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PWU Dental Codes Historical Reference March 31, 2014

DISCLAIMER

The dental codes noted below are for historical references only. Ontario Dental Association (ODA) fee codes are subject to change, please contact the carrier

directly to confirm coverage.

________________________________________________________________

APPENDIX

DENTAL CODES AND PROCEDURES

This appendix contains a complete set of Ontario Dental Association (ODA) Fee Guide Codes covered under The Company's Dental Plan. You may refer to these codes to confirm proper billing by your dentist. You may also wish to refer to the codes to better understand claim acceptance or rejection by Great-West Life.

CLASS A SERVICES

Eligible Expenses - 100% Payment

FEE GUIDE CODES PROCEDURE

EXAMINATIONS

01101,01102,01103 Initial examination of a new patient

01202 Re-examination of a previous patient(every nine months)

01203 Periodontal examination(every nine months)

01204 Specific examination

01205 Emergency examination

Radiographic Examination andInterpretation (X-Ray)


02101,02102 Intraoral radiographs complete, once every 3 calendar years.

02111 to 02125 Introral radiographs (1 to 15).

02131 to 02136 Intraoral, Occlusal radiographs

02141 to 02146 Intraoral, Bitewing radiographs, (from 1 to 6 films), limited to once every nine months.

02201 to 02204,02209 Extraoral Radiographs

02304 Sinus examination

02401,02402,02409 Sialography-

02411,02412,02419 Use of radiopaque dyes to demonstrate lesions

02504,02509 Temporomandibular Joint radiographs

02601 Panoramic (full mouth) radiographs, limit once every three calendar years.

02701 to 02704,02709 Cephalometric radiographs

02751,02752,02759 Tracing of radiographs

02801,02802,02809 Interpretation of radiographs from another source - per unit of time

02921 Hand and wrist radiographs

02931 to 02934,02939 Tomography radiographs

04101,04201,04311,04312, Tests and laboratory examinations04321,04322,04401

04801 to 4803,04809, Diagnostic Photographs04911,04931

05101 to 05104,05109 Treatment Planning

05201,05202,05209 Consultations every nine months93111,93112,93119

Preventive Services


11101,11102,11107, Scaling and Polishing, every nine months

11109,11111 to 11117, This is referred to as prophylaxis11119 (normal cleaning of teeth).

11201,11202,11203, Preventative recall packages, limit to11401,11402,11403, once every nine months.

11301,11302,11303, Preventative recall packages, every nine months

11501,11502,11503 for under age 18 only.

12101,12102 Fluoride treatment every nine months, up to and including, age 18.

13211 to 13214,13219 Oral hygiene instruction13231,13232,13239

13301,13302 Finishing Restorations13401,13409 Pit and Fissure sealant to permanent

molars only, once every three calendar years, up to and including, age 18.

13502 Protective Mouth Guard

13701,13702 Interproximal discing of teeth

14101,14102, Control of Oral Habits14201,14202

14311,14312,14319 Myofunctional Therapy

15101,15103, Space Maintainers15104,15105,15201,15202,15301,15302,15401,15402,15403,15501,15601,15602,15603,15604

20111,20119,20121, Carries, Trauma, and Pain Control20129,20131,20139

Restorative Services


21111 to 21115 Primary teeth - amalgam

21211 to 21215 Permanent bicuspid and anterior teeth - amalgam

21221 to 21225 Permanent molars

21401 to 21405, Retentive pin reinforcement23101 to 23105, Acrylic or composite restorations23111 to 23115,23121 to 23123,23211 to 23215,23221 to 23225,23311 to 23315,23321 to 23325,23401 to 23405,23411 to 23415,23501 to 23505,23511 to 23515


Surgical Services - Removal of Teeth,Removal of Erupted Tooth - Uncomplicated

71101 Single tooth

71109 Each additional tooth in same quadrant, same appointment

71201,71209 Removal of erupted tooth (complicated)

72111,72119,72211,72219 Removal of impacted tooth72221,72229,72231,72239

72311,72319,72321,72329, Removal of Residual Roots72331,72339

Anaesthesia

92101,92102,92212 to 92219,92222 to 92229,92302 to 92309,92411 to 92419, 92421 to 92429,92431 to 92439,92441 to 92449

Periodontal Services

For periodontal disease and therapeutic treatment only, not preventative treatment.

Non-surgical services

41101 to 41104,41109 Displacement Dressing

41221 to 41224,41229 Nervous and Muscular Disorders

41211 to 41214,41219 Oral Manifestations41231 to 41234,41239

41301,41302,41309 Desensitization

42111,42201,42311, Surgical services


42331,42339,42411,42421,42431,42441,42511,42521,42531,42551,42561,42581,42611,42621,42711


Adjunctive services

43111,43211,43231,43241, Periodontal splinting43261,43271,43281,43289

43311 to 43314,43319 Occlusion

43421 to 43426,43429 Root Planing

43511,43519 Antimicrobial agents

43611,43612 Periodontal appliances

43621 to 43623, Maintenance appliances43629,43631

Endodontic Services

32221,32222, Pulpotomy, permanent teeth32231,3223232311 to 32314,32321,32322

33111,33115,33121,33125, Root Canal Therapy33131,33135,33141,33145,33401,33402,33403

33601 to 33604 Apexification

33611 to 33614 Re-insertion of Dentogenic Media

34111,34112,34121,34122, Apicoectomy34123,34131 to 34134,34141,34142,34151 to34153,34161 to 34164

34211,34212, Retrofilling34221 to 34224,34231 to 34234,34241,34242,34251 to 34254,34261 to 34264

34411,34412 Miscellaneous Surgical Services34421 to 34423,34441 to 34446,34451 to 34453,


34511, 34521 to 34523


39101,39201,39202,39211, Miscellaneous Endodontic Procedures39212,39311,39312,39313,39319

42821 to 42823,42829 Post surgical treatment

42831,42832 Periodontal abscess/pericoronitis

Extensive Oral Surgery

72511,72519,72521,72529, Surgical exposure72531,72539

72611,72619,72631,72639 Surgical movement

72711,72719 Surgical Enucleation

73111,73121 Alveoloplasy

73152 to 73154 Excision of bone

73161 Removal of bone

73211,73221 Gingivoplasty and/or stomatoplasty

73411 Vestibuloplasty

74111 to 74118, Surgical excision and drainage74631 to 74638

75111,75112,75121,75122 Surgical incision

76201 to 76204, Fractures76301 to 76304,76911 to 76913,76941,76949,76951,76952,76959,76961 to 76963

77801 to 77803 Frenectomy

79111,79311 to 79313, Miscellaneous surgical procedures79321,79322,79331 to 79333,79341 to 79343,79402 to 79404,79601 to 79604


Adjunctive General Services

96201,96202 Therapeutic injections

99333 In-office laboratory procedures

CLASS B SERVICES

Eligible Expenses - 75% Payment

Prosthodontic Services - Removable

51101 to 53712 - ONCE EVERY 3 CALENDAR YEARS.

51101 Complete maxillary denture

51102 Complete mandibular denture

51103 Complete maxillary and mandibular dentures

51301 to 51303, Immediate and transitional51601 to 51603 dentures

52101 to 52103 Transitional partial dentures

52111 to 52113, Dentures, partial, acrylic52201 to 52203,52211 to 52213,52301 to 52303,52311 to 52313,52401 to 52403,52411 to 52413,52501 to 52503,52511,52512,53101 to 53104,53111 to 53113,53201 to 53203,53205,53211 to 53213,53215

53301,53302,53304, Complete and partial denture53401 to 53403,53501 to 53503,53611 to 53613,53621 to 53623,53701 to 53704,


53711 to 53713


54201,54202,54209, Denture adjustments54301 to 54303,54401 to 54403,54501 to 54503

55101,55102, Denture repairs/additions55201 to 5520355301,55302,55401 to 55403,55501,55509

56211 to 56213, Denture rebasing and relining56221 to 56223,56231 to 56233,56241 to 56243,56251 to 56253,56261 to 56263,56311 to 56313,56321 to 56323,56331 to 56333,56341 to 56343,56411 to 56413

56511 to 56513, Tissue conditioning56521 to 56523

Note:

Denture Therapists/Denturists will be reimbursed under the Denture Therapists' Fee Guide for full upper and/or lower dentures at 75% once every 3 calendar years. The fee for construction of full upper and/or lower dentures by a Denture Therapist/Denturist includes lab fees as set out in the Denturist Fee Guide. As such, separate lab fees are not reimbursed, as these are considered to be included in the allowable fees.

MAJOR RESTORATIVE SERVICES (75% Payment)

22201,22211,22301,22311, Stainless steel crowns22401,22411,22501,22511

24101 to 24104, Gold foil restorations24201 to 24203

25111 to 25113,25511 Metal inlay restorations


25601 to 25605 Retentive pins


25131 to 25133, Porcelain restorations25711 to 25713,25721 to 25723,25781 to 25784,25789,27111,27113,27114,27121,27201,27211,27301,27311,27501,27502,27601,27602,27711,27721

Other Restorative Services (75% Payment)

21301,21302,23601,25741 to 25743,25751,25752,27401,27409,29101 to 29103,29109,29301 to 29303,29309

Prosthodontic Services - Fixed (75% Payment)

62101,62103,62501,62502, Pontics62701,62702

66111,66112,66113,66119 Repairs, Replacement

66711,66719 Porcelain repair

67321,67322,67331,67341 Retainers, Metal

67101,67102,67121,67129, Retainers - Crowns67131,67201,67211,67212,67301,67311,67312,67501,67502

66211 to 66213,66219, Removal/Repairs to Fixed Bridge66301 to 66303,66309

69201 Splinting

69301 to 69305 Retentive pins in fixed prosthetics

69701,69702 Provisional coverage


Temporomandibular Joint Appliances (75% Payment)

43711,43712, Temporomandubular Joint Appliances and43721,43722, maintenance charges, to a lifetime 43731 to 43733, maximum of $1,300.00 per person.43739,43741

Dental Implants

Coverage for dental implants; please read information below:

For the claimant’s protection, if the above course of treatment involves charges of $600.00 or more, it is suggested that the Treatment Plan should be submitted to Great-West Life in advance for predetermination of benefits. Great-West Life in will advise the employee, before treatment is started, of the amount allowed by the plan. Predeterminations are valid for a maximum of 12 months.

Dental Implants are added to the list of covered dental code, BUT coverage will be limited to “Least Costly Alternative” crown reimbursement. This means only the lowest costs of the alternative crown services will be reimbursed, and if you have dental implants rather than a cheaper alternative, only a portion of the cost may be covered.

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