5101:3-5-02 Dental program: covered diagnostic services and limitations.

The following dental examination codes may be billed for any place of service in accordance with the coverage and limitations set forth in Chapter 5101:3-5 of the Administrative Code.

(A) Clinical oral examination.

(1) Comprehensive oral evaluation.

(a) The comprehensive oral evaluation is typically used by a general dentist and/or a specialist when evaluating a consumer comprehensively. It is a thorough evaluation and recording of the extraoral and intraoral hard and soft tissues. It may require interpretation of information acquired through additional diagnostic procedures. Additional diagnostic procedures should be reported separately.

A comprehensive oral evaluation would include the evaluation and recording of the consumer's dental and medical history and a general health assessment. It may typically include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, occlusal relationships, periodontal conditions (including periodontal charting), hard and soft tissue anomalies, oral cancer screening, etc.

(b) The comprehensive oral evaluation shall be limited to one per provider-

consumer relationship.

(c) The comprehensive oral evaluation shall not occur in combination with the periodic oral evaluation.

(2) Periodic oral evaluation.

(a) This includes an evaluation performed on a consumer of record to determine any changes in the consumer's dental and medical health status since a previous comprehensive or periodic evaluation. This includes periodontal screening and may require interpretation of information acquired through additional diagnostic procedures. Report additional diagnostic procedures separately.

(b) Effective for dates of service on or after January 1, 2006, the periodic oral evaluation shall not occur more frequently than once every one hundred eighty days for consumers twenty-years of age and younger. Those exams occurring more frequently shall not be reimbursed by the department.

(c) Effective for dates of service from January 1, 2006 through June 30, 2008, the periodic oral evaluation shall not occur more frequently than once every three hundred sixty-five days for consumers twenty-one years of age and older. Effective for dates of service from July 1, 2008 through December 31, 2009, the periodic oral examination shall not occur more frequently than once every one hundred eighty days irrespective of the consumer's age. Those exams occurring more frequently shall not be reimbursed by the department.

(d) Effective for dates of service on or after January 1, 2010, the periodic oral evaluation shall not occur more frequently than once every three hundred sixty-five days for consumers twenty-one years of age and older.

(d)(e) The periodic oral evaluation shall not occur in combination with the comprehensive oral evaluation and not before one hundred eighty days after the comprehensive oral evaluation.

(3) Limited oral evaluation - problem focused.

(a) An evaluation limited to a specific oral health problem or complaint. This may require interpretation of information acquired though additional diagnostic procedures.

(b) The limited oral evaluation - problem focused shall include any necessary palliative treatment.

(c) Evaluations solely for the purpose of adjusting dentures are noncovered except as specified in rule 5101:3-28-04 of the Administrative Code.

(d) The limited oral evaluation - problem focused may not be billed in conjunction with other dental procedures, with the exception of x-rays on the same date of service.

(B) Radiographs/diagnositc imaging (including interpretation). All radiographs, when presented to the department for review, shall be of diagnostic quality, properly mounted, properly exposed, clearly focused, clearly readable and free from defect for the area of the mouth on which the radiograph was performed.

(1) Intraoral, complete series (including bitewings).

(a) A complete series of radiographs shall consist of a minimum of twelve or more films. This shall include all periapical, bitewing, and occlusal film necessary for the diagnosis.

(b) A complete series of radiographs is allowed only once every five years. If a complete set of radiographs is required more frequently, prior authorization must be obtained.

(c) Periapical films shall show complete visibility of the periodontal ligament, crown and root structure in its entirety.

(2) Intraoral periapical, first film.

(3) Each additional intraoral periapical film.

(4) Intraoral occlusal film.

(5) Extraoral - first film. The extraoral film shall be allowed as an adjunct to complex treatment.

(6) Bitewing - single film.

(7) Bitewing - two films.

(8) Bitewing - three films.

(9) Bitewing - complete series, minimum of four films.

(a) The complete bitewing series is only reimbursable in the presence of erupted permanent second molars. Bitewing radiographs, in combination with other radiographs or when made alone, are allowed at six-month intervals providing they do not exceed the limitations set forth in paragraph (B) of this rule.

(b) Bitewing radiographs are permitted as frequently as at six month intervals, however, they are recommended at intervals of six to twenty four months, consistent with consumer risk for oral disease.

(c) Bitewing films shall show complete visibility of clinical crowns with no overlapping and cannot be substituted for periapical films in instances where endodontic treatment is necessary.

(10) Panoramic film.

(a) The panoramic film is an extraoral radiograph on which the maxilla and mandible are depicted on a single film.

(b) All bitewing and periapical film needed to render the necessary radiographic diagnosis is included in the fee for panoramic radiographs.

(c) Panoramic radiographs shall be permitted for consumers six years of age and older. If the dentist feels that it is medically necessary for a consumer under six years old to receive a panoramic radiograph, prior authorization must be obtained.

(d) Panoramic radiographs shall not be repeated more frequently than once every five years. If such radiographs are required more frequently, prior authorization must be obtained.

(e) Panoramic radiographs shall not occur in combination with a complete series of radiographs. A minimum of five years must elapse between the provision of panoramic radiographs and a complete series of radiographs, unless prior authorization is obtained.

(f) Panoramic films shall show complete visibility of tooth crowns, roots, bony and soft tissues in both arches with little or no overlapping of tooth crowns.

(11) Cephalometric film with tracing. Prior authorization shall be required for cephalometric films and tracings.

(12) Diagnostic photographs in conjunction with orthodontic treatment. Prior authorization shall be required for diagnostic photographs.

(13) Temporomandibular joint films. Prior authorization shall be required for temporomandibular joint films including submission of consumer history and treatment plan. Temporomandibular joint films to include four to six films are covered only if required by the department. Effective for dates of service from January 1, 2006 through June 30, 2008, temporomandibular joint films were covered only for consumers twenty-years of age and younger.

Effective: 01/01/2010
R.C. 119.032 review dates: 01/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.0112 , 5111.02 , Section 309.30.75 of Am. Sub.
H.B. 1, 128th G.A
Rule Amplifies: 5111.01 , 5111.02 , 5111.021 , Section 309.30.75 of
Am. Sub. H.B. 1, 128th G.A
Prior Effective Dates: 4/7/77, 12/21/77, 91/85 (Emer), 11/27/85 (Emer),
5/9/86, 2/1/88, 11/15/93, 12/29/95 (Emer), 3/21/96, 1/1/00, 10/1/03, 1/1/06, 12/29/06 (Emer), 3/29/07,
7/1/08