Vermont MedicaidDental Supplement and2022 Fee Schedule

Attention: Information for Operating During the State’s COVID 19Emergency PeriodThe State of Vermont is operating under COVID 19 public health emergency guidelines. For the mostcurrent information, please refer to the Department of Vermont Health Access COVID 19 webpage at: scroll through this web page for provider information and specifically for informationpertinent to dental/oral health providers. Please revisit this web page often; information will beupdated regularly to reflect the most current guidance.During the State of Vermont’s COVID 19 emergency period, Prior Authorization (PA) requirementsthat are indicated for procedures in this Dental Manual/Fee Schedule are waived. ANY dental feeschedule procedure code that has a frequency limitation that could be increased with approval of aprior authorization can be exceeded. As in the past, documentation of medical necessity forprocedure work completed must be maintained in the patient records. This is required whether it isfor the Adult or Children’s program.It is important that clinical notes reflect medical necessity for procedures that are performed,especially if performed in absence of previously required PA’s or if performed more frequently thanthe standard frequency as stated in this Dental Manual/Fee Schedule.2022-01-06Dental Supplement2

Table of ContentsSECTION 1INTRODUCTION.7HIPAA . 7SECTION 2 BILLING INFORMATION . 8Adult Program (AP) . 82.1.1Exception to Adult Program Limit for Pregnancy . 8By Report . 8Anesthesia . 8Area of Oral Cavity . 8Attending Physician/Attending Practitioner . 9Billing Members for Dental Services Exceeding Annual Cap . 9Billing Members for Dental Services That Are Non-Covered by Vermont Medicaid. 9Date of Service . 10Dental Procedure Fee Schedule . 10EPSDT Program – Well Child Health Care . 10Fluorides (By Prescription) . 10General Assistance (GA) Vouchers . 11Global (Post-Operative) Period . 11Hospital Calls. 11Information Available (Voice Response System) . 11Internal Control Number (ICN) . 11Interpreter Services . 12Medical Necessity . 12Member Cost Sharing/Co-Pays . 122.19.1Exceptions to Co-Payments . 12Missed Appointments/Late Cancellations . 13Modifiers . 13Multiple Page Claims. 13Oral Surgery . 13Prior Authorization . 13Radiographs – Submission Requirements . 14Spenddown . 142022-01-06Dental Supplement3

Supernumerary Teeth . 14TMJ Device . 15Telemedicine . 15Unlisted Services. 15Usual and Customary Charges . 15SECTION 3 PROCEDURE CODES . 16SECTION 4 ADULT AND CHILDREN’S PROGRAMS (COVERED SERVICES) . 17Clinical Oral Evaluation . 17Radiographs . 18Other Diagnostic Procedures . 18Preventive Treatment. 18Topical Fluoride Treatment. 19Other Preventive Services . 19Restorative. 194.7.1Amalgam Restorations . 204.7.2Resin-Based Restorations . 204.7.3Custom Crowns . 204.7.4Prefabricated Crowns . 21Other Restorative Procedures . 21Endodontics . 214.9.1Pulpotomy . 214.9.2Endodontic Therapy for Primary Teeth . 214.9.3Endodontic Therapy .224.9.4Apicoectomy/Periradicular Surgery .22Periodontics . 224.10.1Surgical Services (10 Day Global) .224.10.2Other Periodontal Services . 23Removable Prosthodontics. 234.11.1Denture Adjustments . 234.11.2Other Removable Prosthetic Services . 24Fixed Prosthodontics . 244.12.1Implant Services . 244.12.2Other Prosthodontic Services . 242022-01-06Dental Supplement4

Oral and Maxillofacial Surgery . 244.13.1Extractions . 244.13.2Surgical Extractions . 244.13.3Other Surgical Procedures/Splints . 25Adjunctive General Services . 264.14.1Anesthesia . 264.14.2Professional Visits . 274.14.3Patient Management . 274.14.4Occlusal Therapy . 274.14.5Interpreter Services . 27SECTION 5 ADDITIONAL CHILDREN’S PROGRAM (AGES 0-20 INCLUSIVE) . 28Clinical Oral Evaluations . 28Radiographs . 28Preventive Treatment. 28Other Preventive Services . 285.4.1Space Maintenance . 295.4.2Custom Crowns . 29Other Restorative Procedures . 305.5.1Apexification/Recalcification Procedures . 305.5.2Apexification/Recalcification Procedures. 305.5.3Apicoectomy/Periradicular Surgery. 30Other Endodontic Procedures. 30Periodontics . 305.7.1Surgical Services . 30Removable Prosthodontics. 315.8.1Complete Dentures, Immediate Dentures and Overdentures. 315.8.2Partial Dentures . 315.8.3Denture Repairs . 315.8.4Denture Rebases . 325.8.5Denture Relines . 325.8.6Interim Prosthesis. 325.8.7Other Removable Prosthetic Services. 32Fixed Prosthodontics . 322022-01-06Dental Supplement5

5.9.1Fixed Partial Denture Pontics . 325.9.2Fixed Partial Denture Retainers – Crowns . 335.9.3Other Prosthodontic Services . 33Oral and Maxillofacial surgery . 335.10.1Miscellaneous Surgical Procedures . 34Orthodontics . 345.11.1Limited Orthodontic Treatment . 345.11.2Comprehensive Orthodontic Treatment . 345.11.3Treatment to Control Harmful Habits . 345.11.4Other Orthodontic Services. 35Adjunctive General Services . 355.12.1Occlusal Therapy . 355.12.2Miscellaneous Services . 355.12.3Unspecified Care. 35SECTION 6SECTION 7SECTION 8SECTION 92012 AND 2019 ADA DENTAL CLAIM FORM . 36DENTAL FEE SCHEDULE . 37INDEPENDENTLY BILLING DENTAL HYGIENISTS FEE SCHEDULE . 54PROCEDURE CODES THAT REQUIRE AREA OF ORAL CAVITY. 552022-01-06Dental Supplement6

Section 1IntroductionThe Vermont Medicaid Dental Supplement contains billing information and an alphabetical listing ofreimbursable charges and information.Vermont Medicaid will accept both the 2012 and 2019 ADA Dental Claim Form.Though dental practitioners are not required to include a diagnosis code when submitting claims toVermont Medicaid, if they choose to include codes, they must be valid. For moreinformation/instructions about the 2012 and 2019 Dental Claim Forms, see the dental resourcesavailable on the Vermont Medicaid Portal. billing for services represented by CPT codes are to bill using the CMS-1500 Claim Form.For more information see the Provider Manual: are reminded that the claim form field locator information available on the VermontMedicaid Portal is for use with paper transactions. Providers using HIPAA compliant software tosubmit electronic claims may access the electronic requirements at the Washington Publishingwebsite at Supplement7

Section 2 Billing InformationAdult Program (AP)The Adult Program is limited to 1,000 per individual per calendar year (annual cap).If an individual reaches their 21st birthday and has received dental care during the course of the year,the dental benefit already paid will be applied to the annual 1,000 adult maximum benefit. Thebenefit is considered exhausted if the total reimbursement is greater than or equal to 1,000 and willnot begin again until the start of the new calendar year.2.1.1Exception to Adult Program Limit for PregnancyPregnant women receiving benefits under the Dr. Dynasaur/Vermont Medicaid program receive thesame dental benefits that are available for children on the program and will be excluded from theapplication of the adult dental cap. This benefit will be in effect for the duration of the pregnancy andthrough the end of the calendar month during which the 60th day following the end of pregnancyoccurs. At the end of this period the benefit returns to the standard annual cap. The adult dental capapplies through the end of the current calendar year.It is the member’s responsibility to contact Member Services (800.250.8427) to initiate steps to havetheir eligibility status reflect pregnancy.All dental providers are reminded to use the HD Modifier at the end of each procedure code whensubmitting claims for pregnant women (including the 60-day post pregnancy period) receivingbenefits under the Dr. Dynasaur/Vermont Medicaid program. This will exclude the claim from theapplication of the adult dental cap.By ReportWhen a procedure is followed by this statement, please provide a brief description of the service andforward the claim to the Department of Vermont Health Access (DVHA) for review.AnesthesiaDentists with appropriate anesthesia credentials may bill for general anesthesia administered in theoffice, on a 2012 or 2019 ADA Dental Claim Form.Local anesthesia, or topical anesthesia used by dentists are not reimbursable as a separate service.This would be covered as part of the reimbursement for the procedure.Area of Oral CavityClaims for services that do not include Area of Oral Cavity information, when required, will bedenied. When submitting claims on the 2012 or 2019 ADA Dental Claim Form, please note thefollowing directions to ensure the correct reporting of Item #25 (Area of Oral Cavity) per ADAinstructions:Use of Item # 25 (Area of Oral Cavity) is conditional.The following conditional use requirements apply:2022-01-06Dental Supplement8

Always report the area of the oral cavity when the procedure reported in Item #29 (ProcedureCode) refers to a quadrant or arch and the area of the oral cavity is not uniquely defined bythe procedure’s nomenclature. oExample: Report the applicable area of the oral cavity when the procedure codenomenclature includes a general reference to an arch or quadrant, such as D4263bone replacement graft – first site in quadrant.Do not report the applicable area of the oral cavity when the procedure either: oIncorporates a specific area of the oral cavity in its nomenclature, such as D5110complete denture – maxillary;-or-oDoes not relate to any portion of the oral cavity, such as D9222 deepsedation/general anesthesia – first 15 minutes.Area of oral cavity is designated by one of the following two-digit codes: 00-entire oral cavity, 01-maxillary arch, 02-mandibular arch, 10-upper right quadrant, 20-upper left quadrant, 30-lower left quadrant, 40-lower right quadrant.In order to facilitate correct claims completion by providers, DVHA has identified the procedurecodes that require the reporting of this field. Refer to the Procedure Codes that require reporting forArea of Oral Cavity section.Attending Physician/Attending PractitionerAn attending physician/dental provider is the physician/dental provider who actually performs theservice. The attending provider must be enrolled as a participating Vermont Medicaid provider.When billing on the CMS-1500 claim form, the attending provider NPI # must appear in field 24 foreach line of service being billed. The 2012 or 2019 Dental Claim Form requires the attending providerNPI# to be listed in field 54.Billing Members for Dental Services Exceeding Annual CapProviders may, after obtaining written acknowledgement of financial liability from the member,bill patients for amounts that exceed the adult annual capped payment amount but not morethan the appropriate procedure code rate in the Vermont Medicaid Dental Procedure FeeSchedule, if it is a Vermont Medicaid covered service. Written acknowledgement of financialliability must be obtained from the member prior to performing services.Billing Members for Dental Services That Are Non-Covered by Vermont MedicaidProviders may, after obtaining written acknowledgement of financial liability from the member, billpatients for services not covered by Vermont Medicaid. Providers must confirm and documentverification that a service is not covered by Vermont Medicaid prior to billing a member.See Vermont Medicaid General Billing and Forms Manual, Section 1.5, Notice That Vermont MedicaidWill Not Be Accepted, for additional information.2022-01-06Dental Supplement9

Usual & Customary charges may not be billed to a Vermont Medicaid member without prior writtencommunication to the member explaining their financial liability should they choose to receive aservice that it is not covered by Vermont Medicaid.Date of ServiceThe date of service on the claim must be the date that the service was performed. When the servicespans over several appointments, the date of service will be the date that the service started. Forexample: for orthodontics or crowns, the start date is billed as the date of service.Dental Procedure Fee ScheduleThe dental fee schedule is in Section 7 of this manual, and the most current version of thissupplement and fee schedule are available on the DVHA website at Procedure codes not covered by DVHA’s DentalProgram are not listed.The State of Vermont is operating under COVID-19 public health emergency guidelines. For the mostcurrent information, please refer to the Department of Vermont Health Access COVID 19 webpage at: scroll through this web page for provider information and specifically for informationpertinent to dental/oral health providers. Please revisit this web page often; information will beupdated regularly to reflect the most current guidance.EPSDT Program – Well Child Health CareEPSDT is a federally mandated benefit for all Vermont Medicaid eligible children under age 21. EPSDTrequires the state to provide any health care service that is medically necessary, even if the service isnot covered for adults. EPSDT services include periodic screenings to identify physical and mentalconditions, vision, hearing, dental problems and follow-up diagnostic and treatment services.All providers should deliver pediatric screening and preventive dental services according to theVermont dental periodicity schedule found Schedule.pdfVermont Medicaid tracks service delivery and follow-up and annually reports EPSDT CMS 416measures by collection of data from Vermont Medicaid claims. The link to the CMS page ndex.htmlThe 2012 or 2019 ADA Dental Claim Form requires EPSDT to be listed in field 1.See the Vermont Medicaid General Billing and Forms Manual, Section 5.3.19, EPSDT Program Well –Child Health Care. (By Prescription)Vermont Medicaid reimburses for fluorides when prescribed by a participating physician or dentistfor children and adults. Prescription strength topical fluorides are covered for products designedsolely for use in the dental office. Fluoride must be applied separately from prophylaxis paste.Fluorides in combination with vitamins are not covered. Please see the Dental Procedure Fee2022-01-06Dental Supplement10

Schedule for allowed billing codes, unit limitations and Prior Authorization (PA) requirements l Assistance (GA) VouchersGeneral Assistance (GA) Vouchers are issued by the Economic Services Division of the Departmentfor Children and Families as a means of providing emergency treatment to relieve pain, bleedingand/or infection for income eligible adults who are uninsured or have met the annual cap. Paymentfor covered services is based on the current DVHA Dental Procedure/Fee Schedule. Copays do notapply to GA Voucher funded services.The guidelines and procedure codes that are deemed reimbursable for members with valid GAVouchers can be found on the Vermont Medicaid website at submitted for GA voucher services should, if applicable, include the member’s Unique IDNumber (UID). The UID Number can be accessed via web site or the Voice Response System by dialing800.925.1706, option 1 and then option 1 again.Global (Post-Operative) PeriodEffective for dates of service on and after June 1, 2016: Vermont Medicaid is enforcing a 10-dayglobal period for certain dental procedure codes. During the dental global period, any palliativetreatment for pain is considered included in the payment for the primary procedure for that date andwill not be reimbursed separately. Please refer to the Dental Fee Schedule for code specificguidance.Hospital CallsUse the appropriate procedure code for hospital calls when billing in conjunction with a surgerywhere the patient is admitted as an inpatient or outpatient at a hospital. The pre-operative exam andall other related services are reimbursed within the billed surgery codes. Do not submit for themseparately.Information Available (Voice Response System)Dental Providers accessing the VRS have access to the following: Adult dental benefit (dollars spent) Last dental oral examSee the Vermont Medicaid General Provider Manual, Section 4.1.2, Eligibility Verification for moreinformation. Control Number (ICN)This term refers to the Internal Control Number (ICN) assigned by the Claims Processing Agent toeach claim submitted.See the Vermont Medicaid General Provider Manual, Section 10, Glossary of Terms & -06Dental Supplement11

Interpreter ServicesA provider who pays for interpreter services for Vermont Medicaid members may bill procedurecode T1013 for each 15 minutes of paid interpreter services provided, on-site or via telephone. Thismay include interpreter service outside of the actual healthcare provider encounter to fill out formsor review information/instructions.Services for interpreters can be billed on the 2012 or 2019 ADA Claim Form. One unit of service isequal to 15 minutes. These services do not count toward the adult maximum benefit.Medical NecessitySee the Vermont Medicaid General Billing and Forms Manual, Section 2.4, Medical lsMember Cost Sharing/Co-PaysCertain members must participate in the cost of care for dental services.The copayment for dental services is 3 per provider per date of service unless exemptions apply.Gainwell Technology will automatically deduct the copayment from the amount paid to the provider.See Medicaid Health Care Administrative Rule 6.100 Medicaid Cost Sharing for the complete list ofexceptions and exemptions.Co-payments are never required of Vermont Medicaid members who are: Under age 21 Pregnant or in a 60-day post-pregnancy period Living in a long-term care facility, nursing home, or hospiceCopayments are not required for preventive dental visits (see Section 2.19.1 below).Copayments are also not required for emergency services, including dental services covered by a GAVoucher.Although some members are required to make co-payments under Vermont Medicaid, if the memberis unable to make the payment, Vermont Medicaid providers may not deny services. Per section1916(c) of the Social Security Act, "no provider participating under the State [Medicaid] plan maydeny care of services to an individual eligible for [Medicaid] because of an individual's inability to pay[the copayment]."2.19.1Exceptions to Co-Payments1. Preventive dental vi

pertinent to dental/oral health providers. Please revisit this web page often; information will be updated regularly to reflect the most current guidance. During the State of Vermont’s COVID 19 emergency period, Prior Authorization (PA) requirements that are indicated for procedures in this Dental Manual