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.