Blue Cross Blue Shield FEP Dental
Section 5 Dental Services and Supplies Class A Basic

D0140 Limited oral evaluation - problem focused - Limit 1 per calendar year - see additional limitations at the end of this section

D0145 Oral evaluation for a patient under 3 years of age and counseling with a primary caregiver. Limit 2 per calendar year – see additional benefit limitations at the end of this section

D0150 Comprehensive oral evaluation - new or established patient - Limit 1 per calendar year - see additional benefit limitations at the end of this section

D0160 Detailed and extensive oral evaluation - problem focused, by report - Limit 1 per calendar year - see additional limitations at the end of this section

D0180 Comprehensive periodontal evaluation - new or established patient - Limit 1 per calendar year - see additional benefit limitations at the end of this section. If billed with a D4910, the D0180 will alternate to a D0120.

D0210 Intraoral - comprehensive series of radiographic images including bitewings - Limit 1 every 60 months for any combination of comprehensive series of radiographic images

D0220 Intraoral - periapical radiographic image

D0230 Intraoral - periapical each additional radiographic image

D0240 Intraoral - occlusal radiographic image

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

D0251 Extra-oral - posterior dental radiographic image

D0270 Bitewing - single - radiographic image - Limit 2 per calendar year of any combination of bitewings for patients up to age 22, 1 per calendar year of any combination ofbitewings for all others

D0272 Bitewings - two radiographic images - Limit 2 per calendar year of any combination of bitewings for patients up to age 22, 1 per calendar year of any combination of bitewings for all others.

D0273 Bitewings - three radiographic images Limit - 2 per calendar year of any combination of bitewings for patients up to age 22, 1 per calendar year of any combination of bitewings for all others.

D0274 Bitewings - four radiographic images - Limit 2 per calendar year of any combination of bitewings for patients up to age 22, 1 per calendar year of any combination of bitewings for all others.

D0277 Bitewings - Seven to eight radiographic images - Limit 2 per calendar year for any combination of bitewings for patients up to age 22, 1 per calendar year for any combination of bitewings for all others.

D0330 Panoramic radiographic image - Limit 1 every 60 months

D0372 Intraoral tomosynthesis – comprehensive series of radiographic images - Limit 1 every 60 months for any combination of comprehensive series of radiographic images

D0373 Intraoral tomosynthesis – bitewing radiographic image - Limit 2 per calendar year of any combination of bitewings for patients up to age 22, 1 per calendar year of any combination of bitewings for all others

D0374 Intraoral tomosynthesis – periapical radiographic image

D0425 Caries susceptibility tests

D0486 Laboratory accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written report

Class A Diagnostic Services Notes and Limitations:

Non-problem focused exams – Limit 2 per year

• Periodic oral evaluation (D0120), oral evaluation for a child under age 3 (D0145), comprehensive oral evaluation (D0150) and comprehensive periodontal evaluation (D0180) are combined and limited to a total of 2 per year
  • Comprehensive oral evaluation (D0150) and comprehensive periodontal evaluation(D0180) are combined and limited to 1 per year
  • Comprehensive oral evaluations in excess of the 1 per year limit will be processed as a periodic evaluation

Problem-focused exams – Limit 1 per year

• Limited oral evaluation (D0140) and detailed and extensive oral evaluation (D0160) are combined and limited to 1 per year

Diagnostic Imaging

• 14 or more radiographic images on the same date of service will be processed as a D0210 (complete set of radiographic images)
• Bitewing radiographic images with the same date of service as a panoramic radiographic image will be processed as a D0210