Policy Manual Final_2016

Section 7

Addendum

 Human Resources, TSR, will send the job offer in writing to the candidate.
 Dental software, payroll, culture, email, and any other training is to be
completed with within a short time frame of the new employee start.
The clinic and operations will be notified once the candidate has made a
decision.

Protocol for Complaint Resolution

It is always good HR policy to have a default administrative position which
presumes that the dental clinic or staff has acted appropriately and will be
given the benefit of a doubt when a complaint is logged. Given that, all
complaints should be attempted to be resolved at the clinic level, ideally by
whom the complaint is about. Staff should be adequately trained and
empowered with righting a potential wrong. In most cases when a complaint
is received, the first line of resolution should be to send it right back to the
team of the facility against which the complaint was lodged. The complaint
process does not and should not exist as a way for clinic personnel to dismiss
a patient or a complaint to administration. Handling the complaint as a
boomerang is the most expeditious way of handling a patient with a
complaint, and keeps frontline personnel accountable and responsible for
their actions. Most often a complaint received by the administrative office
indicates a breakdown in communication, or worse, a lack of concern for
achieving patient satisfaction. Patients’ complaints received about an
individual or a clinic should also be recorded as part of our quality
improvement efforts. Depending on their nature, multiple complaints on a
clinic or individual may result in disciplinary administrative action. Patients
should only be directed to the administrative office when either all efforts at
the clinic level have been exhausted, or the response required is above the
authority of team member or the clinic. In the event a complaint needs to be
brought to the next level, a scenario under which it could occur might look
something like the strategy outlined here:

 When efforts have been exhausted at resolving the client’s complaint
at the clinic level, the patient should only then be instructed to call the proper
administrative office or patient contact center to lodge the complaint.

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 Administrative contact center staff will create a report of the
complaint. MCDC uses a form it has created in Survey Monkey to log
complaints.

 Administrative contact center staff will email the appointed
administrative staff (in the case of MCDC, the Regional Office Coordinator,
Chief Dental Officer and Chief Dental Officer) to inform them of the complaint.
If required, the complaint can be emailed to the appropriate staff.
 In nearly all cases the person complained about should be the one to
resolve the problem with the patient and administrative staff.
 If the complaint cannot be resolved by that person or the facility they
work within, then the patient should be referred to contact the administrative
office for further assistance. Where reasonable, the expected outcome is
always to achieve patient satisfaction with the services and the process
involved with receiving the services.
 A copy of the complaint should be kept on file in the administrative
office.

 Monthly reports of complaints should be made available to the
appropriate parties for continued improvement of the processes and policies
of the organization.

In the public health setting there are often multiple partners that may be
contacted to complain about a particular facility or individual. In those cases
it is important that the administration of the local clinic informs these
partners as to the policy and protocol for managing the complaint process,
and asks for their assistance in that regard. The partners should be asked to
disseminate that information to those who may have received past
complaints. The attempt of this policy is not to decrease transparency of the
operation but to foster a culture in which the organization empowers its
employees to manage patient satisfaction and accepts the responsibility and
accountability with that empowerment.

Exposure to Blood Borne Pathogens Incident Checklist

Individual states may vary on how exposures are to be handled. Regardless of
law, the intent is to provide the greatest environment of safety so that neither
patients nor staff is hurt. Below are guidelines to handle exposures. It is
suggested that an organization contact its state governing bodies for specific
regulations.

Immediately upon exposure:

 Obtain wound care for exposed person.
 Ask the source person, if known, to remain in the clinic. It is often
difficult to obtain tests and paperwork once they have left.

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 Review risk factors for Hepatitis B, Hepatitis C, Tetanus, and positive
HIV.
 Contact the OSHA compliance officer for the organization. Typically
this office is held within the HR department. The dental director or chief
dental officer should be made immediately aware of the incident.
 Involving the source person and obtaining his/her approval to be
involved in the process is critical. The source person should be given the
following:
o Post Exposure Laboratory Test Request for SOURCE person to be
taken to the local hospital or clinic.
o Consent Form for the Collection of Blood SOURCE person. Source
person to sign and return to the clinic.
o Important Information Booklet regarding an exposure. The SOURCE
person should read and sign the booklet.
 Give the employee the following:
o Post Exposure Laboratory Test Request form for EMPLOYEE to be
taken to local hospital or clinic.
o Consent Form for the Collection of Blood EMPLOYEE. EMPLOYEE to
sign and return to clinic.
o Important Information Booklet should be given to staff member with
instructions for review and signature.
o Exposure to Blood Borne Pathogens Report form, which is a
worksheet for the chief dental officer or dental director. Fill out completely
both sides and sign.
o Supplementary Record of Occupational Injuries & Illnesses. Fill out
completely both sides and sign.

Mail the originals of all forms to the administrative office the day of the
exposure. Keep a copy of all documents on file in the facility where the
exposure occurred.

Risk Management Tips for Clinics

It is widely believed that the population seeking care in public health settings
are more apt to consider litigation or the threat of litigation. Given that, a
robust policy of placing patients first is a critical component of risk
management.

In the experience of the MCDC, there exist two fundamental areas of concern.
The first is full and transparent communications with patients. The second is
complete and adequate follow-up, showing compassion and concern for
patients when untoward events occur. Other areas of risk management would

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include the following:

 Treat patients and staff courteously, respectfully, and professionally.
Unhappy patients are more likely to file claims.
 Be certain the patient has reasonable expectations concerning the
outcome of treatment before care is rendered.
 Keep complete, accurate, and unaltered records, including all
pertinent diagnostics.
 Perform thorough examinations and document findings, including all
negative findings of periodontal, oral cancer, and TMJ examinations.
 Obtain adequate medical and dental histories on all patients and
update them regularly. Be certain to document the information in the patient’s
dental record.
 Inform patients of untoward events or bad outcomes. Do not attempt
to conceal.
 Document in the patient’s dental record the receipt of written or oral
patient authorization whenever a copy of part or all of the dental record is
released from the office. Never release original records.
 Document the receipt of informed consent in the patient’s dental
record each time an informed consent discussion takes place, and the receipt
of informed refusal for any treatment recommendation refused by the patient.
 Before sending any account to collection, carefully review the patient’s
treatment outcomes, attitude, and level of satisfaction along with the accuracy
and completeness of record keeping.
 When terminating a doctor-patient relationship, send the patient a
letter which includes the reason and a 30-day notice period in which the
patient will continue to be seen for emergent care. The letter should be sent
certified return receipt with adequate documentation in the clinical note.

Authorized Dental Laboratories

In larger organizations there may be an ability to utilize an economy of scale
and obtain advantaged pricing with quality oriented labs. To obtain this
economy it will often be necessary to limit the number of labs which the
organization conducts business with. While this may seem an inconvenience
to some practitioners, this is really in the best interest of all. Creating
strategic partnerships with labs will likely result in improved quality,
personalized service, and dramatic cost savings.

Because practitioners have different needs and requirements, it is suggested
an organization form alliances with multiple labs. Currently MCDC works

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with four quality and value-oriented laboratories.

Abbreviated Note Version of the Michigan Medicaid Provider
Manual

These Cliff Notes are from the Covered Dental Services Provider Manual as
revised in April 2011. It includes the following: Diagnostic, Preventive,
Restorative, Endodontics, Periodontics, Prosthodontics, Oral Surgery, and
Adjunctive General Services. The manual makes use of the current CDT
Procedure Codes published by the ADA.

Great appreciation is extended to Dr. David Murphy, who has spent countless
hours researching the laws and regulations within the Medicaid system for
this presentation. The rule book required to be followed varies by state, but
most states’ Medicaid Manuals are several hundred pages in length. These
notes are the best attempt to simply that information.

6.1 Diagnostic Services

(Organization Uses PA for Prior Authorization), in short notes small pa =
periapical, dx = diagnosis, TX = treatment

6.1. A Clinical Oral Evaluation (OE) is a covered benefit ONLY if there is a
written documentation of the medical and dental findings and tests (cancer
exam) included in the record. Nothing documented=nothing done.

6.1. B. Comprehensive Exam (CE) must include the above, plus charting of
existing extra and intra oral conditions, occlusal relationships, perio
conditions including charting and appropriate radiographs. A treatment plan
must be included that addresses the patient’s needs.

6.1.C. Periodic Exam (PE) shows changes since last periodic or comp. exam
and must include clinically appropriate med/dent update, charting necessary
to update, including perio screening and necessary radiographs plus updated
tx. Plan to address needs.

6.1. D. Limited/Problem focused (Emerg.Ex.) is to diagnose a specific or chief
complaint (cc), oral health problem or trauma and must include charting and
written tx. Plan addressing the need/problem. This code can be billed with
radiographs, simple or surgical extractions, but NOT routine fillings or elective
therapy, such as RCT (include note that endo vs. ext was discussed and patient
chose ext.).

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6.1. E. Consultation is limited to dental/medical specialists who do not render
care to the patient. If the specialist does render care, they must bill under
appropriate code. However, if we as dentists do the consultation, our only
billable service is for necessary radiographs.

6.1. F. Radiographs are limited to the number necessary to make a diagnosis.
See MDCH Dental Database.

6.1. F.1. Complete Series (FMX) once every 5 years. Medicaid Guideline =
Minimum 10 intraoral + minimum of 2 bwx OR intra/extra oral series of Pan +
minimum of 2 bwx.

Any combination of 10 or more films or fee exceeding FMX fee, is considered a
FM series.

6.1. F.2. Bitewings (BWX) once every 12 months.

6.1. F.3 Panoramic once every 5 years. May be submitted with PA request to
replace existing dentures. Pan NOT acceptable in dx of caries, perio, or pa
pathology and is not covered for exts unless fm exts (or 3rd molar ext
performed by an O.S.).

6.1. F.4. Copies of FMX--If a patient changes providers and has had an FMX
within the previous 12 mos., we are obligated to send a copy of the FMX to the
new provider.

6.1. F.5. Radiographs for Prior Authorization (PA) Send them if they help
document your case. Need an FMX or PA X-rays for first denture, optional for
replacement denture, send if you believe it helps document your case. FMX is
required for PA for RPD, periapical for crowns.

6.1. F.6 Technical Considerations When sending in radiographs: 1. Mention an
area or tooth on a PA, it must show on the films. 2. Density and clarity must
be good. 3. On a PA X-ray, the apex and minimum of 1/8 inch surrounding it
must clearly show. 4. If pathology is in question, healthy surrounding bone
must show. 5. Interproximal bone must show without overlap of teeth under
consideration. 6. Posteriors such as third molars must be completely visible.
7. All radiographs must be mounted with patient name, Medicaid ID, date
taken, DDS name and address and R/L clearly labeled.

6.1. F.7. Returned Radiographs - If they don’t like them, they’ll send them back
with the PA = DELAY and no additional reimbursement. Radiographs will be
returned with PA form.

6.1. F.8. Photos not reimbursable, submit to document and/or clarify your
case.

6.1. F.9 Occlusal Films—Film, not view, determines payment.

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6.2 Preventive Services

6.2. A. Prophylaxis—includes routine scaling and debridement, polishing and
stain removal. Covered once every 6 months for single visit (even though 2 or
more visits may be required to complete case). Date of service must be final
visit if more than one visit (see 6.5 Debridement).

6.2. B. Topical fluoride application, once every 6 months, under 16, by tray or
varnish method. Not covered as topical application: fluoride in polishing paste,
topical application to tooth prep prior to restoration, fluoride rinses, home
fluoride or fluoride tablets.

Children age 0-2 may receive fluoride varnish four times per 12 months with
documentation of moderate to high caries risk; age 3-15 fluoride varnish 2
times every 6 mos with documentation of moderate to high caries risk.

6.2. C. Sealants - Coverage limited to molars that are fully erupted, age 5-15
for: prevention of pit and fissure caries, occlusal surfaces must be free of
caries or restorations. No coverage for patients with rampant decay or teeth
with restorations. Limit—once every three years. Fee includes repair or
replacement for three years.

6.2.D. Space Maintainers—coverage for under age 13 to maintain space for
permanent successor due to premature loss of primary tooth, one per
quadrant, once every two years.

6.3 Restorative Treatment - Amalgam or composite may be used to restore
caries or fractured teeth to a healthy state covered no more than once every
two years. Core or post/core is only allowed on permanent teeth.

6.3. A. Amalgam Restorations—bases, liners, adhesives, local anesthesia and
nitrous included in the fee. Restorations covering more than one surface must
use the code for total number of surfaces involved, i.e. two occlusal pits are
paid as one surface (D2140). Pins are reported separately. Fillings on any
deciduous teeth expected to exfoliate within 6 months are NOT reimbursable.

6.3. B. Composite Restorations—may be used posteriors follow requirements
but are reimbursed at the amalgam fee. Anterior resin crowns, under 21 only.

6.3. C. Crowns—SS under age 21 for primary teeth and 6-year molars, resin
window for primary anteriors. Lab processed resin crown reimbursable only
on anterior permanent teeth, requires PA.

6.4 Endodontics

6.4. A. Root Canal Therapy—is covered under 21 for conventional RCT where
otherwise sound teeth can be restored and the rest of the mouth supports this

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type treatment. Under age 21, not covered if: furcation pathology exists, if no
opposing posterior tooth, or is not restorable under Medicaid guidelines such
as with an amalgam, composite or post/core/crown.

6.4. B. Pulpotomy—for primary teeth under age 13 (unless exfoliation
imminent) or permanent teeth with open apices. Not considered first stage of
RCT. See 6.4.D. when opening tooth for endo that will be completed at a later
date (i.e. hot tooth).

6.4. C. Pulpectomy—endodontic therapy under age 8 when tooth is non-vital
or hemostasis unattainable during conventional pulpotomy. Must show
evidence of obturation of canals.

6.4.D. Pulpal debridement—covered under age 13 on primary or permanent
teeth prior to endo that is not done on the same appointment, i.e. opening a
hot tooth, but completing RCT on a different date.

6.4. E. Apexification—under age 13, permanent teeth with apex closure
incomplete.

6.4. F. Apexogenesis—under age 21, permanent teeth, not considered first
step of RCT.

6.4. G. Apicoectomy—covered under age 21.

6.5 Periodontics - Debridement: removal of sub and supra gingival calculus
and plaque—for better evaluation and diagnosis, age 14 up, once per year.
NOT covered if prophy done same day. No other perio. TX covered. Refer to
6.2.A. Prophylaxis which must be on a different date of service.

6.6 Prosthodontics (Removable)

6.6. A. General Instructions—All dentures and RPD’s must have a PA, and
minimum 5 year prognosis. Mx. RPD must have a prognosis which includes 6
sound teeth. Complete or partial dentures are authorized IF the following
conditions are met:

 One or more anterior teeth are missing.

 Less than 8 posteriors in occlusion (fixed bridge and denture
considered occluding teeth).

 Existing complete or partial denture cannot be made serviceable by
repair, reline, etc. IF existing RPD can be made serviceable by restorative
work, extractions and adding teeth and/or removing hyperplastic tissue, this
should be the treatment of choice.

Before final impressions, adequate healing time must be allowed to support

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the prosthesis following any extractions or surgery. Reimbursement includes
all necessary adjustments, relines, repairs within 6 months of insertion. The
only exception to the healing time is with 6 anteriors for an authorized
immediate denture.

If adjustment, reline, repair is done after 6 months, but was needed earlier, no
additional reimbursement will be given. LET IT HEAL. NO PA WILL BE
GRANTED for complete or partial denture IF one of the following applies:

 A previous prosthesis was made within 5 years (even if Medicaid
didn’t pay for it) or an adjustment, reline, repair will make the prosthesis
serviceable.

 Broken/lost prosthesis within 5 years (even if they weren’t obtained
through Medicaid).

 Document the date patient tells you current denture was made.

6.6. B. Complete Dentures - Coverage is for conventional teeth (no gold teeth,
etc.) with acrylic resin bases constructed using the following procedures:

 Individual positioning of the teeth

 Wax up of the entire denture body

 Conventional lab processing

 Preformed dentures, overdentures, or Cusil dentures are not a covered
benefit

6.6. C. Immediate complete denture - Benefit only when the extractions
involve anterior teeth—maxillary or mandibular. Requesting PA must state
denture is immediate, which teeth will be removed on insertion, and the
reason an immediate denture is needed such as job/interview/speaking etc.

For reasons of stability and retention, an immediate is not a benefit:

 For posterior segments of either arch

 Where cast metal base saddles are to be used

6.6. D. Partial Denture - Covered benefit over age 16 (to be sure all teeth are
erupted) with these limitations:

 One piece cast metal, not covered. Metal frame/resin saddles is the
norm.

 Semi-precision, precision, stress-breaker, swing-lock, etc. not covered.

 To replace lost anterior under age 16, PA must be for interim PD
(flipper).

6.6. E. Interim Complete and Partial Dentures - Interim complete or partial

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dentures only authorized in unusual circumstances. MUST submit justification
AND explanation of proposed FUTURE treatment with the PA request. Cusil
dentures are not a covered procedure in the state of Michigan

6.6. F. Relines - After initial 6 months, relines or duplications are covered
ONCE in 2-year period. Lab or chairside relined covered. Reline and
adjustment are not payable on same date of service.

6.6. G. Repairs - After initial 6 months, repairs/adjustments are payable only
twice in 12 months, CD or RPD. Repairs to interim appliances are NOT
covered.

Allowance for repair/reline/rebase cannot exceed half the fee for new
prosthesis IF the repairs are within 6 months of replacement date.

6.7. Oral Surgery

Oral surgical procedures are covered for all beneficiaries. Extractions for
orthodontic purposes are NOT a covered benefit. Jaw or facial bone surgery is
considered a medical not dental benefit.

6.7. A. Extractions

 An extraction is NOT covered if exfoliation is imminent.
Documentation might help, i.e., pain/tooth cutting gums when chewing food,
etc.
 Surgical extraction covered if bone removal and elevation of a
flap AND/OR sectioning required facilitating the extraction. DOCUMENT
WELL.
 PLEASE NOTE: Surgical extraction(s) **NOT** covered if multiple
extractions done in same quadrant in preparation for dentures. They will be
reduced to “simple” extractions.
 Impacted tooth removal covered only when conditions arising from
such an impaction warrant its removal. DOCUMENT THE NEED or WE WILL
NOT BE PAID.
 Prophylactic removal is NOT a covered benefit. Must be overt
pathology AND symptoms. See Delta guide to 3M removal.

6.7. B. Tooth Replantation and Fixation, Under 21 when avulsion or
displacement of permanent anterior teeth involved due to trauma.

6.7. C. Alveoloplasty

Covered benefit when performed in preparation of the ridge for complete or
partial dentures.

Secondary alveoloplasty NOT covered when recent extractions were done in

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that quadrant.

6.8. Adjunctive General Services
 Anesthesia services (IV Sedation or General Anesthesia) are the only
services billable separate from the surgical procedure for ALL beneficiaries.
 General anesthesia limited to situations where local anesthesia is
medically contraindicated.
 IV Sed/Gen NOT for convenience of dentist or patient OR because of
apprehension.
 IV Sed/Gen NOT billable if used only to allow use of local and the local
is the primary agent.
 IV Sed/Gen NOT billable separately if used in combination with each
other.
 Non-IV Conscious Sedation is benefit for ages 0-5 and includes
administration of sedative and/or analgesic agents plus appropriate in-office
monitoring, NOT just administration of nitrous oxide. Nitrous oxide/oxygen
NOT separate billable procedure. See the MCDC’s guidelines for adults.
Clarifications:
 Imminent exfoliation used regarding exts 6.7.A., pulpotomy 6.4.B., and
restorations 6.3.A.
This means the tooth may reasonably be expected to exfoliate within 6
months.
 Six Sound Teeth required for Mx. RPD PA 6.6.A., using fewer for Md.
RPD (example 2 Cuspids). Provide sound reasoning and document on your PA
before proceeding.

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Medicaid Provider Manual MDCH Dental Limitations: Age
Short Notes - Reference Database Code and Frequency
of Use
6.1.B.Comprehensive Exam (CE) D0150 All ages
1 in 6 months
6.1.C. Periodic D0120 3 and over
Exam (PE) D0140 1 in 6 months
6.1.D. Limited All ages
Exam (Emergency) No frequency
limit
*All the above exams may be done D0145 listed
on infants with special coding. 0-2
There is no descriptor specific to 1 in 6 months
this in the MDCH Provider Manual
?
6.1.E. Consultation Limited to No code for general
Medical and Dental Specialist dentists No age limit
1 in 5 years
6.1.F. Intraoral Complete Series D0210 No age limit
No frequency
(including BW) limit
No age limit
Intraoral, periapical D0220 No frequency
limit
First film No age limit
No frequency
Intraoral, each additional film D0230 limit

Intraoral—Occlusal—film— D0240 147
special note—this is payable by
size film (occlusal)—NOT by the
view

See 6.1.F.9

6.1. F.2. Bitewings D0270 Single film No age limit
(BW) Must use appropriate No frequency
code if more than one limit
6.1. F.3. Panoramic Film film is taken
6.1. F.9. Occlusal Films—See D0272 Two Films No age limit
Above 1 in 12 Months
6.1.A. Prophylaxis D0273 Three Films No age limit
(continued) 1 in 12 Months
6.2.B. Topical Fluoride D0274 Four Films No age limit
1 in 12 Months
6.2.C. Sealants D0330 No age limit
1 in 5 years
D0240 Use only Occlusal No age limit
Size Film No frequency
limit
D1110—Adult 14 and over
1 per 6 months
D1120--Child 0-13
1 per 6 months
D1203 3-15
1 per 6 months
D1206 0-2
4 per 12 months
D1206 3-15
1 per 6 months
D1351 per tooth 5-15
Number must be on 1 per 36 months
claim
D1510 Fixed Unilateral Up through age
12
1 in 2 years per

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6.3.A. Amalgams D1515 Fixed Bilateral quadrant
**NOTE** RESTRICTIONS IN THE Up through age
SHORT NOTES D2140 One surface, 12
primary or permanent 1 in 2 years per
Anterior Resins arch
**Note** D2150 Two surfaces, No age limit
RESTRICTIONS IN THE SHORT primary or permanent
NOTES D2160 Three surfaces, No age limit
primary or permanent No age limit
Posterior Resins D2161 Four surfaces, No age limit
**NOTE** primary or permanent No age limit
RESTRICTIONS IN SHORT NOTES D2330 One surface,
anterior No age limit
No age limit
D2331 Two surfaces, No age limit
anterior
D2332 Three surfaces, Covered benefit
anterior for UNDER 21
D2335 Four or more ONLY
surfaces or involving No age limit
incisal angle
D2390 Resin-based No age limit
Composite Crown,
Anterior
D2391 Resin-based
composite, one surface,
posterior

D2392 Resin-based
composite, two surfaces,
posterior

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D2393 Resin-based No age limit
composite, three
surfaces, posterior

D2394 Resin-based No age limit
composite, four or more
surfaces posterior

D2710-Resin based Under 21 ONLY
composite indirect PRIOR NEEDED

D2712-3/4 Resin- based Under 21 ONLY

composite indirect PRIOR NEEDED

D2910-Recement inlay, No age limit
onlay or partial coverage
restoration No frequency
limit

D2915-Recement Cast or Under 21 ONLY
Prefabricated Post and
Core No frequency
limit

D2920-Recement Crown No age limit

No frequency
limit

D2930-Prefab stainless Under 21 only
steel crown-primary
No frequency
limit

D2931-Prefab stainless Under 21 only
steel crown-permanent
No frequency
limit

D2933-Prefab SSC with Under 21 only
resin window
No frequency
limit

D2934-Prefab Esthetic Under 21 only
coated SSC-Primary
tooth No frequency
limit

D2940-Sedative filling Under 21 only

No frequency

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limit

D2950-Core buildup, Under 21 only
incl. pins
No frequency
limit

D2951-Pin retention-per No age limit
tooth, addition to
restoration No frequency
limit

D2952-Cast post core in Under 21 ONLY
addition to crown
No frequency
limit

D2954-Prefab post core Under 21 ONLY
in addition to restoration
No frequency
limit

D2999-unspecified No age limit
restorative procedure,
report No frequency
limit

PRIOR NEEDED

D3110-Pulp cap- Under age 21
direct(excluding final
restoration) No frequency
limit

See 6.4.B. Pulpotomy D3220-Therapeutic Under age 21 (Up
See 6.4.D. Pulpotomy (excluding thru age 12)
final restoration)
No frequency
limit

(One per tooth)

D3221-Pulpal Under age 21 (Up
Debridement, Primary thru age 12)
and Permanent Teeth
No frequency
limit

Obviously not
more than once
on same the
tooth

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D3230-Pulpal Therapy, Age 0-7
anterior, primary
No frequency
D3240-Pulpal Therapy, limit
posterior, primary
Age 0-12
D3310-Anterior
(excluding final No frequency
restoration) limit

D3320-Bicuspid Under age 21
(excluding final
restoration) No frequency
limit
D3330-Molar (excluding
final restoration) Under age 21

D3351-Apexification- No frequency
initial visit limit

D3352-Apexification- Under age 21
interim medication
replacement No frequency
limit
D3353-Apexification-
final visit Age 0-12

D3410-Apicoectomy- No frequency
anterior limit

D3421-Apicoectomy- Age 0-12
bicuspid(first root)
No frequency
D3425-Apicoectomy- limit
molar (first root)
Age 0-12

No frequency
limit

Under age 21

No frequency
limit

Under age 21

No frequency
limit

Under age 21

No frequency

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D3426-Apicoectomy- limit
(each additional root)
Under age 21
D3430-Retrograde
filling-per root No frequency
limit
D3999-Unspecified
endodontic procedure, Under age 21
by report
No frequency
D4355-Full mouth limit
debridement
D5110-Complete Under age 21
Denture-Maxillary
No frequency
D5120-Complete limit
Denture-Mandibular
(documentation
required with
claim)

14 and over

1 per 12 months

Under and Over
age 21

1 per 5 years
(strictly
enforced)

Under and Over
age 21

1 per 5 years
(strictly
enforced)

6.6.C. Immediate Dentures

D5130-Immediate Under and Over
Denture-Maxillary age 21

D5140-Immediate 1 per 5 years
Denture-Mandibular
Under and Over
D5211-Maxillary partial age 21

1 per 5 years

Under and Over
age 21, MUST be

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denture, resin base 16

D5212-Mandibular 1 per 5 years
partial denture, resin
base Under and Over
age 21, MUST be
D5213-Maxillary partial 16
denture, cast metal
frame with resin bases 1 per 5 years

D5214-Mandibular Under and Over
partial denture, cast age 21, MUST be
metal frame, resin bases 16

D5225-Maxillary partial 1 per 5 years
denture-flex base
(including clasps, rests, Under and Over
teeth) age 21, MUST be
D5226-Mandibular 16
partial denture-flex base
(including clasps, rests, 1 per 5 years
teeth)
Under and Over
age 21

1 per 5 years

Under and Over
age 21

1 per 5 years

D5410-Complete Under and Over
denture adjustment- age 21
maxillary
No frequency
D5411-Complete limit
denture adjustment-
mandibular Under and Over
age 21
D5421-Partial denture
adjustment-maxillary No frequency
limit

Under and Over
age 21

No frequency
limit

154

D5422-Partial denture Under and Over
adjustment-mandibular age 21

No frequency
limit

D5510-Repair broken Under/Over age
complete denture base 21

ONLY TWICE in
12 MONTHS

D5520-Replace missing Under and Over
or broken teeth- age 21
complete denture (each
tooth) No frequency
limit

D5610-Repair resin Under and Over
denture base age 21

See above note

D5620-Repair cast Under/Over 21
framework See note above

D5630-Repair or replace Under and Over

broken clasp age 21

See note above

D5640-Replace broken Under and Over
teeth-per tooth age 21

See note above

D5650-Add tooth to Under/Over 21
existing partial See note above

D5660-Add clasp to Under/Over 21
existing partial See note above

D5710-Rebase complete Under/Over 21

maxillary denture See note above

D5711-Rebase complete Under/Over 21

mandibular denture See note above

D5720-Rebase maxillary Under/Over 21

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partial denture See note above
D5721-Rebase
mandibular partial Under/Over 21
denture
D5730-Reline complete See note above
maxillary denture (chair
side) Under/Over 21

D5731-Reline complete After initial 6
mandibular denture months = 1 in 2
(chair side) yrs.

D5740-Reline maxillary Under/Over 21
partial denture (chair
side) After initial 6
months = 1 in 2
D5741-Reline yrs.
mandibular partial
denture (chair side) Under/Over 21

D5750-Reline complete After initial 6
maxillary denture (lab) months = 1 in 2
yrs.
D5751-Reline complete
mandibular denture Under/Over 21
(lab)
After initial 6
D5760-Reline maxillary months = 1 in 2
partial denture (lab) yrs.

D5761-Reline Under/Over 21
mandibular partial
denture (lab) After initial 6
months = 1 in 2
yrs.

Under/Over 21

After initial 6
months = 1 in 2
yrs.

Under/Over 21

After initial 6
months = 1 in 2
yrs.

Under/Over 21

After initial 6
months = 1 in 2

156

yrs.

D5810-Interim complete UNDER 21 ONLY
denture (maxillary)

D5811-Interim complete UNDER 21 ONLY
denture (mandibular)

D5820-Interim partial UNDER 21 ONLY
denture (maxillary)

D5821-Interim partial UNDER 21 ONLY
denture (mandibular)

D6930-Recement fixed Under/Over 21
partial denture
No frequency
listed

D7111-Extractions, UNDER 21 ONLY
Coronal Remnants-
deciduous tooth No frequency
listed

D7140-Extraction Under/Over 21
erupted tooth or exposed
root (elevation and/or No frequency
forceps removal) listed

D7210-Extraction of Under/Over 21
tooth, erupted
No frequency
listed

(SEE SPECIAL
NOTE)

D7220-Extraction of Under/Over 21
tooth, soft tissue
impaction No frequency
listed

D7230-Extraction of Under/Over 21
tooth, partial bony
impaction No frequency
listed

D7240-Extraction of Under/Over 21
tooth, complete bony
impaction No frequency
listed

157

D7250-Surgical removal Under/Over 21
of residual tooth roots
(cutting procedure) No frequency
listed
D7260-Oroantral fistula
closure Under/Over 21

D7261-Primary closure No frequency
of sinus perforation listed

D7270-Tooth Under/Over 21
replantation and/or
stabilization No frequency
listed
D7472-Removal of torus
palatines UNDER 21 ONLY

D7473-Removal of torus No frequency
mandibularis listed

D7485-Surgical Under/Over 21
reduction of osseous
tuberosity No frequency
listed
D7510-Incision and
drainage (intraoral soft Under/Over 21
tissue)
No frequency
D7970-Excision of listed
hyperplastic tissue-per
arch Under/Over 21

D7971-Excision of No frequency
pericoronal gingival listed

D7972-Surgical Under/Over 21
reduction of fibrous
1 per day

2 per 12 months

Under/Over 21

No frequency
listed

Under/Over 21

No frequency
listed

Under/Over 21

No frequency

158

tuberosity listed

D7999-Unspecified oral Under/Over 21
surgery
procedure/report No frequency
listed
D9110-Palliative
treatment UNDER 21 ONLY

D9220-Deep No frequency
Sedation/General listed
Anesthesia-First 30
minutes Under/Over 21

D9221-Deep No frequency
Sedation/General listed

Each add.15 min. Under/Over 21

D9241-IV Conscious No frequency
Sedation/analgesia listed

First 30 min. Under/Over 21

No frequency
listed

D9242-IV Conscious Under/Over 21
Sedation/analgesia
No frequency
Each add. 15 min. listed

D9248-Non-IV Conscious AGE 0-5
Sedation
No frequency
listed

D9310-Consult (service Under/Over 21
rendered by provider
other than dentist No frequency
providing treatment listed

D9420-Hospital Calls Under/Over 21

2 per 12 months

Examples: Treat dry socket or D9930-Complication Under/Over 21
remove bone spicule (Post-surgical-unusual
circumstances) No frequency
listed

Multi-Codes in the Dental Office

159

When reimbursing providers in large group practices where multiple providers may play a
role in a multi-step procedure it may be appropriate to develop codes which may not
necessarily be billable but are utilized to track for staff remuneration. Most billable codes in
the Current Dental Terminology (CDT) are a D code. Below are suggestions as possible multi-
codes an office may utilize. The fees listed are for demonstration purposes only. MCDC itself
does not utilize multi codes.

Multi-Code Groupings for Dental Procedures

Fixed Partial Dentures Removable Partial Dentures

RVU RATE RVU RVU RVU
RATE RATE RATE
CODE DESCRIPTION $600 CODE DESCRIPTION $200
R5200 $200
R6200 Bridge prep, impress, temporary*. To $600 $365 Partial master impression. To be used $200
be used only once per bridge. $398 R5201 only once per partial.
D5211 $251
D6241 Pontic-crn (per unit), porc/base metal at $385 Partial frame try in, bite registration. To
delivery be used only once per partial.

D6751 Retainer-crn (per unit), porc/base metal $430 Maxillary partial, resin base at delivery
at delivery

D6211 Pontic-crn (per unit), base metal at D5212 Mandibular partial, resin base at delivery $251
delivery

D6791 Retainer-crn (per unit), base metal at Total RVU resin based partial/above $651
delivery

Total RVU 3 unit porc/base/above $1,845 D5213 Maxillary partial, cast frame at delivery $583
D5214 $583
Mandibular partial, cast frame at
Total RVU 3 unit base/above $1,761 delivery

*Bridges more than 3 units in length will Total RVU cast frame partial/above $983
need to coordinate with billing to insure Maxillary partial flexible base $420
proper RVU's are administered at the Mandibular partial flexible base $420
R6000 code. $100 will be added for Total RVU partial flexible base/above $820
each additional unit to the R code.

D5225
D5226

Complete Dentures

Denture master impression. To be used $200 $200
R5100 only once per denture. $200

Denture try in, bite registration. To be $200 $562
R5101 used only once per complete denture. $562

D5110 Maxillary complete denture at delivery $473

Mandibular complete denture at 160$473
D5120 delivery

Total RVU D2740/above $705 Total RVU complete denture/above $873
Total RVU D2751/above
$630 D5130 Maxillary immediate denture

D5141 Mandibular immediate denture

Individual Crowns RVU RVU RVU
RATE RATE RATE
DESCRIPTION $200 $200
Crown prep, impress, temporary. To be $200
used only once per crown. $408 $505
Crown, resin (indirect) at delivery Complete Dentures
Crown, all porcelain at delivery
Denture master impression. To be used
R5100 only once per denture. $200 $200
$200
Crown, porcelain/base metal $430 Denture try in, bite registration. To be $200
used only once per complete denture. $473
R5101
$473
D5110 Maxillary complete denture at delivery $873

Total RVU D2710/above $608 D5120 Mandibular complete denture at
Total RVU D2740/above $705 delivery

Total RVU complete denture/above

Total RVU D2751/above $630 D5130 Maxillary immediate denture $562
D5141 Mandibular immediate denture $562
$962
Total RVU immediate denture/above

ABUSE AND NEGLECT

In Michigan, as in all 50 States, physicians and dentists are required to report
suspected cases of abuse and neglect to social services or law enforcement. As
physicians do not have extensive training in oral health or dental injury, we as
dentists are uniquely suited to intercept these cases early. More than 50% of
abuse cases involve injuries to the head and neck, precisely where we as
dentists are focused in our examination and treatment.

Child abuse can be both physical and/or sexual. Signs of abuse include
bruising, burns, lacerations of the tongue, lips, buccal mucosa, palate, gingiva,
alveolar mucosa, or frenum. Fractured or displaced teeth may be indicators as
well. Signs of sexual abuse include pharyngeal gonorrhea and unexplained
injury or petechiae of the palate. If any of these signs are seen on examination
of a patient, further inquiry with both patient and parent as to how they
occurred are warranted, and referral to Child Protective Services (CPS) should
be done as needed.

Dental neglect, as defined by the American Academy of Pediatric Dentistry is
the “willful failure of parent or guardian to seek and follow through with
treatment necessary to ensure a level of oral health essential for adequate
function and freedom from pain and infection.” It is important to recognize
that failure to seek proper dental care may result from factors such as family
isolation, lack of finances, parent ignorance, or lack of perceived value of
health. It is not considered neglect until the parent has been alerted by a

161

health care professional about the nature and extent of the disease, and the
treatment required to remedy the situation.
Within our clinic system we see many children in desperate need of dental
care. Failure to treat oral infection can result in pain, infection, and swelling.
Impacts on the daily life of a child include missed school. If we have pediatric
patients with open treatment plans that include the need for pulpal therapy or
extractions due to abscess that fail to schedule appointments, the case should
be referred to social services for follow-up. Should pediatric patients meeting
the same criterion have enough no-shows/late cancellations to be dismissed
from the clinic system, the treating doctor may choose to refer the case to
social services (Child Protective Services) for follow-up.
In order to refer the case to Child Protective Services (CPS), the treating
doctor must complete the appropriate State form (in Michigan form
DHS3200) and fax it to the county of residence of the patient. The form should
include demographic information and the nature of the concern/complaint
(see attached form). If CPS is involved, the organization will provide an
opportunity for the child to be scheduled again if CPS arranges for
transportation to the visit or appoints a suitable guardian to do the same.
This policy is designed to protect those who do not have a voice of their own.
It is our professional, legal, and ethical responsibility as doctors to look out for
the best interests of our patients. It is important to note that filing a complaint
with CPS does not result in punitive actions being taken against the parents.
The purpose of filing is to protect the patient. CPS involvement is for the
benefit of the child, not the prosecution of the parents.

162

ABW Commonly Used Dental Acronyms
ALS
BLS Adult Benefit Waiver
BMI Advanced Life Support
BOD Basic Life Support
BRFSS Body Mass Index
BYC Board of Directors
CAH Behavioral Risk Factor Surveillance Survey
CDA Boyne City
CDC Critical Access Hospital
CDO Certified Dental Assistant
CEO Centers for Disease Control and Prevention
CFO Chief Dental Officer
CMCF Chief Executive Officer
CMS Chief Financial Officer
CPA County Medical Care Facilities
DAF Centers for Medicare and Medicaid Services
DCN Certified Public Accountant
DDS Dental Assistance Fund
DHS Dental Clinics North
DMD Doctor of Dental Surgery
DO Michigan Department of Health and Human Services
ED Doctor of Dental Medicine
EMS Osteopathic Physician
EMT Emergency Department
ER Emergency Medical Services
FPL Emergency Medical Technician
Emergency Room
Federal Poverty Level

163

FQHC Federally Qualified Health Center
FQHC LA FQHC Look-Alike
FTE Full-Time Equivalent
GME Graduate Medical Education
HIPSA Health Information Privacy and Security Act
HPSA Health Professional Shortage Area
HR Human Resources
HRA Health Risk Assessment
ISD Intermediate School District(s)
IS Information Services
IT Information Technology
LHD Local Health Department(s)
LIP Low-Income Population
LTC Long-term Care
LTCU Long-term Care Units
MALPH Michigan Association for Local Public Health
MBA Master of Business Administration
MCDC Michigan Community Dental Clinics
MCDP Michigan Community Dental Plan
MCRH Michigan Center for Rural Health
MD Allopathic Physician
MDA Michigan Dental Association
MDCH Michigan Department of Community Health
MI Michigan
MOHC Michigan Oral Health Coalition
MSLRP Michigan State Loan Repayment Program
MSU Michigan State University
MUA Medically Underserved Area
MUP Medically Underserved Population

164

NDP Northern Dental Plan
NEAT Nutrition Environment Assessment Tool
NHSC National Health Service Corps
OSHA Occupational Safety and Health Administration
PA 161 Public Act 161
RDA Registered Dental Assistant
RDH Registered Dental Hygienist
RHC Rural Health Clinics
RN Registered Nurse
SLRP State Loan Repayment Program
SMI Severe Mental Illness
UP Michigan's Upper Peninsula

165

166

Supervision Levels Required for Delegated Duties
The definitions that follow are taken from the Administrative Rules of the
Michigan Board of Dentistry.
A = ASSIGNMENT - means that a dentist has designated a patient of record
upon whom services are to be performed by an assistant, registered dental
assistant, or registered dental hygienist and has described the procedure to be
performed. The dentist need not be physically present in the office or in the
treatment room at the time the procedures are being performed.
G = GENERAL SUPERVISION - means that a dentist has designated a patient
of record upon whom services are to be performed. The dentist shall be
physically present in the office during the performance of the procedures.
D = DIRECT SUPERVISON - means that a dentist has designated a patient of
record upon whom services are to be performed by a dental assistant,
registered dental assistant or licensed dental hygienist and has described the
procedures to be performed. The dentist shall examine the patient before
prescribing the procedure to be performed and again upon completion of the
procedure. The licensed dentist shall be physically present in the office at the
time procedures are being performed.
*Delegated duties and levels of supervision required may vary state to state

167

Section 8

Forms

Annual OSHA Training

Bloodborne Pathogens Standard & Exposure Control Plan:
I hereby acknowledge that I have reviewed the current Exposure Control Plan,
including the annual bloodborne pathogens video training and fully
understand:
The modes of transmission of bloodborne disease
How to recognize tasks with a disease transmission hazard
How to apply the concept of universal precautions
How to handle non‐routine hazardous tasks
The requirement for Hepatitis B Immunization
How to comply with standard operating procedures for asepsis
The location, use and limitations of protective equipment
How to handle accidental exposure to blood and saliva
The safe handling and disposal of contaminated waste and sharp items
The necessary disinfection/sterilization techniques for our clinic
How to handle blood/chemical spills
The proper technique for hand‐washing

Acknowledgement of Category A & B Employees:
Employees are categorized by potential exposure to bloodborne pathogens.
These are:
Category A: All occupations that require procedures or occupation‐related
tasks that involve direct exposure or the potential for exposure to blood or
other potentially infectious material.
Category B: Occupations that require tasks that do not involve direct exposure
to blood or other potentially infections material on a routine or non‐routine
basis as a condition of employment.

168

Hazardous Communication & Medical Waste Management:

I hereby acknowledge that I have reviewed Hazardous Communication Plan,
Medical Waste Management & Amalgam Recycling Protocol, and Fire Safety and
Evacuation Protocol and fully understand:

 What this clinic’s Hazard Communication Plan is, and why we need it
 The Right to Know Law for my protection while working in this clinic
 How to understand and use Safety Data Sheets
 How to label hazardous materials and what the labels mean
 This clinic’s Emergency Procedures for spills
 This clinic’s Emergency Procedures for exposures
 This clinic’s Fire Drill and the proper techniques for using the fire

extinguisher(s)
 How to administer First Aid, using our First Aid Kit and First Aid Manual
 How to assure safety from Radiation Exposure
 How to handle and dispose of hazardous chemicals and medical waste
 How to handle and dispose of contaminated sharps
 How to handle and dispose of other contaminated waste: lead aprons,

used Amalgam, and Extracted teeth with Amalgam.

Employee Agreement

My signature on this Condition of Employment Agreement certifies that I have
read the above conditions for my employment here and that I fully understand
each statement therein.

I further understand that I work in the following category as a result of my
current role. I accept and will abide by the conditions above.

Category

AB

Personal Protective Equipment:

I certify that I received training required under OSHA’s rule on Personal
Protective Equipment. As part of this training, I was informed of the personal
protective equipment selected by the dental clinic for their use.

I acknowledge that I have received required OSHA Training and have completed
the Training Quiz.

Employee Name: __________________________ Employee Signature: ____________________

Date: ____/_____/_________ Primary Office:___________________________

Please note: You will need to receive additional training from your Safety
Coordinator if you have additional questions or are unfamiliar with the above
mentioned protocols.

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174

175

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177

178

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180

ETHICSHANDBOOK FOR
DENTISTS

An Introduction to Ethics, Professionalism, and
Ethical Decision Making

Prepared by
American College of Dentists
839J Quince Orchard Boulevard
Gaithersburg, Maryland 20878-1614

This section reprinted with explicit approval of the American College Of Dentists

181

ANAPPEAL

Follow impulses and leaderships that represent ideals; that point the way to your professional destiny;
that express integrity, fidelity, service, and lofty purposes—the finest that is in you individually and
professionally!

William J. Gies July 11, 1937

PURPOSE

The American College of Dentists dedicates this handbook to the dental profession with the expectation
that it will serve as a useful introduction to ethics, professionalism, and ethical decision making. It is
intended to heighten ethical and professional responsibility, promote ethical conduct in dentistry,
advance dialogue on ethical issues, and stimulate further reflection on common ethical problems in
dental practice. It is not intended to solve specific ethical dilemmas. Dentists are strongly encouraged to
further their understanding of ethics and ethical issues beyond this introduction. Dentists should
familiarize themselves with the prevailing laws, regulations, and standards that affect their decisions.

For those who seek the privileges and responsibilities of a dental professional, this handbook will serve
as an introduction to the challenges and opportunities ahead and provide insights to a successful
career.

Copyright © 2000-2013 American College of Dentists All rights reserved.
Revised 2013

Printed in the United States of America

A project of the
American College of Dentists Foundation

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