Update: Crown Prior Authorization (PA) Exception for Endodontic Therapy
On October 19, 2022, the Office of MaineCare Services (OMS) issued a bulletin informing providers that MaineCare will no longer require a PA for crowns provided in conjunction with endodontic therapy when a qualifying diagnosis was included on the dental claim. The list of qualifying diagnosis inadvertently listed ICD-10-CM code K04.0-Pulpitis. Official guidance issued by the American Academy of Professional Coders (AAPC) requires the use of a 5th digit when ICD-10-CM code K04.0 is used. Please reference the chart below for qualifying diagnosis codes and descriptions.
|
Qualifying Diagnosis Code |
Diagnosis Code Description |
|
K02.53 |
Dental caries on pit and fissure surface penetrating into pulp |
|
K02.63 |
Dental caries on smooth surface penetrating into pulp |
|
K04.01 |
Reversible pulpitis |
|
K04.02 |
Irreversible pulpitis |
|
K04.1 |
Necrosis of the pulp |
|
K04.5 |
Chronic apical periodontitis |
|
K04.6 |
Periapical abscess with sinus |
|
K04.7 |
Periapical abscess without sinus |
|
K04.8 |
Radicular cyst |
|
K04.90 |
Unspecified diseases of pulp and periapical tissues |
|
K04.99 |
Other diseases of pulp and periapical tissues |
As a reminder PA is still required when a crown is not delivered as part of endodontic therapy.
If you have questions related to the PA requirements regarding crown delivery, please contact your Provider Relations Specialist, Shannon Beggs.
Check out our new MaineCare logo! Learn more about this logo on the About Us page of our website.
