by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Jun 19th, 2015 - Reviewed/Updated Aug 8th
The following procedures are found in Oxfords Dental policy.
The following procedures MAY qualify for coverage under the general benefits package:
- Oral surgical procedures for the correction of a non-dental physiological condition which results in a severe functional impairment.
- Oral surgical procedures for the excision of cysts and tumors of the maxilla, mandible and surrounding tissues (cysts and tumors associated with the teeth are not covered). Exception: Please check the member specific benefit plan document for New Jersey (NJ) Small Group plans (excision of cysts and tumors associated with teeth may be covered).
- Dental services for the repair (not replacement) of sound and natural teeth, maxilla, mandible, and surrounding tissues following accidental injury (not including injuries caused by eating, biting, or chewing).
- Treatment must be rendered within 12 months of the injury. Exception: Please check the member specific benefit plan document for NJ Small Group plans for additional coverage limitations.
- Accidental injury must be documented.
- Pre- and post-accident x-rays are required.
- Teeth were stable and functional immediately prior to the time of the accident without evidence of decay, periodontal disease, or endodontic pathology.
- Surgical removal of bony impacted teeth. Note: This benefit is limited to specific lines of business; refer to the member specific benefit plan document.
Dental services that are medically necessary and incident to a covered medical service including:
- Extraction of teeth before radiation treatment of the head and neck
- Extraction of teeth incidental to reducing a fracture of the jaw
- Dental examination prior to major surgery o Reconstructive surgery and grafting procedures in conjunction with oral resective surgery if completed at the same time as resective surgery (not including replacement of teeth.
- Obturators and obturator prosthesis after resective surgery.
- Removal of odontogenic cysts or tumors >1.5 cm in diameter.
- Removal of soft tissue neoplasms of the of lips, tongue, palate, floor of mouth, and vestibule (e.g., fibromas, mucocoeles, etc.).
Oxford's Dental Department will review requests for dental services rendered:
- for the following services when delivered in conjunction with dental services:
- Dental services
- Oral surgical services
- Anesthesia services delivered in conjunction with dental services.
- by practitioners of the following specialties:
- oral/maxillofacial surgery
- pediatric dentistry
- endodontics
- orthodontices
NOTE: All other specialties require Medical Director review through Oxford's Medical Management Department.
- Precertification with review by a Medical Director or their designee is required.
The codes listed in this policy are for reference purposes only, this listing does not mean teh procedure is covered. Be sure to verify the patients benefits and eligibility.
This list of CPT® Codes may not be all inclusive.
| 21010 | Arthrotomy, temporomandibular joint |
| 21015 | Radical resection of tumor (eg, sarcoma), soft tissue of face or scalp; less than 2 cm |
| 21016 | Radical resection of tumor (eg, sarcoma), soft tissue of face or scalp; 2 cm or greater |
| 21025 | Excision of bone (eg, for osteomyelitis or bone abscess); mandible |
| 21026 | Excision of bone (eg, for osteomyelitis or bone abscess); facial bone(s) |
| 21029 | Removal by contouring of benign tumor of facial bone (eg, fibrous dysplasia) |
| 21030 | Excision of benign tumor or cyst of maxilla or zygoma by enucleation and curettage |
| 21031 | Excision of torus mandibularis |
| 21032 | Excision of maxillary torus palatinus |
| 21034 | Excision of malignant tumor of maxilla or zygoma |
| 21040 | Excision of benign tumor or cyst of mandible, by enucleation and/or curettage |
| 21044 | Excision of malignant tumor of mandible; |
| 21045 | Excision of malignant tumor of mandible; radical resection |
| 21046 | Excision of benign tumor or cyst of mandible; requiring intra-oral osteotomy (eg, locally Aggressive or destructive lesion[s]) |
| 21047 | Excision of benign tumor or cyst of mandible; requiring extra-oral osteotomy and partial mandibulectomy (eg, locally aggressive or destructive lesion[s]) |
| 21048 | Excision of benign tumor or cyst of maxilla; requiring intra-oral osteotomy (eg, locally Aggressive or destructive lesion[s]) |
| 21049 | Excision of benign tumor or cyst of maxilla; requiring extra-oral osteotomy and partial maxillectomy (eg, locally aggressive or destructive lesion[s]) |
| 21050 | Condylectomy, temporomandibular joint (separate procedure) |
| 21060 | Meniscectomy, partial or complete, temporomandibular joint (separate procedure) |
| 21070 | Coronoidectomy (separate procedure) |
| 21076 | Impression and custom preparation; surgical obturator prosthesis |
| 21077 | Impression and custom preparation; orbital prosthesis |
| 21079 | Impression and custom preparation; interim obturator prosthesis |
| 21080 | Impression and custom preparation; definitive obturator prosthesis |
| 21081 | Impression and custom preparation; mandibular resection prosthesis |
| 21082 | Impression and custom preparation; palatal augmentation prosthesis |
| 21083 | Impression and custom preparation; palatal lift prosthesis |
| 21084 | Impression and custom preparation; speech aid prosthesis |
| 21085 | Impression and custom preparation; oral surgical splint |
| 21086 | Impression and custom preparation; auricular prosthesis |
| 21087 | Impression and custom preparation; nasal prosthesis |
| 21088 | Impression and custom preparation; facial prosthesis |
| 21089 | Unlisted maxillofacial prosthetic procedure |
| 21100 | Application of halo type appliance for maxillofacial fixation, includes removal (separate procedure) |
| 21110 | Application of interdental fixation device for conditions other than fracture or dislocation, includes removal |
| 21116 | Injection procedure for temporomandibular joint arthrography |
| 21188 | Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts) |
| 21206 | Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard) |
| 21208 | Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) |
| 21209 | Osteoplasty, facial bones; reduction |
| 21210 | Graft, bone; nasal, maxillary or malar areas (includes obtaining graft) |
| 21215 | Graft, bone; mandible (includes obtaining graft) |
| 21240 | Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft) |
| 21242 | Arthroplasty, temporomandibular joint, with allograft |
| 21243 | Arthroplasty, temporomandibular joint, with prosthetic joint replacement |
| 21244 | Reconstruction of mandible, extraoral, with transosteal bone plate (eg, mandibular staple bone plate) |
| 21245 | Reconstruction of mandible or maxilla, subperiosteal implant; partial |
| 21246 | Reconstruction of mandible or maxilla, subperiosteal implant; complete |
| 21248 | Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial |
| 21249 | Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); complete |
| 21255 | Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts) |
| 21296 | Reduction of masseter muscle and bone (eg, for treatment of benign masseterichypertrophy); intraoral approach |
| 21299 | Unlisted craniofacial and maxillofacial procedure |
| 21421 | Close treatment of palatal or maxillary fracture (LeFort I type), with interdental wire Fixation or fixation of denture or splint |
| 21422 | Open treatment of palatal or maxillary fracture (LeFort I type); |
| 21423 | Open treatment of palatal or maxillary fracture (LeFort I type); complicated (comminuted or involving cranial nerve foramina), multiple approaches |
| 21431 | Closed treatment of craniofacial separation (LeFort III type) using interdental wire fixation of denture or splint |
| 21432 | Open treatment of craniofacial separation (LeFort III type); with wiring and/or internal fixation |
| 21433 | Open treatment of craniofacial separation (LeFort III type); complicated (eg, comminuted or involving cranial nerve foramina), multiple surgical approaches |
| 21435 | Open treatment of craniofacial separation (LeFort III type); complicated, utilizing internal and/or external fixation techniques (eg., head cap, halo device, and/or intermaxillary fixation) internal and/or external fixation techniques (eg., head cap, halo device, and/or intermaxillary fixation) internal |
| 21436 | Open treatment of craniofacial separation (LeFort III type); complicated, multiple surgical approaches, internal fixation, with bone grafting (includes obtaining graft) |
| 21440 | Closed treatment of mandibular or maxillary alveolar ridge fracture (separate procedure) |
| 21445 | Open treatment of mandibular or maxillary alveolar ridge fracture (separate procedure) |
| 21450 | Closed treatment of mandibular fracture; without manipulation |
| 21451 | Closed treatment of mandibular fracture; with manipulation |
| 21452 | Percutaneous treatment of mandibular fracture, with external fixation |
| 21453 | Closed treatment of mandibular fracture with interdental fixation |
| 21454 | Open treatment of mandibular fracture with external fixation |
| 21461 | Open treatment of mandibular fracture; without interdental fixation |
| 21462 | Open treatment of mandibular fracture; with interdental fixation |
| 21465 | Open treatment of mandibular condylar fracture |
| 21470 | Open treatment of complicated mandibular fracture by multiple surgical approaches including internal fixation, interdental fixation, and/or wiring of dentures or splints |
| 21480 | Closed treatment of temporomandibular dislocation; initial or subsequent |
| 21485 | Closed treatment of temporomandibular dislocation; complicated (eg, recurrent requiring intermaxillary fixation or splinting), initial or subsequent |
| 21490 | Open treatment of temporomandibular dislocation |
| 21495 | Open treatment of hyoid fracture |
| 21497 | Interdental wiring, for condition other than fracture |
| 21499 | Unlisted musculoskeletal procedure, head |
| 29800 | Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure) |
| 29804 | Arthroscopy, temporomandibular joint, surgical |
| 40530 | Resection of lip, more than one-fourth, without reconstruction |
| 40654 | Repair lip, full thickness; over one -half vertical height, or complex |
| 40700 | Plastic repair of cleftlip/nasal deformity; primary, partial or complete, unilateral |
| 40701 | Plastic repair of cleft lip/nasal deformity; primary bilateral, 1 stage procedure |
| 40702 | Plastic repair of cleft lip/nasal deformity; primary bilateral, 1 of 2 stages |
| 40720 | Plastic repair of cleft lip/nasal deformity; secondary, by recreation of defect and reclosure |
| 40761 | Plastic repair of cleft lip/nasal deformity; with cross lip pedicle flap (Abbe-Estlander type), including sectioning and inserting of pedicle |
| 40799 | Unlisted procedure, lips |
| 40800 | Drainage of abscess, cyst, hematoma, vestibule of mouth; simple |
| 40801 | Drainage of abscess, cyst, hematoma, vestibule of mouth; complicated |
| 40804 | Removal of embedded foreign body, vestibule of mouth; simple |
| 40805 | Removal of embedded foreign body, vestibule of mouth; complicated |
| 40806 | Incision of labial frenum (frenotomy) |
| 40814 | Excision of lesion of mucosa and submucosa, vestibule of mouth; with complex repair |
| 40816 | Excision of lesion of mucosa and submucosa, vestibule of mouth; complex, with excision of underlying muscle |
| 40818 | Excision of mucosa of vestibule of mouth as donor graft |
| 40819 | Excision of frenum, labial or buccal (frenumectomy, frenulectomy, frenectomy) |
| 40820 | Destruction of lesion or scar of vestibule of mouth by physical methods (eg, laser, thermal, cryo, chemical) |
| 40840 | Vestibuloplasty; anterior |
| 40842 | Vestibuloplasty; posterior, unilateral |
| 40843 | Vestibuloplasty; posterior, bilateral |
| 40844 | Vestibuloplasty; entire arch |
| 40845 | Vestibuloplasty; complex (including ridge extension, muscle repositioning) |
| 40899 | Unlisted procedure, vestibule of mouth |
| 41000 | Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; lingual |
| 41005 | Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; sublingual, superficial |
| 41006 | Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; sublingual, deep, supramylohyoid |
| 41007 | Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; submental space |
| 41008 | Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; submandibular space |
| 41009 | Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; masti cator space |
| 41010 | Incision of lingual frenum (frenotomy) |
| 41015 | Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; sublingual |
| 41016 | Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; submental |
| 41017 | Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; submandibular |
| 41018 | Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; masticator space |
| 41114 | Excision of lesion of tongue with closure; with local tongue flap |
| 41115 | Excision of lingual frenum (frenectomy) |
| 41120 | Glossectomy; less than one-half tongue |
| 41130 | Glossectomy; hemiglossectomy |
| 41252 | Repair of laceration of tongue, floor of mouth, over 2.6 cm or complex |
| 41500 | Fixation of tongue,mechanical, other than suture (eg, K-wire) |
| 41512 | Tongue base suspension, permanent suture technique |
| 41520 | Frenoplasty (surgical revision of frenum, eg, with Z-plasty) |
| 41530 | Submucosal ablation of the tongue base, radiofrequency, 1 or more sites, per session |
| 41800 | Drainage of abscess, cyst, hematoma from dentoalveolar structures |
| 41805 | Removal of embedded foreign body from dentoalveolar structures; soft tissues |
| 41806 | Removal of embedded foreign body from dentoalveolar structures; bone |
| 41820 | Gingivectomy, excision gingiva, each quadrant |
| 41821 | Operculectomy, excision pericoronal tissues |
| 41822 | Excision of fibrous tuberosities, dentoalveolar structures |
| 41823 | Excision of osseous tuberosities, dentoalveolar structures |
| 41825 | Excision of lesion or tumor (except listed above), dentoalveolar structures; without repair |
| 41826 | Excision of lesion or tumor (except listed above), dentoalveolar structures; with simple repair |
| 41827 | Excision of lesion or tumor (except listed above), dentoalveolar structures; with complex repair |
| 41828 | Excision of hyperplastic alveolar mucosa, each quadrant (specify) |
| 41830 | Alveolectomy, including curettage of osteitis or sequestrectomy |
| 41850 | Destruction of lesion (except excision), dentoalveolar structures |
| 41870 | Periodontal mucosal grafting |
| 41872 | Gingivoplasty, each quadrant (specify) |
| 41874 | Alveoloplasty, each quadrant (specify) |
| 41899 | Unlisted procedure, dentoalveolar structures |
| 42000 | Drainage of abscess of palate, uvula |
| 42107 | Excision, lesion of palate, uvula; with local flap closure |
| 42120 | Resection of palate or extensive resection of lesion |
| 42140 | Uvulectomy, excision of uvula |
| 42145 | Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty) |
| 42182 | Repair, laceration of palate; over 2 cm or complex |
| 42200 | Palatoplasty for cleft palate, soft and/or hard palate only |
| 42205 | Palatoplasty for cleft palate, with closure of alveolar ridge; soft tissue only |
| 42210 | Palatoplasty for cleft palate, with closure of alveolar ridge; with bone graft to alveolar ridge (includes obtaining graft) |
| 42215 | Palatoplasty for cleft palate; major revision |
| 42220 | Palatoplasty for cleft palate; secondary lengthening procedure |
| 42225 | Palatoplasty for cleft palate; attachment pharyngeal flap |
| 42226 | Lengthening of palate, and pharyngeal flap |
| 42227 | Lengthening of palate, with island flap |
| 42235 | Repair of anterior palate, including vomer flap |
| 42280 | Maxillary impression for palatal prosthesis |
| 42281 | Insertion of pin-retained palatal prosthesis |
| 42299 | Unlisted procedure, palate, uvula |
References/Resources
About Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Christine Woolstenhulme, CPC, QCC, CMCS, CMRS, is a Certified coder and Medical Biller currently employed with Find-A-Code. Bringing over 30 years of insight, business knowledge, and innovation to the healthcare industry. Establishing a successful Medical Billing Company from 1994 to 2015, during this time, Christine has had the opportunity to learn all aspects of revenue cycle management while working with independent practitioners and in clinic settings. Christine was a VAR for AltaPoint EHR software sales, along with management positions and medical practice consulting. Understanding the complete patient engagement cycle and developing efficient processes to coordinate teams ensuring best practice standards in healthcare. Working with payers on coding and interpreting ACA policies according to state benchmarks and insurance filings and implementing company procedures and policies to coordinate teams and payer benefits.
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