Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report

2700.4

Instructions for Completing Form CMS-416: Annual Early and Periodic Screening, Diagnostic,
and Treatment (EPSDT) Participation Report

A. Purpose -- The annual EPSDT report (form CMS-416) provides basic information on
participation in the Medicaid child health program. The information is used to assess the effectiveness of
state EPSDT programs in terms of the number of individuals under the age of 21 (by age group and basis
of Medicaid eligibility) who are provided child health screening services, referred for corrective treatment,
and receiving dental services. Child health screening services are defined for purposes of reporting on this
form as initial or periodic screens required to be provided according to a state’s screening periodicity
schedule.
The completed report demonstrates the state’s attainment of its participation and screening goals.
Participation and screening goals are two different standards against which EPSDT performance (or
penetration) is measured on the form CMS-416. From the completed reports, trend patterns and
projections are developed for the nation and for individual states or geographic areas, from which decisions
and recommendations can be made to ensure that eligible children are given the best possible health care.
The information is also used to respond to congressional and public inquiries.
B. Reporting Requirement -- Each state that supervises or administers a medical assistance program
under Title XIX of the Social Security Act must report annually on form CMS-416. These data must
include services reimbursed directly by the state under fee-for-service, or through managed care,
prospective payment, or other payment arrangement or through any other health or dental plans that
contract with the state. Each state is required to collect encounter data (or other data as necessary) from
managed care and prospective payment entities in sufficient detail to provide the information required by
this report. You may contact your CMS regional office EPSDT specialist if you need technical assistance
in completing this form.
C. Effective Date -- The form CMS-416 effective date was April 1, 1990. The first full fiscal year
for which the form was effective began October 1, 1990. This version of the form is not changed from the
previous version, but the associated instructions must be used effective fiscal year 2015, beginning October
1, 2014 through September 30, 2015, for data due on or after April 1, 2016.
D. Submittal Procedure -- States should submit the annual form CMS-416 and your state medical
and dental periodicity schedules electronically to the CMS central office via the EPSDT mailbox at
[email protected] not later than April 1 of the year following the end of the federal fiscal year being
reported. The electronic form and instructions are available on the CMS website at
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Early-andPeriodic-Screening-Diagnostic-and-Treatment.html States may not modify the electronic form. It must
be submitted as downloaded. A “hard copy” submittal to CMS is no longer required.
States that have made program changes during a reporting period that significantly impact data results,
such as a change in the periodicity schedule to follow the most recent version of Bright Futures™, may
include a note, not to exceed 50 words, with the cover correspondence accompanying their CMS-416
submissions. This information will be included in a separate footnotes page on the Medicaid.gov website,
accompanying the national data report.
E. Detailed Instructions -- Enter your state name and the federal fiscal year as directed below.
For each of the following line items, report total counts by the age groups indicated and by whether
categorically and medically needy. In cases where calculations are necessary, perform separate

Instructions for Form CMS-416 Annual EPSDT Participation Report
calculations for the total column and each age group. You must enter a number in each line and
column of data requested even if the number is “0.”
Helpful Notes about Reporting:
• Report age based upon the individual’s age as of September 30 of the reporting year.
• Report all data in the age category reflecting the individual’s age at the end of the federal fiscal
year even if the individual received services in two age categories. For example, if a child turned
age 3 on September 1st, but had a 30-month well-child visit in March, the 30-month visit would be
counted in the age 3-5 category.
• Screening data on Line 3a through Line 14 should reflect unduplicated counts of individuals from
Line 1b (individuals enrolled for at least 90 continuous days during the reporting period).
• Report data on visits based only on adjudicated, i.e., paid claims.
State -- Enter the name of your state using two character state code in upper case format.
Fiscal Year -- Enter the federal fiscal year (FFY) being reported in YYYY format.
Note: The federal fiscal year is from October 1 through September 30. For example, FFY 2015 is October
1, 2014 through September 30, 2015.
Line 1a -- Total Individuals Eligible for EPSDT-- Enter the total unduplicated number of individuals
under the age of 21 enrolled in Medicaid or a Children’s Health Insurance Program (CHIP) Medicaid
expansion program determined to be eligible for EPSDT services, distributed by age and by basis of
eligibility as of September 30. “Unduplicated” means that an eligible person is reported only once
although he/she may have had more than one period of eligibility during the year. Include all individuals
regardless of whether the services are provided under fee-for-service, prospective payment, or managed
care arrangements. States should determine the basis of eligibility consistent with the instructions from the
Medicaid Statistical Information System (MSIS) Data Dictionary. Medicaid-eligible individuals under age
21 are considered eligible for EPSDT services regardless of whether they have been informed about the
availability of EPSDT services or whether they accept EPSDT services at the time of informing.
Individuals for whom third-party liability is available should also be counted in the number.
Do not include in this count the following groups of individuals: 1) medically needy individuals under the
age of 21 if you do not provide EPSDT services for the medically needy population;
2) individuals eligible for Medicaid only under a §1115 waiver as part of an expanded population for
which the full complement of EPSDT services is not available; 3) undocumented aliens who are eligible
only for emergency Medicaid services; 4) children in separate state CHIP programs; or 5) other groups of
individuals under age 21 who are eligible only for limited services as part of their Medicaid eligibility (i.e.,
pregnancy-related services).
Line 1b -- Total Individuals Eligible for EPSDT for 90 Continuous Days -- Enter the total unduplicated
number of individuals under the age of 21 from Line 1a who have been continuously enrolled in Medicaid
or a CHIP Medicaid expansion program for at least 90 days in the federal fiscal year and determined to be
eligible for EPSDT services, distributed by age and by basis of eligibility. For example, if an individual
was enrolled from August 1st to September 30th and October 1st to November 30, the individual would not
be considered eligible for 90 continuous days in the federal fiscal year.
Line 1c -- Total Individuals Eligible for EPSDT under a CHIP Medicaid Expansion Program -- Enter
the total unduplicated number of individuals included in Line 1b who are under the age of 21 and eligible
for EPSDT services as part of a CHIP Medicaid expansion program. For children who have been eligible
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Instructions for Form CMS-416 Annual EPSDT Participation Report
for EPSDT under both Medicaid and a CHIP Medicaid expansion program during the report year, include
the child on this line if they are enrolled in CHIP as of September 30.
Line 2a -- State Periodicity Schedule -- Enter the number of initial or periodic general health screenings
required to be provided to individuals within the age group specified according to the state’s periodicity
schedule. (Example: If your state periodicity schedule requires screening at 12, 18 and 24 months, the
number 3 should be entered in the 1-2 age group column.) Make no entry in the total column.
Note: Use the state’s most recent periodicity schedule and attach a copy to the completed report for
submittal to CMS.
Line 2b -- Number of Years in Age Group -- Make no entries on this line. This is a fixed number
reflecting the number of years included in each age group.
Line 2c -- Annualized State Periodicity Schedule -- Divide Line 2a by the number in Line 2b. Enter the
quotient. This is the number of screenings expected to be received by an individual in each age group in
one year. Make no entry in the total column.
Line 3a -- Total Months of Eligibility -- Enter the total months of eligibility for the individuals in each
age group in Line 1b during the reporting year. An individual child should only be counted once in the age
group the individual is in as of September 30. Include the total months of eligibility in the age category
where the individual is reported, even if the individual had months of eligibility in two age categories
during the reporting period. For example, if an individual was eligible 12 months, from October 1st
through September 30th, but turned age 3 on August 1st, all 12 months of eligibility would be counted
in the age 3-5 category.
Line 3b -- Average Period of Eligibility -- Divide Line 3a by the number in Line 1b. Divide that number
by 12 and enter the quotient. This number represents the portion of the year that individuals remain
eligible for EPSDT services during the reporting year.
Line 4 -- Expected Number of Screenings per Eligible -- Multiply Line 2c by Line 3b. Enter the
product. This number reflects the expected number of initial or periodic screenings per individual under
age 21 per year based on the number required by the state-specific periodicity schedule and the average
period of eligibility. Make no entries in the total column.
Line 5 -- Expected Number of Screenings -- Multiply Line 4 by Line 1b. Enter the product. This
reflects the total number of initial or periodic screenings expected to be provided to the eligible individuals
in Line 1b.
Line 6 -- Total Screens Received -- Enter the total number of initial or periodic screens furnished to
eligible individuals from Line 1b under fee-for-service, prospective payment, or managed care
arrangements.
Note: States may use the CPT codes listed below as a proxy for reporting these initial or periodic screens.
Use of these proxy codes is for reporting purposes only. States must continue to ensure that all five ageappropriate elements of an EPSDT screen, as defined by law, are provided to EPSDT recipients.
This number should not reflect sick visits or episodic visits provided to the enrolled individual unless
an initial or periodic screen was also performed during the visit. However, it may reflect a screen
outside of the normal state periodicity schedule that is used as a "catch-up" EPSDT screening. (A catch-up
Page 3 of 30

Instructions for Form CMS-416 Annual EPSDT Participation Report
EPSDT screening is defined as a complete screening that is provided to bring an individual child up-todate with the state's screening periodicity schedule. For example, a child who did not receive a periodic
screen at age five visits a provider at age 5 years and 4 months. The provider may use that visit to provide
a complete age appropriate screening and the screening may be counted on the CMS-416.) Report all
screening data in the age category reflecting the individual’s age at the end of the federal fiscal year
even if the individual received services in two age categories. For example, if a child turned age 3 on
September 1st, but had a 30-month well-child visit in March, the 30-month visit would be counted in
the age 3-5 category. Use the codes below or other documentation of such services furnished under
capitated arrangements. The codes to be used to document the receipt of an initial or periodic screen are as
follows:
CPT-4 codes: Preventive Medicine Services *
99381 New Patient under one year
99382 New Patient (ages 1-4 years)
99383 New Patient (ages 5-11 years)
99384 New Patient (ages 12-17 years)
99385 New Patient (ages 18-39 years)
99391 Established patient under one year
99392 Established patient (ages 1-4 years)
99393 Established patient (ages 5-11years)
99394 Established patient (ages 12-17 years)
99395 Established patient (ages 18-39 years)
99460 Initial hospital or birthing center care for normal newborn infant
99461 Initial care in other than a hospital or birthing center for normal newborn infant
99463 Initial hospital or birthing center care of normal newborn infant (admitted/
discharged same date)
*These CPT codes do not require use of a “Z” code.
or
CPT-4 codes: Evaluation and Management Codes **
99202-99205 New Patient
99213-99215 Established Patient
** These CPT-4 codes must be used in conjunction with the following Z codes:
Z76.2 (Encounter for health supervision and care of other healthy infant and child),
Z00.121 (Encounter for routine child health examination with abnormal findings),
Z00.129 (Encounter for routine child health examination without abnormal findings),
Z00.110 (Health examination for newborn under 8 days old) and
Z00.111 (Health examination for newborn 8 to 28 days old)
and/or
Z00.00-01 (Encounter for general adult medical examination without/with abnormal findings),
and/or
Z02.0 (Encounter for examination for admission to educational institution),
Z02.1 (Encounter or pre-employment examination),
Z02.2 (Encounter for examination for admission to residential institution),
Z02.3 (Encounter for examination for recruitment to armed forces),
Z02.4 (Encounter for examination for driving license),
Z02.5 (Encounter for examination for participation in sport),
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Instructions for Form CMS-416 Annual EPSDT Participation Report
Z02.6 (Encounter for insurance purposes),
Z02.81 (Encounter for paternity testing),
Z02.82 (Encounter for adoption services),
Z02.83 (Encounter for blood-alcohol and blood-drug test),
Z02.89 (Encounter for other administrative examinations),
Z00.8 (Encounter for other general examination),
Z00.6 (Encounter for examination for normal comparison and control in clinical research program),
Z00.5 (Encounter for examination of potential donor of organ and tissue),
Z00.70 (Encounter for examination for period of delayed growth in childhood without abnormal findings),
Z00.71 Encounter for examination for period of delayed growth in childhood with abnormal findings),
Line 7 -- Screening Ratio -- Divide the actual number of initial and periodic screening services received
(Line 6) by the expected number of initial and periodic screening services (Line 5). This ratio indicates the
extent to which EPSDT eligibles receive the number of initial and periodic screening services required by
the state's periodicity schedule, prorated by the proportion of the year for which they are Medicaid eligible.
Note: In calculating Line 7, if the number exceeds 100 percent, enter 1.0 in this field.
Line 8 -- Total Eligibles Who Should Receive at Least One Initial or Periodic Screen -- The number of
individuals who should receive at least one initial or periodic screen is dependent on each state's
periodicity schedule. Use the following calculations:
1.

Look at the number entered in Line 4 of this form. If that number is greater than 1, use the number 1.
If the number on Line 4 is less than or equal to 1, use the number in Line 4. (This procedure will
eliminate situations where more than one visit is expected in any age group in a year.).

2.

Multiply the number from calculation 1 above by the number on Line 1b of the form. Enter the
product on Line 8.

Line 9 -- Total Eligibles Receiving at Least One Initial or Periodic Screen -- Enter the unduplicated
number of individuals under age 21 with at least 90 days continuous enrollment within the federal fiscal
year from Line 1b, including those enrolled in managed care arrangements, who received at least one
documented initial or periodic screen during the year. Refer to codes in Line 6.
Line 10 -- Participant Ratio -- Divide Line 9 by Line 8. Enter the quotient. This ratio indicates the
extent to which eligibles are receiving any initial and periodic screening services during the year.
Note: In calculating Line 10, if this number exceeds 100 percent, enter 1.0 in this field.
Line 11 -- Total Eligibles Referred for Corrective Treatment -- Enter the unduplicated number of
individuals from Line 1b, including those in managed care arrangements, who had a paid claim for a
visit/service that occurred within 90 days from the date of an initial or periodic screening where none of
the following is included as part of the paid claim: capitation payments, administrative fees, transportation
services, nursing home services, ICF-MR services, HIPP payments, inpatient services, dental care, home
health services, long-term care services, or pharmacy services. Include only those instances where both the
screening and the visit/service for which the subsequent claim was paid occurred within the reporting
period.

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Instructions for Form CMS-416 Annual EPSDT Participation Report
Dental Lines 12a – 12g
NOTE A: For purposes of reporting the information on dental and oral health services in Lines 12a – 12g,
“unduplicated” means that an individual may be counted only once for each line of dental or oral health
data. However, an individual may be counted on two or more lines. For example, individuals under the
age of 21 may be counted once on Line 12a for receiving any dental service, counted again on Line 12c for
receiving a dental treatment service and, if applicable, counted again on Line 12f for receiving an oral
health service by a non-dentist or by a dental professional not working under the supervision of a dentist.
These numbers should be inclusive of services reimbursed directly by the state under fee-for-service, or
under managed care, prospective payment, or any other payment arrangements through any other private
health or dental plans that contract with the state.
NOTE B: We use the term “dental services” to refer to services provided by or under the supervision of a
dentist. Supervision is a spectrum and includes, for example, direct, indirect, general, collaborative or
public health supervision as provided in the dental practice act. We use the term “oral health services” to
refer to services provided by a health care practitioner working within their scope of practice and who is
neither a dentist nor providing services under the supervision of a dentist. For each line, the universe of
appropriate procedure codes to report is provided in the instructions (HCPCS and CDT) or on Table 1
(CPT).
Line 12a -- Total Eligibles Receiving Any Dental Services -- Enter the unduplicated number of
individuals under the age of 21 with at least 90 days continuous enrollment during the federal fiscal year
from Line 1b who received at least one dental service by or under the supervision of a dentist as defined by
HCPCS codes D0100 - D9999 (CDT codes D0100 - D9999) or the CPT codes listed in Table 1. All
individuals reported on Lines 12b through 12e should be reported on this line, though an individual should
be counted only once on this line regardless of how many dental services he or she received during the
reporting period. See Notes A and B, above.
Line 12b -- Total Eligibles Receiving Preventive Dental Services -- Enter the unduplicated number of
individuals under the age of 21 with at least 90 days continuous enrollment during the federal fiscal year
from Line 1b who received at least one preventive dental service by or under the supervision of a dentist as
defined by HCPCS codes D1000 - D1999 (CDT codes D1000 - D1999) or the CPT codes listed in Table 1.
See Notes A and B, above.
Line 12c -- Total Eligibles Receiving Dental Treatment Services -- Enter the unduplicated number of
individuals under the age of 21 with at least 90 days continuous enrollment during the federal fiscal year
from Line 1b who received at least one dental treatment service by or under the supervision of a dentist, as
defined by HCPCS codes D2000 - D9999 (CDT codes D2000 – D9999) or the CPT codes listed in Table 1.
See Notes A and B, above.
Line 12d -- Total Eligibles Receiving a Sealant on a Permanent Molar Tooth -- Enter the unduplicated
number of individuals under the age of 21 with at least 90 days continuous enrollment during the federal
fiscal year from Line 1b, in the appropriate age categories of 6-9 and 10-14, who received a sealant on a
permanent molar tooth, as defined by HCPCS code D1351 (CDT code D1351). For this line, include
sealants placed by any dental professional for who placing a sealant is within his or her scope of practice.
Permanent molars are teeth numbered 2, 3, 14, 15, 18, 19, 30, 31, and additionally, for those states that
cover sealants on third molars, also known as wisdom teeth, the teeth numbered 1, 16, 17, 32 See Notes A
and B, above.

Page 6 of 30

Instructions for Form CMS-416 Annual EPSDT Participation Report
Line 12e -- Total Eligibles Receiving Diagnostic Dental Services -- Enter the unduplicated number of
individuals under the age of 21 with at least 90 days continuous enrollment during the federal fiscal year
from Line 1b who received at least one diagnostic dental service by or under the supervision of a dentist, as
defined by HCPCS codes D0120 – D0191 (CDT codes D0120 – D0191) or the CPT codes listed in Table
1. See Notes A and B, above.
12f -- Total Eligibles Receiving Oral Health Services Provided by a Non-Dentist Provider -- Enter the
unduplicated number of individuals under the age of 21 with at least 90 days continuous enrollment during
the federal fiscal year from Line 1b who received at least one oral health service, as defined by HCPCS,
CDT, CPT (see Table 1), ICD-9 or ICD-10 codes, including CDT D0190 (screening) and CDT D0191
(assessment). A “non-dentist provider” is any health care practitioner working within their scope practice
and who is neither a dentist nor providing services under the supervision of a dentist. NOTE: Due to the
variance in state practice acts and reimbursement policies some states may not have data to report on this
line. See Notes A and B, above.
12g -- Total Eligibles Receiving any Dental or Oral Health Service -- Enter the unduplicated number of
individuals under the age of 21 with at least 90 days continuous enrollment during the federal fiscal year
from Line 1b who received either a “dental service” by or under the supervision of a dentist or an “oral
health service” by a health care practitioner working within their scope of practice and who is neither a
dentist nor providing services under the supervision of a dentist. All individuals reported in Lines 12a
through 12f should also be reported on this line, though an individual should be counted only once on this
line regardless of how many dental services and oral health services he or she received during the reporting
period. See Notes A and B, above.
Line 13 -- Total Eligibles Enrolled in Managed Care -- This number is reported for informational
purposes only. Enter the total unduplicated number of individuals from Line 1b who are enrolled in any
type of managed care arrangement at any time during the reporting year. It includes any capitated
arrangements such as health maintenance organizations or individuals assigned to a primary care provider
or primary care case manager regardless of whether reimbursement is fee-for-service or capitated.
Line 14 -- Total Number of Screening Blood Lead Tests -- Enter the total number of screening blood
lead tests furnished to eligible individuals from Line 1b under fee-for-service, prospective payment, or
managed care arrangements. Follow-up blood tests performed on individuals who have been diagnosed
with or are being treated for lead poisoning should not be counted. You may use one of two methods, or a
combination of these methods, to calculate the number of blood lead screenings provided:
1) Count the number of times CPT code 83655 (“lead”) for a blood lead test is reported within
certain ICD-10 CM codes (see Note below); or
2) You may include data collected from use of the HEDIS® 1 measure developed by the National
Committee for Quality Assurance to report blood lead screenings if your state had elected to use
this performance measure.
NOTE: On a claim, CPT code 83655 is the procedure code used to identify that a blood lead test was
performed. CPT code 83655, when accompanied on the claim by a diagnosis code of Z77.011 (exposure
to lead) or Z13.88 (Encounter for screening for disorder due to exposure to contaminants) may be used to
identify a person receiving a screening blood lead test, or Z57.8 (occupational exposure to other risk
factors). However, a claim in which the procedure code 83655 is accompanied by a diagnosis code of
984.0 through 984.9 (toxic effect of lead and its compounds), T56.0X1A–4A (Toxic effect of lead and its
1

Health Effectiveness Data and Information Set

Page 7 of 30

Instructions for Form CMS-416 Annual EPSDT Participation Report
compounds, initial encounter); M1A.10X0-1, M1A.1110-11, M1A.1120-21, M1A1190-91, M1A.1210-11,
M1A.1610-11, M1A.1621, M1A.1690-91, M1A.1710-11, M1A1720-21, M1A.1790-91, M1A.18X0-X1,
M1A.19X1A-X4A (See Table 2 for a description of these codes) would generally indicate that the
person receiving the blood lead test had already been diagnosed or was being treated for lead poisoning
and should not be counted.
F. Disclosure Statement - According to the Paperwork Reduction Act of 1995, no persons are
required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0938-0354. The time required to complete
this information collection is estimated to average 28 hours per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the
information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Mail Stop: C4-26-05, Baltimore, Maryland 21244-1850.

Page 8 of 30

Table 1 to CMS 416 Reporting Instructions for Lines 12a through 12g
Crosswalk of CPT Codes to CDT Codes

(Form CMS-416)

Nomenclature

CPT Codes
Diagnostic - Report these
codes on lines 12a, 12e and
12g if performed by or
under the supervision of a
dentist; report them on lines
12f and 12g if performed by
a health care practitioner
working within their scope of
practice and who is neither
a dentist nor providing
services under the
supervision of a dentist.

D0210
D0220
D0230
D0240
D0250
D0260
D0270
D0272
D0273
D0274
D0277

D0290
D0310
D0320

D0321
D0322

Intraoral - complete series
(including bitewings)
Intraoral - periapical first film
Intraoral - periapical
each additional film
Intraoral - occlusal film
Extraoral - first film

70300, 70310, 70320
70300, 70310, 70320
70300, 70310, 70320
70300, 70310, 70320
70300, 70310, 70320

Extraoral - each additional
film
Bitewing - single film
Bitewings - two films
Bitewings - three films
Bitewings - four films

70300, 70310, 70320

Vertical bitewings - 7 to 8
films

70300, 70310, 70320

Posterior-anterior or lateral
skull and facial bone
survey film
Sialography
Tempromandibular joint
arthrogram, including
injection
Other temporomandibular
joint arthrogram, including
injection
Tomographic survey
Page 9 of 30

70300, 70310, 70320
70300, 70310, 70320
70300, 70310, 70320
70300, 70310, 70320

70140, 70150, 70250,
70260
70390
21116, 70332

70328, 70330, 76499
70486

Table 1 to CMS 416 Reporting Instructions for Lines 12a through 12g
Crosswalk of CPT Codes to CDT Codes
D0330
D0340

Panoramic film
Cephalometric film

70320, 70355
70350

(Form CMS-416)

Nomenclature

CPT Codes

D0360

Cone beam CT craniofacial data capture

70486, 70487, 70488

D0362

D0363

D0364

D0365

D0366

D0367

D0368

D0369

Cone beam - twodimensional image
reconstruction using existing
data includes multiple
images
Cone beam - threedimensional image
reconstruction using existing
data, includes multiple
images
Cone beam CT capture and
interpretation with limited
field of view - less than one
whole jaw
Cone beam CT capture and
interpretation with field of
view of one full dental arch mandible
Cone beam CT capture and
interpretation with field of
view of one full dental arch maxilla, with or without
cranium
Cone beam CT capture and
interpretation with field of
view of both jaws; with or
without cranium
Cone beam CT capture
and interpretation for TMJ
series including two or
more exposures
Maxillofacial MRI capture
and interpretation
Page 10 of 30

70486

76376

70486, 70487, 70488

70486, 70487, 70488

70486, 70487, 70488

70486, 70487, 70488

70486, 70487, 70488

70540, 70542, 70543

Table 1 to CMS 416 Reporting Instructions for Lines 12a through 12g
Crosswalk of CPT Codes to CDT Codes
D0380

Cone beam CT capture with
limited field of view - less
than one whole jaw

(Form CMS-416)

Nomenclature

D0381

D0382
D0383

D0384

Cone beam CT capture
with field of view of one full
dental arch - mandible
Cone beam CT capture
with field of view of one full
dental arch - maxilla, with or
ith beam
t
iCT capture
Cone
with field of view of both
jaws; with or without
Cone beam CT capture
for TMJ series including
two or more exposures

70486-TC, 70487-TC,
70488- TC

CPT Codes
70486-TC, 70487-TC,
70488- TC
70486-TC, 70487-TC,
70488- TC
70486-TC, 70487-TC,
70488- TC
70486-TC, 70487-TC,
70488- TC
70540-TC, 70542-TC,
70543- TC

D0385

Maxillofacial MRI capture

D0391

Interpretation of diagnostic
image by a practitioner not
associated with capture of
the image, including report

Any radiology code
consistent with the image
being reviewed with a
modifier -26 appended to
the CPT code

Collection of
microorganisms for culture
and sensitivity

87070, 87071, 87207,
87999,
99000, 99001

D0415

D0416

D0417

D0418

D0421

Viral culture

Collection and preparation
of saliva sample for
laboratory diagnostic
testing
Analysis of saliva sample

Genetic test for
susceptibility to oral
diseases
Page 11 of 30

87070, 87071, 87207,
87999,
99000, 99001
87070, 87071, 87081,
87207,
87999, 99000, 99001
87070, 87071, 87081,
87207,
87999
87181, 87184, 99000,
99001

Table 1 to CMS 416 Reporting Instructions for Lines 12a through 12g
Crosswalk of CPT Codes to CDT Codes

(Form CMS-416)

Nomenclature

CPT Codes

D0425

Caries susceptibility tests

87181, 87184, 99000,
99001

D0431

D0472

D0473

Adjunctive pre-diagnostic
test that aids in detection of
mucosal abnormalities
including premalignant and
malignant lesions, not to
include cytology or biopsy
procedures
Accession of tissue, gross
examination, preparation
and transmission of written
report
Accession of tissue, gross
and microscopic
examination, preparation
and transmission of written
report

82397

88300

88302, 88304, 88305,
88307

88305, 88307

D0474

D0475
D0476

Accession of tissue, gross
and microscopic
examination, including
assessment of surgical
margins for presence of
disease, preparation and
transmission of written report
Decalcification procedure

88311

Special stains
for
microorganisms

88312, 88313, 99000,
99001

D0477

Special stains, not
for microorganisms

D0478

Immunohistochemical stains

Page 12 of 30

87207, 87209, 99000,
99001
88314, 99000, 99001

Table 1 to CMS 416 Reporting Instructions for Lines 12a through 12g
Crosswalk of CPT Codes to CDT Codes

(Form CMS-416)
D0479

D0480

D0481
D0482
D0483
D0484

D0485

D0486

Nomenclature

CPT Codes

Tissue in-situ
hybridization, including
interpretation

88365, 88367, 99000,
99001

Accession of exfoliative
cytologic smears,
microscopic examination,
preparation and
transmission of written
report
Electron microscopy
- diagnostic
Direct immunofluorescence
Indirect immunofluorescence
Consultation on
slides prepared
elsewhere
Consultation, including
preparation of slides from
biopsy material supplied
by referring source
Accession of transepithelial
cytologic sample,
microscopic examination,
preparation and
transmission of written
report

Page 13 of 30

88104, 88112, 99000,
99001

88104, 88112, 99000,
99001
88346, 99000, 99001
88347, 99000, 99001
80500, 80502, 88321,
88323

80500, 80502, 88321,
88323

88160, 88161, 88162

Table 1 to CMS 416 Reporting Instructions for Lines 12a through 12g
Crosswalk of CPT Codes to CDT Codes

(Form CMS-416)

Nomenclature

CPT Codes
Preventive - Report these
codes on lines 12a, 12b
and 12g if performed by or
under the supervision of a
dentist; report them on
lines 12f and 12g if
performed by a health care
practitioner working within
their scope of practice and
who is neither a dentist nor
providing services under
the supervision of a dentist.

D1310

D1320
D1330

Nutritional counseling
for control of dental
disease
Tobacco counseling for the
control and prevention of
oral disease
Oral hygiene instructions

96152

96152, 4000F
96152
Periodontics, Maxillofacial
Prosthetics, Implants, Oral &
Maxillofacial Surgery,
Adjunctive General Services
- Report these codes on
lines 12a, 12c and 12g if
performed by or under the
supervision of a dentist;
report them on lines 12f and
12g if performed by a health
care practitioner working
within their scope of practice
and who is neither a dentist
nor providing services under
the supervision of a dentist.

Page 14 of 30

Table 1 to CMS 416 Reporting Instructions for Lines 12a through 12g
Crosswalk of CPT Codes to CDT Codes

(Form CMS-416)

Nomenclature

D4210

Gingivectomy or gingivoplasty
- four or more contiguous
41820, 41872
teeth or tooth bounded
spaces per quadrant

D4211

Gingivectomy or gingivoplasty
- one to three contiguous
41820, 41872
teeth or tooth bounded
spaces per quadrant

D4212

Gingivectomy or
gingivoplasty to allow
access for restorative
procedure, per tooth

CPT Codes

41820, 41872

D4230

Anatomical crown exposure
- four or more contiguous
teeth per quadrant

41820, 41821

D4231

Anatomical crown exposure
- one to three teeth per
quadrant

41820, 41821

D4240

D4241

D4245

Gingival flap procedure,
including root planing - four
or more contiguous teeth or
tooth bounded spaces per
quadrant
Gingival flap procedure,
including root planing - one
to three contiguous teeth or
tooth bounded spaces per
quadrant
Apically positioned flap

Page 15 of 30

41870

41870

41870

Table 1 to CMS 416 Reporting Instructions for Lines 12a through 12g
Crosswalk of CPT Codes to CDT Codes

(Form CMS-416)

D4260

D4261

D4263
D4264

D4266

D4267

D4270
D4271
D4275

Nomenclature
Osseous surgery (including
flap entry and closure) four or more contiguous
teeth or tooth bounded by
spaces per quadrant
Osseous surgery (including
flap entry and closure) - one
to three contiguous teeth or
tooth bounded by spaces per
quadrant
Bone replacement graft first site in quadrant
Bone replacement graft each additional site in
quadrant
Guided tissue regeneration
- resorbable barrier, per
site
Guided tissue regeneration nonresorbable barrier, per
site (includes membrane
removal)
Pedicle soft tissue
graft procedure
Free soft tissue graft
procedure (including
donor site surgery)
Soft tissue allograft

CPT Codes

41823

41823

21127
21127

41870

41870

15574
41870
41870

D4276

Combined connective
tissue and double pedicle
graft, per tooth

41870

D4381

Localized delivery of
antimicrobial agents via a
controlled release vehicle
into diseased crevicular
tissue, per tooth, by report

41899

Page 16 of 30

Table 1 to CMS 416 Reporting Instructions for Lines 12a through 12g
Crosswalk of CPT Codes to CDT Codes

(Form CMS-416)
D4999
D5913
D5914
D5915
D5919
D5932

D5934

D5935

D5936
D5952
D5953
D5954
D5955

D5958
D6010

D6012

D6040

Nomenclature
Unspecified
periodontal
Nasal prosthesis
Auricular prosthesis
Orbital prosthesis
Facial prosthesis
Obturator prosthesis,
definitive
Mandibular resection
prosthesis with guide flange
mandibular resection
prosthesis without guide
flange
Obturator prosthesis, interim
Speech aid
prosthesis, pediatric
Speech aid prosthesis, adult
Palatal
augmentation
Palatal lift
prosthesis,
definitive
Palatal lift prosthesis, interim
Surgical replacement
of implant body:
endosteal implant
Surgical placement of
interim implant body for
transitional prosthesis:
endosteal implant
Surgical placement:
eposteal implant

Page 17 of 30

CPT Codes
41899
21087
21086
21077
21088
21080

21081

21081

21079
21084
21084
21082
21083

21083
21248

21248

21248

Table 1 to CMS 416 Reporting Instructions for Lines 12a through 12g
Crosswalk of CPT Codes to CDT Codes

(Form CMS-416)
D6050
D7260
D7261
D7285
D7286

D7310

D7311

D7320

D7321

D7340
D7350

D7410

Nomenclature
Surgical placement:
transosteal implant
Oroantral fistula closure
Primary closure of a
sinus perforation
Biopsy of oral tissue - hard
(bone, tooth)
Biopsy of oral tissue - soft
Alveoloplasty in conjunction
with extractions - four or
more teeth or tooth spaces,
per quadrant
Alveoloplasty in conjunction
with extractions - one to
three teeth or tooth spaces,
per quadrant
Alveoloplasty not in
conjunction with extractions
- four or more teeth or tooth
spaces, per quadrant
Alveoloplasty not in
conjunction with extractions
- one to three teeth or tooth
spaces, per quadrant
Vestibuloplasty ridge extension
(secondary
Vestibuloplasty - ridge
extension (including soft
tissue grafts, muscle
reattachment, revision of soft
tissue attachment and
management of
hypertrophied and
hyperplastic tissue)
Excision of benign lesion up
to
Page 18 of 30

CPT Codes
21248
30580, 30600
30580, 30600
20220, 20240
11100, 11101, 40808

41870, 41874

41870, 41874

41874

41874

40840, 40842, 40843,
40844
40845

40810, 40812, 40814

Table 1 to CMS 416 Reporting Instructions for Lines 12a through 12g
Crosswalk of CPT Codes to CDT Codes

(Form CMS-416)
D7411
D7412
D7413
D7414

D7415

D7440

D7441

D7450

D7451

D7460

Nomenclature
Excision of benign
lesion greater than
Excision of benign
lesion, complicated
Excision of malignant
lesion up to 1.25 cm
Excision of malignant
lesion greater than 1.25
cm
Excision of malignant
lesion, complicated
Excision of malignant tumor
- lesion diameter up to 1.25
cm
Excision of malignant tumor
- lesion diameter greater
than
Removal of benign
odontogenic cyst or tumor lesion diameter up to 1.25
cm
Removal of benign
odontogenic cyst or tumor
- lesion diameter greater
than 1.25 cm

CPT Codes
40810, 40812, 40814
40814, 40816
40810, 40812, 40814
40810, 40812, 40814

40814, 40816

21034, 21044

21034, 21044

41825, 41826, 41827

41825, 41826, 41827

Removal of benign
nonodontogenic cyst or tumor 41825, 41826, 41827
- lesion diameter up to 1.25
cm

D7461

Removal of benign
nonodontogenic cyst or tumor
41825, 41826, 41827
- lesion diameter greater than
1.25 cm

D7465

Destruction of lesion(s) by
physical or chemical
method, by report
Page 19 of 30

40820, 41850

Table 1 to CMS 416 Reporting Instructions for Lines 12a through 12g
Crosswalk of CPT Codes to CDT Codes

(Form CMS-416)

Nomenclature

CPT Codes

D7471

Removal of lateral exostosis
(maxilla or mandible)

21031, 21032

D7472

Removal of torus palatinus

21032

D7473

Removal of torus
mandibularis

21031

D7485
D7490

D7510

D7511

D7520

D7521

D7530

D7540

D7610

Surgical reduction of
osseous tuberosity
Radical resection of maxilla
or mandible
Incision and drainage of
abscess - intraoral soft
tissue
Incision and drainage of
abscess - intraoral soft tissue
- complicated (includes
drainage of multiple
fascial spaces
Incision and drainage of
abscess - extraoral soft
tissue
Incision and drainage of
abscess - extraoral soft tissue
- complicated (includes
drainage of multiple
fascial spaces
Removal of foreign body
from mucosa, skin or
subcutaneous alveolar tissue
Removal of reaction
producing foreign bodies,
musculoskeletal system
Maxilla - open reduction
(teeth immobilized, if
present)
Page 20 of 30

41823
21045

40800, 41800

40801, 41800

40801, 41800

40801, 41800

40804, 40805, 41805
20520, 20525, 40804,
40805,
41806
21422, 21423

Table 1 to CMS 416 Reporting Instructions for Lines 12a through 12g
Crosswalk of CPT Codes to CDT Codes

(Form CMS-416)
D7620

D7630

D7640

D7650

Nomenclature
Maxilla - closed reduction
(teeth immobilized, if
present)
Mandible - open reduction
(teeth immobilized, if
present)
Mandible - closed reduction
(teeth immobilized, if
present)
Malar and/or zygomatic arch
- open reduction

CPT Codes
21421

21454, 21461, 21462,
21470

21450, 21451, 21453

21356, 21360, 21365,
21366

D7660

Malar and/or zygomatic arch
- closed reduction

21355

D7670

Alveolus - closed
reduction, may include
stabilization of teeth

21440

D7671

Alveolus - open
reduction, may include
stabilization of teeth

21445

D7680

Facial bones - complicated
reduction with fixation and
multiple surgical
approaches

21433, 21435

D7710

Maxilla - open reduction

21422, 21423

D7720

Maxilla - closed reduction

21421

D7730

Mandible - open reduction

21454, 21461, 21462,
21470

D7740

Mandible - closed reduction

21450, 21451, 21453

D7750

Malar and/or zygomatic arch
- open reduction

Page 21 of 30

21356, 21360, 21365,
21366

Table 1 to CMS 416 Reporting Instructions for Lines 12a through 12g
Crosswalk of CPT Codes to CDT Codes

(Form CMS-416)

Nomenclature

CPT Codes

D7760

Malar and/or zygomatic arch
- closed reduction

21355

D7770

Alveolus - open
reduction stabilization of
teeth

21445

D7771

Alveolus - closed
reduction stabilization of
teeth

21440

D7780

Facial bones - complicated
reduction with fixation and
multiple surgical
approaches

21433, 21435

D7810

Open reduction of dislocation 21490

D7820

Closed reduction
of dislocation

21480, 21485

D7830

Manipulation
under anesthesia

21073

D7840

Condylectomy

21050

D7850

Surgical
discectomy,
with/without
implant

21060

D7858

Joint reconstruction

21242, 21243

D7860

Arthrotomy

21010

D7865

Arthroplasty

21240

D7870

Arthrocentesis
Arthroscopy - diagnosis,
with or without biopsy

20605

D7872

D7873

Arthroscopy - surgical:
lavage and lysis of
adhesions

Page 22 of 30

29800

29804

Table 1 to CMS 416 Reporting Instructions for Lines 12a through 12g
Crosswalk of CPT Codes to CDT Codes

(Form CMS-416)

Nomenclature

CPT Codes

D7874

Arthroscopy - surgical: disc
repositioning and
stabilization

29804

D7875

Arthroscopy - surgical:
synovectomy

29804

D7877

Arthroscopy - surgical:
discectomy
Arthroscopy - surgical:
debridement

D7910

Suture of recent small
wounds up to 5 cm

D7911

Complicated suture - up to
5 cm

D7876

29804
29804
12011, 12013, 40830,
40831,
41250, 41251, 41252,
42180,
42182
12051, 12052, 13131,
13132,
13150, 13151, 13152,
40831,
41252, 42182
12053, 12054, 12054,
12055,
12056, 12057, 13132,
13133,
13152, 13153, 40831,
41252,
42182

D7912

Complicated suture greater than 5 cm

D7940

Osteoplasty - for
orthognathic deformities

21208, 21209

D7941

Osteotomy - mandibular rami

21193, 21195, 21196

D7943
D7944

Osteotomy - mandibular
rami with bone graft;
includes obtaining the graft
Osteotomy - segmented
or subapical

Page 23 of 30

21194
21198, 21199, 21206

Table 1 to CMS 416 Reporting Instructions for Lines 12a through 12g
Crosswalk of CPT Codes to CDT Codes

(Form CMS-416)

Nomenclature

CPT Codes

D7945

Osteotomy - body of
mandible

21193, 21194, 21195,
21196

D7946

LeFort I (maxilla - total)

21141, 21142, 21143,
21145,
21147

LeFort I (maxilla segmented)

Any of the codes
crosswalked to D7946
would be appropriate, but
should be reported with a 52 modifier

D7948

LeFort II or LeFort III
(osteoplasty of facial bones
for midface hypoplasia or
retrusion) - without bone
graft

21150

D7949

LeFort II or LeFort III with bone graft

D7950

Osseous, osteoperiosteal,
or cartilage graft of the
madible or maxilla autogenous or
nonautogenous, by report

D7960

Frenulectomy - also known
as frenectomy or frenotomy
- separate procedure not
incidental to another

40806, 40819, 41010,
41115

D7963

Frenuloplasty

41520

D7970

Excision of hyperplastic
tissue per arch

D7947

D7971

Excision of pericoronal
gingiva

Page 24 of 30

21151, 21154, 21155,
21159,
21160

21210, 21215

-

41828
41821

Table 1 to CMS 416 Reporting Instructions for Lines 12a through 12g
Crosswalk of CPT Codes to CDT Codes

(Form CMS-416)

Nomenclature

CPT Codes

D7972

Surgical reduction of
osseous tuberosity

41822

D7980

Sialolithotomy

42330, 42335, 42340

D7981

Excision of salivary gland,
by report

42410, 42415, 42420,
42425,
42426, 42440, 42450

D7982

Sialodochoplasty

D7983

Closure of salivary fistula

D7990

Emergency tracheotomy

42600
42600 - Closure
salivary fistula
31603, 31605

D7991

Coronoidectomy

21070

D7996

D9212
D9220

D9221

D9241

D9242

Implant - mandible for
augmentation purposes
(excluding alveolar ridge),
by report
Trigeminal division
block anesthesia
Deep sedation/general
anesthesia - first 30
minutes
Deep sedation/general
anesthesia - each
additional 15 minutes
Intravenous conscious
sedation/analgesia - first
30 minutes
Intravenous conscious
sedation/analgesia each additional 15
minutes

Page 25 of 30

21125, 21127

64400
00170, 00172, 00174,
00176
00170, 00172, 00174,
00176
99143, 99144, 99148,
99149
99145, 99150

Table 1 to CMS 416 Reporting Instructions for Lines 12a through 12g
Crosswalk of CPT Codes to CDT Codes

(Form CMS-416)

Nomenclature

CPT Codes

Consultation - diagnostic
service provided by a
dentist or physician other
than requesting dentist or
physician

Office consultation - 99241,
99242, 99243, 99244,
99245
Inpatient consultation 99251,
99252, 99253, 99254,
99255

D9310

Page 26 of 30

Table 2: Form CMS-416 EPSDT Reporting Instructions
Crosswalk of ICD-9 to ICD-10 Codes for Line 14
Total Number of Screening Blood Lead Tests
ICD-9 Codes (Form CMS-416)
984.0 Toxic effect of inorganic
lead compounds

984.1 Toxic effect of organic
lead compounds

984.8 Toxic effect of other lead
compounds

984.9 Toxic effect of unspecified
lead compound

ICD-10 Codes and Description (for Form CMS-416)
effective 10/1/2014
T56.0X1A Toxic effect of lead and its compounds,
accidental (unintentional), initial encounter
T56.0X2A Toxic effect of lead and its compounds,
intentional self-harm, initial encounter
T56.0X3A Toxic effect of lead and its compounds, assault,
initial encounter
T56.0X4A Toxic effect of lead and its compounds,
undetermined, initial encounter
T56.0X1A Toxic effect of lead and its compounds,
accidental (unintentional), initial encounter
T56.0X2A Toxic effect of lead and its compounds,
intentional self-harm, initial encounter
T56.0X3A Toxic effect of lead and its compounds, assault,
initial encounter
T56.0X4A Toxic effect of lead and its compounds,
undetermined, initial encounter
T56.0X1A Toxic effect of lead and its compounds,
accidental (unintentional), initial encounter
T56.0X2A Toxic effect of lead and its compounds,
intentional self-harm, initial encounter
T56.0X3A Toxic effect of lead and its compounds, assault,
initial encounter
T56.0X4A Toxic effect of lead and its compounds,
undetermined, initial encounter
M1A.10X0 Lead-induced chronic gout, unspecified site,
without tophus (tophi),
M1A.10X1 Lead-induced chronic gout, unspecified site,
with tophus (tophi)
M1A.1110 Lead-induced chronic gout, right shoulder,
without tophus (tophi)
M1A.1111 Lead-induced chronic gout, right shoulder, with
tophus (tophi)
M1A.1120 Lead-induced chronic gout, left shoulder,
without tophus (tophi)
M1A.1121 Lead-induced chronic gout, left shoulder, with
tophus (tophi)
M1A.1190 Lead-induced chronic gout, unspecified
shoulder, without tophus (tophi)
Page 27 of 30

Table 2: Form CMS-416 EPSDT Reporting Instructions
Crosswalk of ICD-9 to ICD-10 Codes for Line 14
Total Number of Screening Blood Lead Tests
ICD-9 Codes (Form CMS-416)

984.9 Toxic effect of unspecified
lead compound
(continued from prior page)

ICD-10 Codes and Description (for Form CMS-416)
effective 10/1/2014
M1A.1191 Lead-induced chronic gout, unspecified
shoulder, with tophus (tophi)
M1A.1210 Lead-induced chronic gout, right elbow, without
tophus (tophi)
M1A.1211 Lead-induced chronic gout, right elbow, with
tophus (tophi)
M1A.1220 Lead-induced chronic gout, left elbow, without
tophus (tophi)
M1A.1221 Lead-induced chronic gout, left elbow, with
tophus (tophi)
M1A.1290 Lead-induced chronic gout, unspecified elbow,
without tophus (tophi)
M1A.1291 Lead-induced chronic gout, unspecified elbow,
with tophus (tophi)
M1A.1310 Lead-induced chronic gout, right wrist, without
tophus (tophi)
M1A.1320 Lead-induced chronic gout, left wrist, without
tophus (tophi)
M1A.1321 Lead-induced chronic gout, left wrist, with
tophus (tophi)
M1A.1390 Lead-induced chronic gout, unspecified wrist,
without tophus (tophi)
M1A.1391 Lead-induced chronic gout, unspecified wrist,
with tophus (tophi)
M1A.1410 Lead-induced chronic gout, right hand, without
tophus (tophi)
M1A.1411 Lead-induced chronic gout, right hand, with
tophus (tophi)
M1A.1420 Lead-induced chronic gout, left hand, without
tophus (tophi)
M1A.1421 Lead-induced chronic gout, left hand, with
tophus (tophi)
M1A.1490 Lead-induced chronic gout, unspecified hand,
without tophus (tophi)
M1A.1491 Lead-induced chronic gout, unspecified hand,
with tophus (tophi)
M1A.1510 Lead-induced chronic gout, right hip, without
tophus (tophi)
M1A.1511 Lead-induced chronic gout, right hip, with
Page 28 of 30

Table 2: Form CMS-416 EPSDT Reporting Instructions
Crosswalk of ICD-9 to ICD-10 Codes for Line 14
Total Number of Screening Blood Lead Tests
ICD-9 Codes (Form CMS-416)

984.9 Toxic effect of unspecified
lead compound
(continued from prior page)

ICD-10 Codes and Description (for Form CMS-416)
effective 10/1/2014
tophus (tophi)
M1A.1520 Lead-induced chronic gout, left hip, without
tophus (tophi)
M1A.1521 Lead-induced chronic gout, left hip, with tophus
(tophi)
M1A.1590 Lead-induced chronic gout, unspecified hip,
without tophus (tophi)
M1A.1591 Lead-induced chronic gout, unspecified hip,
with tophus (tophi)
M1A.1610 Lead-induced chronic gout, right knee, without
tophus (tophi)
M1A.1611 Lead-induced chronic gout, right knee, with
tophus (tophi)
M1A.1620 Lead-induced chronic gout, left knee, without
tophus (tophi)
M1A.1621 Lead-induced chronic gout, left knee, with
tophus (tophi)
M1A.1690 Lead-induced chronic gout, unspecified knee,
without tophus (tophi)
M1A.1691 Lead-induced chronic gout, unspecified knee,
with tophus (tophi)
M1A.1710 Lead-induced chronic gout, right ankle and foot,
without tophus (tophi)
M1A.1711 Lead-induced chronic gout, right ankle and foot,
with tophus (tophi)
M1A.1720 Lead-induced chronic gout, left ankle and foot,
without tophus (tophi)
M1A.1721 Lead-induced chronic gout, left ankle and foot,
with tophus (tophi)
M1A.1790 Lead-induced chronic gout, unspecified ankle
and foot, without tophus (tophi)
M1A.1791 Lead-induced chronic gout, unspecified ankle
and foot, with tophus (tophi)
M1A.18X0 Lead-induced chronic gout, vertebrae, without
tophus (tophi)
M1A.18X1 Lead-induced chronic gout, vertebrae, with
tophus (tophi)
M1A.19X0 Lead-induced chronic gout, multiple sites,
without tophus (tophi)
Page 29 of 30

Table 2: Form CMS-416 EPSDT Reporting Instructions
Crosswalk of ICD-9 to ICD-10 Codes for Line 14
Total Number of Screening Blood Lead Tests
ICD-9 Codes (Form CMS-416)

984.9 Toxic effect of unspecified
lead compound
(continued from prior page)

V15.85 Personal history of
contact with and (suspected)
exposure to potentially
hazardous body fluids
V15.86 Personal history of
contact with and (suspected)
exposure to lead
V82.5 Screening for Chemical
Poisoning and other
contamination

ICD-10 Codes and Description (for Form CMS-416)
effective 10/1/2014
M1A.19X1 Lead-induced chronic gout, multiple sites, with
tophus (tophi)
T56.0X1A Toxic effect of lead and its compounds,
accidental (unintentional), initial encounter
T56.0X2A Toxic effect of lead and its compounds,
intentional self-harm, initial encounter
T56.0X3A Toxic effect of lead and its compounds, assault,
initial encounter
T56.0X4A Toxic effect of lead and its compounds,
undetermined, initial encounter
Z57.8 Occupational exposure to other risk factors

Z77.011 Contact with and (suspected) exposure to lead

Z13.88 Encounter for screening for disorder due to
exposure to contaminants

Page 30 of 30