titanium 20 - 29
alloys

1. See additional guidelines for D6753 alternate benefits shaded in gray.

D6753 X-ray 1 -3, 14 -16,

retainer crown - porcelain fused to titanium and titanium 17-19, 30-32
alloys

1. For most plans, upon review- the alternate benefit of D6790 will be applied. Patients
should be informed that they are responsible for the cost difference if they elect to have
this service. Refer to current group benefit information for specific coverage for crowns.

D6780 X-ray 1 - 32
retainer crown – ¾ cast high noble metal

D6781
retainer crown – ¾ cast predominantly base metal

D6782
retainer crown – ¾ cast noble metal

D6784
retainer crown ¾ - titanium and titanium alloys

D6783 X-ray 1 - 32
retainer crown – ¾ porcelain/ceramic

1. For most plans, upon review- the alternate benefit of D6780 will be applied. Patients
should be informed that they are responsible for the cost difference if they elect to have
this service. Refer to current group benefit information for specific coverage for crowns.

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Code & Nomenclature Submission Requirements Surface

D6790 X-ray 1 - 32
retainer crown – full cast high noble metal

D6791
retainer crown – full cast predominantly base metal

D6792
retainer crown – full cast noble metal
D6793 X-ray, Narrative 1 - 32
Interim retainer crown – further treatment or completion
of diagnosis necessary prior to final impression
Not to be used as a temporary retainer crown for routine prosthetic fixed partial dentures.
1. Covered as a benefit only in the event of an injury/trauma. Narrative must detail the
cause and nature of the injury/trauma.
2. D6793 is not billable to the patient when used as temporary retainer crown for a fixed
partial denture.

D6794 X-ray 1 - 32
retainer crown - titanium and titanium alloys
1. For most plans, upon review- the alternate benefit of D6790 will be applied. Patients
should be informed that they are responsible for the cost difference if they elect to have
this service. Refer to current group benefit information for specific coverage for crowns.

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HDS PROCEDURE CODE GUIDELINES PROSTHODONTICS (FIXED)

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

Other Fixed Partial Denture Services D6920 – D6999

D6930 1 - 32
re-cement or re-bond fixed partial denture
1. Benefit is limited to once every 12 months beginning 6 months after the fixed partial
denture is inserted.

2. Fees for recementation of fixed partial dentures are not billable to the patient if done
within six months of the initial seating date by the same dentist or dental office.

3. Recement by a different dentist within 6 months of the initial seating date may be
benefited.

D6940 X-ray, 1 - 32
stress breaker Lab Invoice
A non-rigid connector.

1. Coverage is limited to once every 5 years unless specified otherwise by group contract.

2. Procedure D6940 includes:

 Rest for fixed partial denture (in lieu of abutment).

 Misaligned fixed partial denture abutments.

3. This procedure code is not to be submitted for the rigid splinting of crowns.

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Code & Nomenclature Submission Requirements Surface

D6980 Narrative, 1 - 32
fixed partial denture repair necessitated by restorative Lab Invoice
material failure
1. Includes removal of fixed partial denture, if necessary.

2. Repairs are allowed 6 months after the insertion date. Benefit is limited to once every 12
months. Repair is a benefit 6 months after the initial insertion and then only a benefit
once every 12 months.

3. For most plans, ceramic repairs on molars are not benefits and the patient is responsible
for the cost. Refer to current group benefit information for specific coverage for
porcelain/ceramic repairs on molars.

4. Fixed partial denture repair due to caries should be submitted using D6999 unspecified
restorative procedure, by report or the appropriate corresponding restorative
procedure code.

5. Any restoration performed by the same dentist on the same tooth within 12 months after
crown insertion will be not billable to the patient. Special consideration may be given by
report.

6. The submitted information should include:

 Clinical diagnosis
 The tooth surfaces involved in the repair
 Type of restorative materials used for the repair (composite, amalgam, etc.)
 Tooth number
 Chair time
 Laboratory invoice when appropriate
 X-ray or photographic image(s)when available
 Additional other supporting information

7. Upon review of the submitted narrative and other documentation, an appropriate benefit
allowance will be applied.

D6999 Narrative, 1 - 32,

unspecified, fixed prosthodontic procedure, by report Lab Invoice LL, LR, UL, UR,
UA, LA

Used for procedure that is not adequately described by a code.

1. Narrative should include the clinical diagnosis, restorative materials used, tooth number
and surfaces, chair time. Intraoral photographic images (when available), X-ray images
when appropriate or other supporting information may be requested.

2. Upon review of documentation, the appropriate benefit allowance will be applied.

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HDS PROCEDURE CODE GUIDELINES ORAL & MAXILLOFACIAL SURGERY

ORAL AND MAXILLOFACIAL SURGERY D7000 - D7999

Local anesthesia is usually considered to be part of Oral and Maxillofacial Surgical procedures.
For dental benefit reporting purposes, a quadrant is defined as four or more contiguous teeth and/or teeth spaces
distal to the midline.

General Guidelines

1. The fee for all oral and maxillofacial surgery includes local anesthesia, suturing if needed and
postoperative care 30 days following surgery (e.g., dry socket, bleeding). Separate fees for these
procedures when performed in conjunction with oral and maxillofacial surgery are not billable to the
patient when done by the same dentist/dental office and are denied and the approved amount is
collectable from the patient when done by another dentist/dental office.

2. When a medical carrier statement is required, the procedure should be submitted to the patient’s
medical carrier first. When submitting to HDS, a copy of the explanation of benefits (EOB) or payment
voucher from the medical carrier should be included with the claim, pathology report if appropriate, and
any other pertinent information. In the absence of such information, the procedure will not be benefited
by HDS.

3. Medical carrier statement of payment is not required for HMO. Indicate the HMO name in a narrative.

4. Impaction codes are based on the anatomical position of the tooth, rather than the surgical procedure
necessary for removal.

5. Exploratory surgery is denied.

6. Benefits are not billable to the patient for incomplete or unsuccessful attempts at extractions.

7. When submitting for surgical extraction (D7210) and the tooth is not cariously broken down, fractured,
or otherwise compromised, the provider should submit a narrative that states the clinical reason(s)
which prevented removal of the tooth via customary elevation and forceps.

8. When a “narrative” is required, the corresponding guidelines may state what is expected in the
narrative. When “narrative” expectations are not specifically stated in the guidelines, the narrative must
include:

a. Diagnosis
Example: Acute periapical abscess #30 with fluctuant swelling on buccal.

b. Determination of Treatment (Brief description of the procedure performed)

Example: I & D of Acute periapical abscess.

c. Procedure or Treatment Performed (Steps of surgical procedure, to include location and

instrument used)
Example: Incision on buccal of #30 with #15 scalpel, drain placed and secured with one 3-0
black silk suture.

9. Oral surgery benefits do not apply to Implant surgical services.

10. General Guidelines are subject to the group contract. Specific government programs (e.g.,
Supplemental Medicaid) have defined limits for the number of restorative and extraction procedures.
Verify the benefit eligibility in advance of patient treatment.

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HDS PROCEDURE CODE GUIDELINES ORAL & MAXILLOFACIAL SURGERY

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

Extractions (Includes local anesthesia, suturing, if needed, and routine postoperative

care) D7111 - D7140

General Guidelines

1. Upon request, the clinical necessity for an extraction may be required. The benefit criteria for extraction
may include but are not limited to:

 Non-restorable caries or fracture

 Recurrent infection / Pericoronitis / cellulitis / abscess / osteomyelitis
 Associated cysts/tumors
 Resorption/damage to adjacent teeth
 Damage/destruction of bone
 Non-treatable pulpal / periapical pathology
 Internal/ external resorption of third molar
 Ectopic position or eruption of third molar

2. Specific government programs (e.g., Supplemental Medicaid) have defined limits for the number of
restorative and extraction procedures. Verify the benefit eligibility in advance of patient treatment.
D7111 A-T
extraction, coronal remnants – primary tooth

Removal of soft tissue-retained coronal remnants.

1. Includes soft tissue-retained coronal remnants.

2. D7111 is considered part of any other primary surgery in the same surgical area on the
same date and the fee is not billable to the patient if performed by the same
dentist/dental office.

D7140 A - T,
extraction, erupted tooth or exposed root (elevation and/or 1 - 32
forceps removal)

Includes removal of tooth structure, minor smoothing of socket bone and closure, as necessary.

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HDS PROCEDURE CODE GUIDELINES ORAL & MAXILLOFACIAL SURGERY

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

Surgical Extractions (Includes local anesthesia, suturing, if needed, and routine

postoperative care) D7210 - D7251

General Guidelines

1. The fee for surgical extraction includes local anesthesia, suturing if needed, and postoperative care 30
days following surgery (e.g., dry socket, bleeding).

2. When the x-ray or other submitted documentation does not support the procedure code D7210, the
procedure code will be processed as D7140.

3. Upon request, the clinical necessity for an extraction may be required. The benefit criteria for extraction
may include but are not limited to:

 Non-restorable caries or fracture

 Recurrent infection / Pericoronitis / cellulitis / abscess / osteomyelitis
 Associated cysts/tumors
 Resorption/damage to adjacent teeth
 Damage/destruction of bone
 Non-treatable pulpal / periapical pathology
 Internal/ external resorption of third molar
 Ectopic position or eruption of third molar

4. Specific government programs (e.g., Supplemental Medicaid) limit the number and type of extractions to
non-emergent services only. Refer to specific group benefit contracts where this exception applies.

D7210 X-ray A - T,
Extraction, erupted tooth requiring removal of bone and/or 1 - 32
sectioning of tooth, and including elevation of
mucoperiosteal flap if indicated

Includes cutting of gingiva and bone, removal of tooth structure, minor smoothing of socket bone and
closure.

1. When extracting a tooth that is not significantly broken down due to caries or fracture, the
provider should submit a narrative which details the reason(s) that prevented non-complicated
removal via elevator/forceps.

2. Incisional biopsy of oral tissue – soft (D7286) and removal of benign odontogenic cyst or
tumor up to 1.25 cm (D7450) are subject to dental consultant review and may not be billable
to the patient in conjunction with this procedure.

D7220 X-ray A - T,
removal of impacted tooth – soft tissue 1 - 32

Occlusal surface of tooth covered by soft tissue; requires mucoperiosteal flap elevation.

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Code & Nomenclature Submission Requirements Surface

D7230 X-ray A - T,
removal of impacted tooth – partially bony 1 - 32

Part of crown covered by bone; requires mucoperiosteal flap elevation and bone removal.

D7240 X-ray A - T,
removal of impacted tooth – completely bony 1 - 32

Most or all of crown covered by bone; requires mucoperiosteal flap elevation and bone removal.

1. For benefit purposes, completely bony is considered as 90% of the crown covered by bone.

D7241 X-ray, A - T,
removal of impacted tooth – completely bony, with Operative Report 1 - 32
unusual surgical complications

Most or all of crown covered by bone; unusually difficult or complicated due to factors such
as nerve dissection required, separate closure of maxillary sinus required or aberrant tooth
position.

1. Operative report must clearly indicate the specific complication/s incurred during the
course of the surgical procedure.

2. When the operative report does not indicate the complication or difficulty incurred during
the course of the surgical procedure, this service will be processed as D7240 or the
appropriate procedure code.

D7250 X-ray A - T,
removal of residual tooth roots (cutting procedure) 1 - 32

Includes cutting of soft tissue and bone, removal of tooth structure, and closure.

1. This benefit applies only to retained sub-osseous root tips.

2. This benefit is not billable to the patient if submitted in conjunction with a surgical
extraction on the same tooth by the same dentist/dental office.

3. When the submitted X-ray image or other documentation does not support the HDS
clinical criteria for D7250, the procedure may be processed as noted below:

 When the residual root is not fully encased in bone (sub-osseous), the procedure will
be processed as either D7210 (surgical removal of erupted tooth) or D7140
(extraction, erupted tooth or exposed root) based on the clinical circumstances and
submitted documentation.

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Code & Nomenclature Submission Requirements Surface

D7251 Pre-op X-ray 17, 32

coronectomy – intentional partial tooth removal

Intentional partial tooth removal is performed when a neurovascular complication is likely if

the entire impacted tooth is removed.

1. Benefited under individual consideration and only for documented probable

neurovascular complications such as proximity to the inferior alveolar nerve.

2. This procedure code is not to be submitted for incomplete or failed extractions.

Other Surgical Procedures D7260 - D7291

D7260 Operative Report 1 - 16,

oroantral fistula closure UL, UR

Excision of fistulous tract between maxillary sinus and oral cavity and closure by
advancement flap.

D7261 Operative Report 1 - 16,

primary closure of a sinus perforation UL, UR

Subsequent to surgical removal of tooth, exposure of sinus requiring repair, or immediate closure
of oroantral or oralnasal communication in absence of fistulus tract.

1. Procedure is by report. D7261 is not billable to the patient when submitted with
D7241 (removal of impacted tooth, completely bony, with unusual complications).

D7270 X-ray, A - T,
tooth reimplantation and/ or stabilization of accidentally Narrative 1 - 32
evulsed or displaced tooth

Includes splinting and/or stabilization.

1. Includes postoperative care for and removal of splint by the same dentist/dental office.

2. Narrative should indicate all teeth involved and describe the method of stabilization.

D7280 X-ray A - T,
Exposure of an unerupted tooth 1 - 32

An incision is made and the tissue is reflected and bone removed as necessary to expose
the crown of an impacted tooth not intended to be extracted.

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Code & Nomenclature Submission Requirements Surface

D7282 X-ray A - T,
mobilization of erupted or malpositioned tooth to aid 1 - 32
eruption

To move/luxate teeth to eliminate ankylosis; not in conjunction with an extraction.

D7283 X-ray A - T,
Placement of device to facilitate eruption of impacted 1 - 32
tooth

Placement of an attachment on an unerupted tooth, after its exposure, to aid in its eruption.
Report the surgical exposure separately using D7280.

1. Coverage for this procedure is limited to members who have Orthodontic plan benefits.

2. Services listed with the description of “limited to members who have Orthodontic plan
benefits” are only covered under those plans that have Orthodontic coverage and are
payable as part of the diagnostic or basic benefits.

D7285 Pathology Report 1 - 32

incisional biopsy of oral tissue-hard (bone, tooth) UA, LA,
UL, UR,
LL, LR

For partial removal of specimen only. This procedure involves biopsy of osseous lesions and is not
used for apicoectomy/periradicular surgery. This procedure does not entail an excision.

1. This service is not billable to the patient when performed in conjunction with an apicoectomy
(D3410, D3421, D3425 or D3426), or surgical extraction (D7210), by the same dentist/dental
office in the same surgical area and on the same date of service.

2. In the absence of the pathology report, this service is not billable to the patient.

D7286 Pathology Report 1 - 32

incisional biopsy of oral tissue-soft UA, LA,
UL, UR,
LL, LR

For partial removal of an architecturally intact specimen only. This procedure is not used at the
same time as codes for apicoectomy/periradicular curettage. This procedure does not entail an
excision.

1. This service is not billable to the patient when performed in conjunction with an apicoectomy
(D3410, D3421, D3425 or D3426). Procedure code D7286 performed in conjunction with
extractions in the same surgical area on the same date of service are subject to dental
consultant review and may not be billable to the patient.

2. In absence of the pathology report, this service is not billable to the patient.

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Code & Nomenclature Submission Requirements Surface

D7290 X-ray 1 - 32
surgical repositioning of teeth A-T

Grafting procedure(s) is/are additional.

1. Coverage for this procedure is limited to members who have Orthodontic plan benefits.

2. Services listed with the description of “limited to members who have Orthodontic plan
Benefits” are only covered under those plans that have Orthodontic coverage and are
payable as part of the diagnostic or basic benefits.

D7291 Operative Report 1 - 32

transseptal fiberotomy/supra crestal fiberotomy, by A-T
report

The supraosseous connective tissue attachment is surgically severed around the involved
teeth. Where there are adjacent teeth, the transseptal fiberotomy of a single tooth will involve
a minimum of three teeth. Since the incisions are within the gingival sulcus and tissue and
the root surface is not instrumented, this procedure heals by the reunion of connective tissue
with the root surface on which viable periodontal tissue is present (reattachment).

1. Coverage for this procedure is limited to members who have Orthodontic plan benefits.

2. Services listed with the description of “limited to members who have Orthodontic plan
benefits” are only covered under those plans that have Orthodontic coverage and are
payable as part of the diagnostic or basic benefits.

3. Upon review of documentation, the appropriate benefit allowance will be applied.

Alveoloplasty – Preparation of Ridge D7310 - D7321

D7310 UR, UL
alveoloplasty in conjunction with extractions – four or LR, LL
more teeth or tooth spaces, per quadrant

The alveoloplasty is distinct (separate procedure) from extractions. Usually in preparation for a
prosthesis or other treatments such as radiation therapy and transplant surgery. Alveoloplasty is
included in the fee for surgical extractions (D7210-D7250), and is not billable to the patient if
performed by the same dentist/dental office in the same surgical area on the same date of
service.

1. Allowed with multiple D7140 (extraction, erupted tooth or exposed root) in the same
quadrant, when periodontal disease is present.

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Code & Nomenclature Submission Requirements Surface

D7311 1 - 32
alveoloplasty in conjunction with extractions – one to
three teeth or tooth spaces, per quadrant

The alveoloplasty is distinct (separate procedure) from extractions. Usually in preparation for
a prosthesis or other treatments such as radiation therapy and transplant surgery.

1. Alveoloplasty is included in the fee for surgical extractions and is not billable to the patient if
performed by the same dentist/dental office in the same surgical area on the same date of
service as surgical extraction(s) (D7210-7250).

2. Allowed with D7140 in the same quadrant when periodontal disease is present.

3. If more than one tooth, indicate additional teeth numbers in narrative.

D7320 UR, UL,

alveoloplasty not in conjunction with extractions – four or LR, LL
more teeth or tooth spaces, per quadrant

No extractions performed in an edentulous area. See D7310 if teeth are being extracted
concurrently with the alveoloplasty. Usually in preparation for a prosthesis or other
treatments such as radiation therapy and transplant surgery.

D7321 1 - 32
alveoloplasty not in conjunction with extractions – one to
three teeth or tooth spaces, per quadrant

No extractions performed in an edentulous area. See D7311 if teeth are being extracted
concurrently with the alveoloplasty. Usually in preparation for a prosthesis or other treatments
such as radiation therapy and transplant surgery.

1. If more than one tooth, indicate additional teeth numbers in narrative.

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Code & Nomenclature Submission Requirements Surface

Excision of Soft Tissue Lesions D7410 - D7415, D7465

General Guidelines

1. Pathology Report should include site and size of growth.

D7410 Medical Carrier Statement, 1 - 32,

excision of benign lesion up to 1.25 cm Pathology Report UA, LA,
UR, UL
D7411 LR, LL
excision of benign lesion greater than 1.25 cm

1. The benefit for D7410/D7411 is subject to the review of the pathology report and may be
included in the benefit for another surgery when performed on the same date of service.

2. This service is not billable to the patient if not submitted with a pathology report.

D7413 Medical Carrier Statement, 1 - 32,

excision of malignant lesion up to 1.25 cm Pathology Report UA, LA,
UR, UL
D7414 LR, LL
excision of malignant lesion greater than 1.25 cm

1. This service is not billable to the patient if not submitted with a pathology report.

D7465 Narrative 1 - 32,

destruction of lesion(s), by physical or chemical method, UA, LA,
by report UR, UL
LR, LL
Examples include using cryo, laser or electro surgery.

1. Narrative should describe lesion and method of destruction.

Excision of Intra-Osseous Lesions D7440 - D7461

1. All procedures are subject to coverage under medical.

2. Pathology Report should include site and size of growth.

D7440 Medical Carrier Statement, 1 - 32,

excision of malignant tumor – lesion diameter up to 1.25 cm Pathology Report UR, UL,
LR, LL,
D7441 UA, LA
excision of malignant tumor –- lesion diameter greater than
1.25 cm

1. This service is not billable to the patient if not submitted with a pathology report.

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Code & Nomenclature Submission Requirements Surface

D7450 Medical Carrier Statement, 1 - 32,

removal of benign odontogenic cyst or tumor – lesion Pathology Report UR, UL,
diameter up to 1.25 cm LR, LL,
UA, LA
D7451
removal of benign odontogenic cyst or tumor – lesion
diameter greater than 1.25 cm

Odontogenic Cyst – Cyst derived from the epithelium of odontogenic tissue (developmental,
primordial).

1. The benefit for D7450 / D7451 is subject to the review of the pathology report and may be
included in the benefit for another surgery when performed in the same area of the mouth on
the same date of service by the same dentist/dental office.

2. This service is not billable to the patient if not submitted with a pathology report.

D7460 Medical Carrier Statement, 1 - 32,

removal of benign nonodontogenic cyst or tumor – lesion Pathology Report UR, UL,
diameter up to 1.25 cm LR, LL,
UA, LA
D7461
removal of benign nonodontogenic cyst or tumor –
lesion diameter greater than 1.25 cm

1. This service is not billable to the patient if not submitted with a pathology report.

Excision of Bone Tissue D7471 – D7490

D7471 Operative Report 1 - 32,

removal of lateral exostosis (maxilla or mandible) UL, UR,
LL, LR,
UA, LA

D7472 Operative Report UA

removal of torus palatinus

D7473 Operative Report LL, LR

removal of torus mandibularis

D7485 Operative Report UL, UR

reduction of osseous tuberosity

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Code & Nomenclature Submission Requirements Surface

D7490 Medical Carrier Statement, UL, UR,

radical resection of maxilla or mandible Operative Report, LL, LR
Pathology Report

Partial resection of maxilla or mandible; removal of lesion and defect with margin of normal
appearing bone. Reconstruction and bone grafts should be reported separately.

1. This service is not billable to the patient if not submitted with a pathology report.

Surgical Incision D7510 - D7560

D7510 Operative Report A - T,

incision and drainage of abscess – intraoral soft tissue 1 - 32

Involves incision through mucosa, including periodontal origins.

1. The benefit for D7510 is subject to the review of the operative report and may be included in
the benefit for another procedure when performed on the same date of service by the same
dentist/dentist office.

2. For benefit purposes, the Operative Report must include a clinical diagnosis, site of
incision and instrument used.

3. This is not an appropriate code when performing endodontic access opening and
drainage.
D7511 Medical Carrier Statement, A-T
incision and drainage of abscess – intraoral soft tissue – Operative Report 1 - 32
complicated (includes drainage of multiple fascial
spaces)

Incision is made intraorally and dissection is extended into adjacent fascial space(s) to
provide adequate drainage of abscess/cellulitis.

1. The benefit for D7511 is subject to the review of the operative report and may be
included in the benefit for another procedure when performed on the same date of
service by the same dentist/dentist office.

D7520 Operative Report LL, LR,

incision and drainage of abscess – extraoral soft tissue UL, UR,
LA, UA
Involves incision through skin.

1. Incision and drainage of abscess - extraoral soft tissue is a benefit only if dental related
infection is present.

2. The benefit is denied if not related to a dental infection.

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Code & Nomenclature Submission Requirements Surface

D7521 Medical Carrier Statement, LL, LR

incision and drainage of abscess – extraoral soft tissue – Operative Report UL, UR
complicated (includes drainage of multiple fascial spaces) LA, UA

Incision is made extraorally and dissection is extended into adjacent fascial space(s) to
provide adequate drainage of abscess/cellulitis.

1. This procedure is subject to coverage under medical.

2. Incision and drainage of abscess-extraoral soft tissue is a benefit only if an odontogenic

related infection is present.

3. Upon review of documentation, the appropriate benefit allowance will be applied.

D7530 Medical Carrier Statement, A - T,

removal of foreign body from mucosa, skin, or Operative Report 1 - 32
subcutaneous alveolar tissue

D7540 Operative Report A - T,

removal of reaction producing foreign bodies, 1 - 32
musculoskeletal system

May include, but is not limited to, removal of splinters, pieces of wire, etc., from muscle
and/or bone.

D7550 Operative Report A - T,

partial ostectomy/ 1 - 32
sequestrectomy for removal of non-vital bone

Removal of loose or sloughed-off dead bone caused by infection or reduced blood supply.

D7560 Operative Report A - T,

maxillary sinusotomy for removal of tooth fragment or 1 - 32
foreign body

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Code & Nomenclature Submission Requirements Surface

Treatment of Closed Fractures - D7610 - D7680

General Guidelines

1. All procedures are subject to coverage under medical.

2. A separate fee for splinting, wiring or banding is not billable to the patient when performed by the same
dentist/dental office rendering the primary procedure.

D7610 Medical Carrier Statement,

maxilla – open reduction (teeth immobilized, if present) Operative Report

Teeth may be wired, banded or splinted together to prevent movement. Incision required for
interosseous fixation.

D7620 Medical Carrier Statement,

maxilla – closed reduction (teeth immobilized, if present) Operative Report

No incision required to reduce fracture. See D7610 if interosseous fixation is applied.

D7630 Medical Carrier Statement,

mandible – open reduction (teeth immobilized, if Operative Report
present)
Teeth may be wired, banded or splinted together to prevent movement. Incision required to
reduce fracture.

D7640 Medical Carrier Statement,

mandible – closed reduction (teeth immobilized, if Operative Report
present)
No incision required to reduce fracture. See D7630 if interosseous fixation is applied.

D7650 Medical Carrier Statement,

malar and /or zygomatic arch – open reduction Operative Report

D7660 Medical Carrier Statement,

malar and /or zygomatic arch – closed reduction Operative Report

D7670 Medical Carrier Statement,

alveolus – closed reduction, may include stabilization of Operative Report,
teeth X-ray

D7671
alveolus – open reduction, may include stabilization of teeth

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Code & Nomenclature Submission Requirements Surface

Treatment of Open Fractures - D7710 - D7771

D7710 Medical Carrier Statement,

maxilla – open reduction Operative Report

Incision required to reduce fracture.

D7720 Medical Carrier Statement,

maxilla – closed reduction Operative Report

D7730 Medical Carrier Statement,

mandible – open reduction Operative Report

Incision required to reduce fracture.

D7740 Medical Carrier Statement,

mandible – closed reduction Operative Report

D7750 Medical Carrier Statement,

malar and/or zygomatic arch – open reduction Operative Report

Incision required to reduce fracture.

D7760 Medical Carrier Statement,

malar and/or zygomatic arch – closed reduction Operative Report

D7770 Medical Carrier Statement,

alveolus – open reduction stabilization of teeth Operative Report

Fractured bone(s) are exposed to mouth or outside the face. Incision required to reduce
fracture.

D7771 Medical Carrier Statement,

alveolus, closed reduction stabilization of teeth Operative Report

Fractured bone(s) are exposed to mouth or outside the face.

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Code & Nomenclature Submission Requirements Surface

Reduction of Dislocation and Management of Other Temporomandibular Joint

Dysfunctions D7810 - D7830

D7810 Medical Carrier Statement,

open reduction of dislocation Operative Report

Access to TMJ via surgical opening

1. Coverage is limited to members who have TMJ benefits

D7820 Medical Carrier Statement,

closed reduction of dislocation Operative Report

Joint manipulated into place; no surgical exposure.

1. Coverage is limited to members who have TMJ benefits.

D7830 Medical Carrier Statement,
manipulation under anesthesia Operative Report

1. Coverage is limited to members who have TMJ benefits.

Repair of Traumatic Wounds D7910

Excludes closure of surgical incisions.

D7910 Medical Carrier Statement,

suture of recent small wounds up to 5 cm Operative Report

Complicated Suturing (Reconstruction Requiring Delicate Handling of Tissues and Wide

Undermining for Meticulous Closure)

1. Specify site in operative report.

2. Repair of traumatic wounds is limited to oral structures.

3. Operative report should include diagnosis and treatment.

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Code & Nomenclature Submission Requirements Surface

Other Repair Procedures D7920 - D7999

D7953 1 - 32
bone replacement graft for ridge preservation – per site

Graft is placed in an extraction or implant removal site at the time of the extraction or removal to
preserve ridge integrity (e.g., clinically indicated in preparation for implant reconstruction or where
alveolar contour is critical to plan prosthetic reconstruction). Does not include obtaining graft
material. Membrane, if used should be reported separately.

1. Bone replacement graft for ridge preservation – per site is denied and the approved
amount is collectable from the patient unless it is a group contract specific benefit.

2. Benefit is limited to once in a 24-month period.

D7961 Narrative UA, LA,

buccal/labial frenectomy (frenulectomy) 1 - 32

1. Narrative should include diagnosis and clinical reason(s) for the procedure.

2. The fee for frenectomy is not billable to the patient when billed on the same date as any
other surgical procedure(s) in the same surgical area by the same dentist/dental office.

3. This code should not be submitted for ankyloglossia (tongue-tie).

D7962 Narrative UA, LA,

lingual frenectomy (frenulectomy) 1 - 32

1. Narrative should include diagnosis and clinical reason(s) for the procedure.

2. The fee for frenectomy is not billable to the patient when billed on the same date as any
other surgical procedure(s) in the same surgical area by the same dentist/dental office.

D7963 Narrative UA, LA,

frenuloplasty 6 -11,
22 - 27

Excision of the frenum with accompanying excision or repositioning of aberrant muscle and z-
plasty or other local flap closure.

1. Narrative should include diagnosis and clinical reason(s) for the procedure.

2. The fee for frenectomy is not billable to the patient when billed on the same date as any
other surgical procedure(s) in the same surgical area by the same dentist/dental office.

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Code & Nomenclature Submission Requirements Surface

D7970 Narrative UA, LA

excision of hyperplastic tissue – per arch

1. The benefit for excision of hyperplastic tissue is not billable to the patient when billed in
conjunction with other surgical procedure(s) in the same surgical area by the same
dentist/dental office.

2. Limited to edentulous areas.

D7971 Narrative 1 - 2,
excision of pericoronal gingiva 15 - 16,
17 - 18,
31 – 32

Removal of inflammatory or hypertrophied tissues surrounding partially erupted/impacted teeth.

1. The benefit for excision of pericoronal gingiva is not billable to the patient when billed in
conjunction with other surgical procedure(s) in the same surgical area by the same
dentist/dental office.

2. This procedure is applicable only to the excision of gingival tissue (operculum) distal to
the 2nd or 3rd molars.
D7972 Medical Carrier Statement, UA, UR,
surgical reduction of fibrous tuberosity Operative Report UL

1. The benefit for surgical reduction of fibrous tuberosity is not billable to the patient when
billed in
conjunction with other surgical procedure(s) in the same surgical area by the same
dentist/dental office.

D7979 Narrative LA, LL,

non-surgical sialolithotomy LR

A sialolith is removed from the gland or ductal portion of the gland without surgical incision
into the gland or the duct of the gland, for example via manual manipulation, ductal dilation,
or any other non-surgical method.

D7980 Medical Carrier Statement, LA, LL,

surgical sialolithotomy Operative Report LR

Surgical procedure by which a stone within a salivary gland or its duct is removed either
intraorally or extraorally.

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Code & Nomenclature Submission Requirements Surface

D7983 Medical Carrier Statement, UA, UR,

closure of salivary fistula Operative Report UL, LA,
LL, LR
Closure of an opening between a salivary duct and/or gland and the cutaneous surface or an
opening into the oral cavity through other than the normal anatomic pathway.

D7999 Operative Report

unspecified oral surgery procedure, by report

Used for procedure that is not adequately described by a code. Describe procedure.

1. Documentation should include a clinical diagnosis, materials used, tooth number, arch, quadrant,
or area of the mouth, chair time, intraoral photographic images when available, X-ray images or
additional supporting information.

2. Upon review of documentation, the appropriate benefit allowance will be applied.

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ORTHODONTICS D8000 - D8999

Primary Dentition: Teeth developed and erupted first in order of time.

Transitional Dentition: The final phase of the transition from primary to adult teeth, in which the deciduous molars
and canines are in the process of shedding and the permanent successors are emerging.

Adolescent Dentition: The dentition that is present after the normal loss of primary teeth and prior to cessation of
growth that would affect orthodontic treatment.

Adult Dentition: The dentition that is present after the cessation of growth that would affect orthodontic treatment.

All of the following orthodontic treatment codes may be used more than once for the treatment of a particular
patient depending on the particular circumstance. A patient may require more than one limited procedure
depending on their particular problem.

General Guidelines

1. Orthodontic benefits may be based on individual plan design and may not be a benefit for some plans. Some
plans may have contracted to provide different benefits/limitations. Please refer to the current Group Benefits
or Patient Eligibility Verification (available on HDS Online or DenTel) for specific group coverage.

2. Under certain plans where Enhanced ACA Pediatric Benefits apply, the orthodontic treatment must meet the
medical necessity criteria in order to benefit. Orthodontic coverage is limited to cases involving cleft lip and
palate or other severe facial birth defects or injury for which the function of speech, swallowing or chewing is
restored.

3. The fee for orthodontic treatment includes appliances, adjustments, insertion and removal, associated office
visits and any post-treatment.

a. Radiographic images, extractions and other services related to orthodontic treatment are benefited
under diagnostic or basic coverage and are not deducted from the lifetime orthodontic benefits
maximum unless otherwise specified.

4. Orthodontics, including oral evaluations and all treatment, must be performed by a licensed dentist or his or
her supervised staff, acting within the scope of applicable law. The dentist of record must perform an in-
person clinical evaluation of the patient (or the telehealth equivalent where required under applicable law to
be reimbursed as an alternative to an in-person clinical evaluation) to establish the need for orthodontics and
have adequate diagnostic information, including appropriate radiographic imaging, to develop a proper
treatment plan. Self-administered (or any type of "do it yourself") orthodontics is denied.

5. Payments are scheduled according to the plan’s contractual agreement and the payment schedule
is designated in the current Group Benefits or Patient Eligibility Verification information (available
on HDS Online or DenTel).

6. For two phase treatment plans, submit a narrative for each phase. Phase I may be benefited as Limited treatment
instead of Comprehensive. Phase II will be benefited as Comprehensive treatment.

7. When clear aligners, cosmetic or specialized brackets are elected by the patient for cosmetic purposes, it
is not a covered benefit. The dentist must explain to the patient that additional laboratory costs as
specified on the laboratory invoice are denied and chargeable. A patient consent form must be
maintained on file stating that the additional charges are the patient’s responsibility. The claim must be
submitted as follows:

 Enter the orthodontic procedure code and charge amount.

 Enter a separate line as procedure code D8999 with the additional fee for the clear aligner

Revised: 01/01/2022 1
Effective: 01/01/2022
HDS PROCEDURE CODE GUIDELINES ORTHODONTICS

laboratory charges, cosmetic or specialized brackets. Include a narrative describing the

additional charge.

 Provide a dental laboratory invoice that documents the additional charge.

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

Limited Orthodontic Treatment D8010 - D8040

Orthodontic treatment utilizing any therapeutic modality with a limited objective or scale of treatment. Treatment
may occur in any stage of dental development or dentition.
The objective may be limited by:
- not involving the entire dentition.
- not attempting to address the full scope of the existing or developing orthodontic problem.
- mitigating an aspect of a greater malocclusion (i.e., crossbite, overjet, overbite, arch length, anterior
alignment, one phase of multi-phase treatment, treatment prior to the permanent dentition, etc.).
- a decision to defer or forego comprehensive treatment

D8010
limited orthodontic treatment of the primary dentition

D8020
limited orthodontic treatment of the transitional dentition

D8030
limited orthodontic treatment of the adolescent dentition

D8040
limited orthodontic treatment of the adult dentition

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HDS PROCEDURE CODE GUIDELINES ORTHODONTICS

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

COMPREHENSIVE ORTHODONTIC TREATMENT D8070 - D8090

Comprehensive orthodontic care includes a coordinated diagnosis and treatment leading to the improvement of a
patient’s craniofacial dysfunction and/or dentofacial deformity which may include anatomical, functional and/or esthetic
relationships. Treatment may utilize fixed and/or removable orthodontic appliances and may also include functional
and/or orthopedic appliances in growing and non-growing patients. Adjunctive procedures to facilitate care may be
required. Comprehensive orthodontics may incorporate treatment phases focusing on specific objectives at various
stages of dentofacial development.

D8070 Narrative
comprehensive orthodontic treatment of the transitional
dentition

D8080
comprehensive orthodontic treatment of the adolescent
dentition

D8090
comprehensive orthodontic treatment of the adult dentition

1. A Comprehensive Orthodontic treatment is benefited once per lifetime unless specified in the
group contract.

2. The narrative should include the following:

a. Class of malocclusion (Class I, II, III)

b. Location and extent of crowding
c. Overbite/overjet
d. Specify the arch(es) to be treated.

3. Due to the contract limitation of one Comprehensive treatment per lifetime, for two phase
treatment plans, submit narrative for each phase. Phase I may be benefited as Limited
treatment, instead of Comprehensive. Phase II will be benefited as Comprehensive
treatment.

4. Orthodontic plans allow one retainer per arch per lifetime. Retainer adjustments are
included in the fee for “Comprehensive Orthodontic Treatment” and are not billable to the
patient if performed by the same dentist/dental office, denied if performed by a different
dentist/dental office.

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HDS PROCEDURE CODE GUIDELINES ORTHODONTICS

Code & Nomenclature Submission Requirements Valid Tooth/ Quad/Arch/

Surface

Minor Treatment to Control Harmful Habits D8210 - D8220

D8210 Narrative UA, LA

removable appliance therapy

Removable indicates patient can remove; includes appliances for thumb sucking and tongue
thrusting.

1. Limited to one appliance per arch.

2. The narrative must state the purpose for the appliance. Not to be used for treating
bruxism and the control of TMD symptoms.

3. This benefit is limited to patients through age 18.

D8220 Narrative UA, LA

fixed appliance therapy

Fixed indicates patient cannot remove appliance; includes appliances for thumb sucking and
tongue thrusting.

1. Limited to one appliance per arch.

2. The narrative must state the purpose for the appliance. Not to be used for treating
bruxism and the control of TMD symptoms.

3. This benefit is limited to patients through age 18.

Other Orthodontic Services D8680 - D8999

D8680 Narrative
orthodontic retention (removal of appliances, construction
and placement of retainer(s))

1. Limited to the removal of appliances.

2. The narrative should describe the procedure performed and reason(s) for the procedure.

3. This procedure is not billable to the patient unless performed by a dentist other than the
original dentist/dental office.

4. This is an incorrect code submission when fabricating replacement orthodontic retainers.

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HDS PROCEDURE CODE GUIDELINES ORTHODONTICS

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D8698
re-cement or re-bond fixed retainer – maxillary

D8699
re-cement or re-bond fixed retainer – mandibular

1. This procedure is included in the Orthodontic treatment fee.

2. A separate fee is not billable to the patient to the same dentist/dental office.

3. This procedure is not billable to the patient unless performed by a dentist other than the
original dentist/dental office.

D8701
repair of fixed retainer, includes reattachment – maxillary

D8702
repair of fixed retainer, includes reattachment – mandibular

1. This procedure is included in the Orthodontic treatment fee.

2. A separate fee is not billable to the patient to the same dentist/dental office.

3. In the case where a different dentist is repairing the fixed retainer, a separate benefit
may be given once in a lifetime.

D8703
replacement of lost or broken retainer – maxillary

D8704
replacement of lost or broken retainer – mandibular

1. Limited to one replacement per arch lifetime.

2. The fabrication of an extra (“spare”) retainer is not covered and is denied.

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HDS PROCEDURE CODE GUIDELINES ORTHODONTICS

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D8999 Narrative,
unspecified orthodontic procedure, by report Lab Invoice

Used for procedure that is not adequately described by the code. Describe the procedure.

1. Documentation should include a clinical diagnosis, materials used, tooth number, arch,
quadrant, or area of the mouth, chair time. Laboratory invoices, photographic images, X-ray
images, intraoral photos or additional supporting information may be requested.

2. Upon review of documentation, the appropriate benefit allowance will be applied.

3. When clear aligners, cosmetic or specialized brackets are elected by the patient for
cosmetic purposes, it is not a covered benefit. The dentist must explain to the patient that
additional laboratory costs as specified on the laboratory invoice are denied and
chargeable. A patient consent form must be maintained on file stating that the additional
charges are the patient’s responsibility. The claim must be submitted as follows:

 Enter the orthodontic procedure code and charge amount.

 Enter a separate line as procedure code D8999 with the additional fee for the clear
aligner laboratory charges, cosmetic or specialized brackets. Include a narrative
describing the additional charge.

 Provide a dental laboratory invoice that documents the additional charge.

Revised: 01/01/2022 6
Effective: 01/01/2022
HDS PROCEDURE CODE GUIDELINES ADJUNCTIVE GENERAL SERVICES

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

ADJUNCTIVE GENERAL SERVICES D9000 - D9999

Unclassified Treatment D9110 - D9120

D9110 Narrative A - T,
palliative (emergency) treatment of dental pain – minor 1 - 32,
procedure LL, LR,
UL, UR,
UA, LA

This is typically reported on a “per visit” basis for emergency treatment of dental pain.

1. Allowance is made for one palliative treatment per visit. (This service is payable per visit,
not per tooth.) An additional palliative treatment is not billable to the patient, if performed
on the same date, by the same dentist/dental office.

2. All procedures necessary for the relief of pain are included in the allowance for D9110.

3. The narrative must include the diagnosis and treatment performed to relieve pain. When
a specific procedure has been performed, it will be processed as that specific procedure.

4. This code should not be submitted when a pulpectomy/pulpal debridement (D3221) or

placement of a temporary/protective restoration (D2940) is performed.

5. Palliative treatment may be a benefit when performed on the same date as definitive
care if the treatment sites are different.

6. Periodic (D0120), problem focused (D0140) or comprehensive (D0150/ D0180)

evaluations and prophylaxis (D1110 or D1120) are allowed if performed on the same
date as palliative treatment.

7. This code should not be submitted for endodontic interim treatment by the same dentist
as the fee for endodontic therapy includes all appointments necessary to complete
treatment.

8. Office Visits (D9430) are not billable to the patient if performed on the same date as
palliative treatment, by the same dentist/dental office.

9. When the submitted narrative only indicates that a referral to a specialist or a prescription
for antibiotics and/or pain medication was provided, the palliative treatment will be
processed as a D0140 (limited examination – problem focused) and submitted charges
in excess of a D0140 are not billable to the patient.

Revised: 01/01/2022 1
Effective: 01/01/2022
HDS PROCEDURE CODE GUIDELINES ADJUNCTIVE GENERAL SERVICES

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D9120 A - T,
fixed partial denture sectioning 1 - 32

Separation of one or more connections between abutments and/or pontics when some
portion of a fixed prosthesis is to remain intact and serviceable following sectioning and
extraction or other treatment. Includes all recontouring and polishing of retained portions.

1. The removal and replacement of an existing fixed partial denture is considered a

component of a new fixed partial denture. A separate fee for this procedure is not
billable to the patient.

2. This procedure is limited to once per fixed partial denture.

3. This procedure is covered under the Prosthodontics benefit category.

D9130
temporomandibular joint dysfunction – non-invasive physical
therapies

1. Temporomandibular joint dysfunction-non-invasive physical therapies are denied and the

approved amount is collectable from the patient unless it is a group contract specific
benefit.

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HDS PROCEDURE CODE GUIDELINES ADJUNCTIVE GENERAL SERVICES

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

Unclassified Treatment D9210 - D9248

D9222
deep sedation/general anesthesia – first 15 minutes

D9223
deep sedation/general anesthesia – each subsequent 15-
minute increment

Anesthesia time begins when the doctor administering the anesthetic agent initiates the
appropriate anesthesia and non-invasive monitoring protocol and remains in continuous
attendance of the patient. Anesthesia services are considered completed when the patient
may be safely left under the observation of trained personnel and the doctor may safely
leave the room to attend to other patients or duties. The level of anesthesia is determined by
the anesthesia provider’s documentation of the anesthetics effects upon the central nervous
system and not dependent upon the route of administration.

1. Deep sedation/general anesthesia is a benefit only when provided in conjunction with

implant placement (D6010) or covered endodontic (D3410-D3426), periodontal (D4210-
D4275) and oral surgical procedures. When provided otherwise, the fee for deep
sedation/general anesthesia is denied and the approved amount is collectable from the
patient.

2. General anesthesia is a benefit for up to four 15-minute increments or as specified in the

group contract. Additional increments are not billable to the patient unless clinical
documentation supports more than one hour was necessary. When documentation of
exceptional circumstances is submitted, benefits may be approved dependent on
group/individual contract.

3. The benefit for deep sedation/general anesthesia is not billable to the patient when
performed by anyone other than an appropriately licensed qualified provider certified to
administer deep sedation/general anesthesia.

4. The evaluation for moderate, deep sedation or general anesthesia (D9219) is considered
part of this procedure and is not billable to the patient.

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HDS PROCEDURE CODE GUIDELINES ADJUNCTIVE GENERAL SERVICES

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D9230
inhalation of nitrous oxide / analgesia, anxiolysis

1. For patients covered by an Enhanced ACA Pediatric Benefit Plan, Inhalation of nitrous
oxide / analgesia, anxiolysis (D9230) is a benefit only on a patient under age 13 in
conjunction with operative dentistry or oral surgery. D9230 is denied when performed on
a patient age 13 through 18 and the patient is responsible for the Maximum Plan
Allowance.

2. For all patients not covered by an Enhanced ACA Pediatric Benefit Plan, D9230 is denied
and the patient is responsible for the submitted charge amount.

3. Multiple submissions of D9230 by the same dentist/dental office on the same date of
service are not billable to the patient.

4. D9230 is not billable to the patient when performed on the same date as D9223, D9243.

D9239
intravenous moderate (conscious) sedation/analgesia-
first 15 minutes

D9243
intravenous moderate (conscious) sedation/analgesia –
each subsequent 15-minute increment

Anesthesia time begins when the doctor administering the anesthetic agent initiates the
appropriate anesthesia and non-invasive monitoring protocol and remains in continuous
attendance of the patient. Anesthesia services are considered completed when the patient
may be safely left under the observation of trained personnel and the doctor may safely leave
the room to attend to other patients or duties.

The level of anesthesia is determined by the anesthesia provider’s documentation of the

anesthetics effects upon the central nervous system and not dependent upon the route of
administration.

1. Intravenous moderate (conscious) sedation is a benefit only when provided in

conjunction with implant placement (D6010) or covered endodontic (D3410-D3426),
periodontal (D4210-D4275) and oral surgical procedures. When provided otherwise, the
fee for intravenous moderate (conscious) sedation/analgesia is denied and the approved
amount is collectable from the patient.

2. Intravenous moderate (conscious) sedation/analgesia is a benefit for up to four 15-minute

increments or as specified in the group contract. Additional increments are not billable to
the patient unless clinical documentation supports more than one hour was necessary.
When documentation of exceptional circumstances is submitted, benefits may be
approved dependent on group/individual contract.

3. The benefit for intravenous moderate conscious sedation/anesthesia is not billable to the
patient when performed by anyone other than an appropriately licensed qualified provider
certified to administer intravenous sedation.
Revised: 01/01/2022 4
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HDS PROCEDURE CODE GUIDELINES ADJUNCTIVE GENERAL SERVICES

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

Professional Consultation D9310

D9310 Narrative A – T,
consultation - diagnostic service provided by dentist or 1 – 32,
physician other than requesting dentist or physician LL, LR,
UL, UR,
UA, LA

A patient encounter with a practitioner whose opinion or advice regarding evaluation and/or
management of a specific problem; may be requested by another practitioner or appropriate
source. The consultation includes an oral evaluation. The consulted practitioner may initiate
diagnostic and/or therapeutic services.

1. The benefit for consultation is not billable to the patient when performed in conjunction
with an examination/evaluation by the same dentist/dental office.

2. This code is not applicable and is not covered when a patient is self-referred for
consultation.

3. This procedure is benefited once per patient per dentist per twelve-month period.

4. Narrative must indicate the referring dentist’s full name and the reason for consultation.

Professional Visits D9410 - D9450

D9420 Narrative A - T,
hospital or ambulatory surgical center call 1 - 32

Care provided outside the dentist’s office to a patient who is in a hospital or ambulatory
surgical center. Services delivered to the patient on the date of service are documented
separately using the applicable procedure codes.

1. Hospital or ambulatory surgical center call (D9420) is a benefit only where Enhanced
ACA Pediatric Benefits apply and only where it is specified by the group contract.

2. Hospital or ambulatory surgical center call (D9420) performed not in conjunction with
operative dentistry or oral surgery is denied.

3. Benefit is limited to one visit per patient per day.

4. Narrative must include the hospital name and the nature / purpose for the hospital call.

5. Submitting dentist must be a licensed, credentialed provider at the specific hospital or

ambulatory surgical center.

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HDS PROCEDURE CODE GUIDELINES ADJUNCTIVE GENERAL SERVICES

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D9430 Narrative A - T,
office visit for observation (during regularly scheduled hours) 1 - 32
– no other services performed

1. This is not an evaluation procedure. It is allowable only when the visit is for observing
injuries and no other services are provided.

2. This procedure is not billable to the patient when related to a prior service that has a
post-operative period.

3. Office visits for reasons other than injury/trauma will be denied. The patient will be
responsible up to the allowed amount.

4. An office visit performed in conjunction with a procedure (other than X-ray images), is not
billable to the patient as included in the allowance for the procedure.

5. Narrative must include the diagnosis and the cause of the injury/trauma.

D9440 Narrative A - T,
office visit – after regularly scheduled hours 1 - 32

1. The narrative must include the time and nature of the office visit and include a statement
of normal working hours.

2. This is a benefit only when the office is closed and the dentist has physically left the
office and must return to provide services outside of normal working hours.

Revised: 01/01/2022 6
Effective: 01/01/2022
HDS PROCEDURE CODE GUIDELINES ADJUNCTIVE GENERAL SERVICES

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

Drugs D9610, D9612

D9610
therapeutic parenteral drug, single administration

Includes single administration of antibiotics, steroids, anti-inflammatory drugs, or other

therapeutic medications. This code should not be used to report administration of sedative,
anesthetic or reversal agents.

1. Therapeutic parenteral drug, single administration is denied and the approved amount is
collectable from the patient unless it is a group contract specific benefit.

D9612
therapeutic parenteral drugs, two or more administrations,
different medications

Includes multiple administrations of antibiotics, steroids, anti-inflammatory drugs or other

therapeutic medications. This code should not be used to report administration of sedatives,
anesthetic or reversal agents. This code should be reported when two or more different
medications are necessary and should not be reported in addition to code D9610 on the
same date.

1. Therapeutic parenteral drugs, two or more administrations, different medications are

denied and the approved amount is collectable from the patient unless it is a group
contract specific benefit.

Revised: 01/01/2022 7
Effective: 01/01/2022
HDS PROCEDURE CODE GUIDELINES ADJUNCTIVE GENERAL SERVICES

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

Miscellaneous Services D9910 - D9999

D9930 Narrative A - T,
treatment of complications (post-surgical) – unusual 1 - 32,
circumstances, by report LL, LR,
UL, UR,
UA, LA

1. Covered only if performed by a dentist other than the treating dentist/dental office.

2. Narrative must detail the complication and treatment rendered.

3. Benefit is limited to once per dentist/dental office.

D9941
fabrication of athletic mouthguard

1. Fabrication of athletic mouthguard benefit may be phased in as employer group

contracts renew. Patient benefits should be verified.

2. Benefit is limited for patients age 18 and younger, allowed once in a 24-month period.

D9944
occlusal guard – hard appliance, full arch

Removable dental appliance designed to minimize the effects of bruxism or other occlusal
factors. Not to be reported for any type of sleep apnea, snoring or TMD appliances.

1. Occlusal guard is denied and the approved amount is collectable from the patient unless
it is a group contract specific benefit or the group contract includes TMD coverage.

2. Benefit is limited to one appliance in a 5-year period.

D9945
occlusal guard – soft appliance, full arch

Removable dental appliance designed to minimize the effects of bruxism or other occlusal
factors. Not to be reported for any type of sleep apnea, snoring or TMD appliances.

1. Occlusal guard is denied and the approved amount is collectable from the patient unless
it is a group contract specific benefit or the group contract includes TMD coverage.

2. Benefit is limited to one appliance in a 5-year period.

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HDS PROCEDURE CODE GUIDELINES ADJUNCTIVE GENERAL SERVICES

Valid Tooth/ Quad/Arch/

Code & Nomenclature Submission Requirements Surface

D9946
occlusal guard – hard appliance, partial arch

Removable dental appliance designed to minimize the effects of bruxism or other occlusal
factors. Provides only partial occlusal coverage such as anterior deprogrammer. Not to be
reported for any type of sleep apnea, snoring or TMD appliances.

1. Occlusal guard is denied and the approved amount is collectable from the patient unless
it is a group contract specific benefit or the group contract includes TMD coverage.

2. Benefit is limited to one appliance in a 5-year period.

D9974 X-ray 6 -11,

internal bleaching – per tooth 22 - 27

1. Only a benefit for discolored non-vital teeth.

2. Benefit allowance is limited to once every 12 months per tooth.

D9985
general sales tax

1. Charges for Hawaii General Excise Tax are not covered benefits unless the group
contract specifies GET coverage.

2. For specific government programs (e.g., Supplemental Medicaid, Medicare), Hawaii

General Excise Tax is not billable to the patient and not payable by HDS.

D9997
Dental case management-patients with special health care
needs

Special treatment considerations for patients/individuals with physical, medical,

developmental or cognitive conditions resulting in substantial functional limitations or
incapacitation, which require that modifications be made to delivery of treatment to provide
customized or comprehensive oral health care services.

1. The fees for patients with special health care needs are considered administrative and
used to identify services provided to a particular type of patient and are not billable to the
patient.

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HDS PROCEDURE CODE GUIDELINES ADJUNCTIVE GENERAL SERVICES

Code & Nomenclature Submission Requirements Valid Tooth/ Quad/Arch/

Surface

D9999 Narrative
unspecified adjunctive procedure, by report

Used for procedure that is not adequately described by a code. Describe procedure.

1. Provide complete description of services/treatment to allow determination of appropriate

benefit allowance.

2. Narrative should include a clinical diagnosis, restorative materials used, tooth number, arch,
quadrant, or area of the mouth and chair time. Intraoral photographic images when available,
X-ray images, lab invoices or additional supporting information may be requested.

Revised: 01/01/2022 10
Effective: 01/01/2022
 Addendum
HDS Procedure Code Guidelines
New Medicare Advantage Codes
for
WellCare By 'Ohana
ADDENDUM - HDS PROCEDURE CODE GUIDELINES
WELLCARE BY ‘OHANA ONLY – NEW MEDICARE ADVANTAGE CODES

Benefit
Code Description Category Frequency Required

DIAGNOSTIC D120 – D999

D0160 Detailed and extensive oral evaluation – 1x/yr/dental office. Counts toward
Op Rpt
problem focused, by report By Contract annual exam frequency for D0140,
D0160, D0170, D0171
D0170 Re-evaluation – limited, problem focused 1x/yr dental office. Counts toward
Op Rpt
(established patient; not post-operative By Contract annual exam frequency for D0140,
visit) D0160, D0170, D0171
D0171 Re-evaluation – post-operative office visit 1x/yr dental office. Counts toward
Op Rpt
By Contract annual exam frequency for D0140,
D0160, D0170, D0171
D0251 Extra-oral posterior dental radiographic 2x/yr Op Rpt
By Contract
image
D0310 Sialography By Contract 1x/3 yrs Op Rpt

D0391 Interpretation of diagnostic image by a By Contract Op Rpt

practitioner not associated with capture of
the image, including report
D0414 Laboratory processing of microbial By Contract 1x/yr/procedure
specimen to include culture and Op Rpt
sensitivity studies, preparation and
transmission of written report
D0415 Collection of microorganisms for culture By Contract 1x/yr/procedure Op Rpt
and sensitivity
D0416 Viral Culture By Contract 1x/yr/procedure Op Rpt

D0431 Adjunctive pre-diagnostic test that aids in By Contract 1x/yr/procedure

detection of mucosal abnormalities
Op Rpt
including premalignant and malignant
lesions, not to include cytology or biopsy
procedures
By Contract 1x/yr/procedure Op Rpt
D0475 Decalcification procedure
By Contract 1x/yr/procedure Op Rpt
D0476 Special stains for microorganisms
By Contract 1x/yr/procedure Op Rpt
D0477 Special stains not for microorganisms
By Contract 1x/yr/procedure Op Rpt
D0478 Immunohistochemical stains
D0479 Tissue in-situ hybridization, including By Contract 1x/yr/procedure Op Rpt
interpretation
By Contract 1x/yr/procedure Op Rpt
D0481 Electron microscopy
D0482 Direct immunofluorescence By Contract 1x/yr/procedure Op Rpt

D0483 Indirect immunofluorescence By Contract 1x/yr/procedure Op Rpt

D0485 Consultation, including preparation of By Contract 1x/yr/procedure

Op Rpt
slides from biopsy material supplied by
referring source
D0486 Accession of transepithelial cytologic By Contract 1x/yr/procedure Op Rpt
sample, microscopic examination,
preparation and transmission of written
report
Revised: 11/15/2021
Effective: 01/01/2022
1
ADDENDUM - HDS PROCEDURE CODE GUIDELINES
WELLCARE BY ‘OHANA ONLY – NEW MEDICARE ADVANTAGE CODES

Benefit
Code Description Category Frequency Required

D0502 Other oral pathology procedures, by By Contract 1x/yr/procedure Op Rpt

report
D0604 Antigen testing for a public health related By Contract Op Rpt
1x/visit/test
pathogen, including coronavirus
D0605 Antibody testing for a public health By Contract Op Rpt
1x/visit/test
related pathogen, including coronavirus
PREVENTIVE D1000 – D1999
D1355 Caries preventive medicament application Op Rpt
– per tooth
By Contract 1x/yr

RESTORATIVE D2000 – D2999

D2975 Coping By Contract 1x/7 yrs/tooth Op Rpt

ENDODONTICS D3000 – D3999

D3460 Endodontic endosseous implant By Contract Op Rpt
1x/tooth/lifetime
D3470 Intentional reimplantation (including By Contract 1x/tooth/lifetime Op Rpt
necessary splinting)
PERIODONTICS D4000 – D4999
D4230 Anatomical crown exposure - four or By Contract
Op Rpt
more contiguous teeth or tooth bounded 1 site/quad/3 yrs
spaces per quadrant
D4231 Anatomical crown exposure - one to By Contract 1 site/quad/3 yrs
Op Rpt
three teeth or tooth bounded spaces
per quadrant
D4245 Apically positioned flap By Contract 1 site/quad/3 yrs Op Rpt

D4270 Pedicle soft tissue graft procedure By Contract 1 site/quad/3 yrs Op Rpt

D4274 Mesial/distal wedge procedure, single By Contract 1 site/quad/3 yrs

tooth (when not performed in conjunction Op Rpt
with surgical procedures in the same
anatomical area)
D4276 Combined connective tissue and pedicle By Contract 1 site/quad/3 yrs Op Rpt
graft, per tooth
D4381 Localized delivery of Antimicrobial agents
via a controlled release vehicle into
Op Rpt
diseased crevicular tissue, per tooth, by By Contract 2 sites/quad/2 yrs
report

PROSTHODONTICS (REMOVABLE) D5000 – D5899

D5810 Interim complete denture (maxillary) By Contract 1x/5 yrs/arch/procedure Op Rpt

D5811 Interim complete denture (mandibular) By Contract 1x/5 yrs/arch/procedure Op Rpt

D5867 Replacement of replaceable part of semi- By Contract 1x/5 yrs/arch/procedure

Op Rpt
precision or precision attachment, per
attachment
D5875 Modification of removable prosthesis By Contract 1x/5 yrs/arch/procedure Op Rpt
following implant surgery

Revised: 11/15/2021
Effective: 01/01/2022
2
ADDENDUM - HDS PROCEDURE CODE GUIDELINES
WELLCARE BY ‘OHANA ONLY – NEW MEDICARE ADVANTAGE CODES

Benefit
Code Description Category Frequency Required

ORAL & MAXILLOFACIAL SURGERY D7000 – D7999

D7272 Tooth transplantation (includes By Contract Op Rpt
reimplantation from one site to another 1x/tooth/lifetime
and splinting and/or stabilization
D7287 Exfoliative cytological sample collection By Contract Op Rpt
1x/2 yrs/site/procedure
D7288 Brush biopsy – transepithelial sample By Contract Op Rpt
1x/2 yrs/site/procedure
collection
D7292 Placement of temporary anchorage By Contract Op Rpt
device (screw retained plate) requiring 1x/2 yrs per tooth/site/procedure
flap
D7293 Placement of temporary anchorage By Contract Op Rpt
1x/2 yrs per tooth/site/procedure
device requiring flap
D7294 Placement of temporary anchorage By Contract Op Rpt
1x/2 yrs per tooth/site/procedure
device without flap
D7340 Vestibuloplasty – ridge extension By Contract Op Rpt
1x/5 yrs/site/quad
(secondary epithelialization)
D7350 Vestibuloplasty – ridge extension By Contract Op Rpt
(including soft tissue grafts, muscle
reattachment, revision of soft tissue 1x/5 yrs/site/quad
attachment and management of
hypertrophied and hyperplastic tissue)
D7412 Excision of benign lesion, complicated By Contract Op Rpt

D7415 Excision of malignant lesion, complicated By Contract Op Rpt

D7997 Appliance removal (not by dentist who By Contract

Op Rpt
placed appliance), includes removal of 1x/5 yrs/procedure
archbar
ADJUNCTIVE GENERAL SERVICES D9000 – D9999
D9248 Non-intravenous (conscious) sedation By Contract Op Rpt

D9410 House/extended care facility call By Contract Op Rpt

D9630 Drugs or medicaments dispensed in By Contract 1x/6 mos Op Rpt

office for home use
D9911 Application of desensitizing resin for By Contract Op Rpt
1x/2 yrs/procedure
cervical and/or root surface, per tooth
D9920 Behavior management, by report By Contract 1x/2 yrs/procedure Op Rpt

D9932 Cleaning and inspection of a removable By Contract 1x/2 yrs/procedure Op Rpt

complete denture, maxillary
D9933 Cleaning and inspection of a removable By Contract 1x/2 yrs/procedure Op Rpt
complete denture, mandibular
D9934 Cleaning and inspection of a removable By Contract 1x/2 yrs/procedure Op Rpt
partial denture, maxillary
D9935 Cleaning and inspection of a removable By Contract 1x/2 yrs/procedure Op Rpt
partial denture, mandibular
D9942 Repair and/or reline of occlusal guard By Contract 1x/2 yrs/procedure Op Rpt

Revised: 11/15/2021
Effective: 01/01/2022
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