Name of Manual - Blue Cross and Blue Shield of Minnesota

Coding Policies and Guidelines (Dental Services)
Medical-Surgical
Procedures
11-2
Many of our member contracts cover several medical-surgical
procedures that dentists perform. The procedures are:
• Treatment (repair or replacement only) of accidental injury to
natural teeth, which is not regular dental repair or maintenance.
• Surgical and nonsurgical treatment of TMJ and
craniomandibular disorder.
• Treatment of cleft lip and palate for a dependent child up to
age 19, if medically necessary.
• Reconstructive surgery to correct a functional physical defect
for dependent children — this would include orthognathic
surgery. Treatment involving dental implants is specifically
excluded.
• Removal of cysts/lesion(s)/tumor(s) and the accompanying
pathology reports, scans, and anesthesia and allowable
supplies.
Certain dental services may be reported using either a CPT or
dental HCPCS code. CPT codes are generally five numeric digits.
Dental HCPCS codes, which are developed by the American
Dental Association (ADA), start with the letter D and are followed
by four numeric digits.
It is important to note that pricing will vary between a comparable
CPT and dental HCPCS code and that claims will be reimbursed
based on the pricing associated with the code submitted. Pricing
for CPT codes is based on Resource Based Relative Value System
(RBRVS). Pricing for dental HCPCS codes is based on Delta
Dental pricing.
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (03/06/12)