chapter dental 7 - tmhp 2006/07_dental.pdforthodontic procedures require prior authorization and may...

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7Dental
7.1 Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-2

7.2 Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-2

7.3 Benefits and Limitations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-27.3.1 Anesthesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-27.3.2 Dental Orthodontics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-37.3.3 Coverage/Policy Clarifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-7

7.4 Summary of Authorization Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-97.4.1 Prior Authorization Required. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-9

7.4.1.1 Diagnostic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-97.4.1.2 Restorative Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-97.4.1.3 Endodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-97.4.1.4 Periodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-107.4.1.5 Prosthodontic (Removable) Procedures . . . . . . . . . . . . . . . . . . . . . . . . . 7-107.4.1.6 Maxillofacial Prosthodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . 7-107.4.1.7 Implant Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-107.4.1.8 Prosthodontic (Fixed) Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-107.4.1.9 Oral and Maxillofacial Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-117.4.1.10 Orthodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-117.4.1.11 Adjunctive General Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-11

7.4.2 Prior Authorization Not Required. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-117.4.2.1 Diagnostic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-117.4.2.2 Preventive Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-117.4.2.3 Restorative Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-127.4.2.4 Endodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-127.4.2.5 Periodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-127.4.2.6 Prosthodontic (Removable) Procedures . . . . . . . . . . . . . . . . . . . . . . . . . 7-137.4.2.7 Oral and Maxillofacial Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-137.4.2.8 Orthodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-137.4.2.9 Adjunctive General Services Procedures . . . . . . . . . . . . . . . . . . . . . . . . 7-13

7.5 Dental Treatment in Hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-137.5.1 Dental Hospital Call . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-137.5.2 Dental Surgeries Performed in ASC/HASC . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-13

7.6 Doctor of Dentistry Services as a Limited Physician . . . . . . . . . . . . . . . . . . . . . . . . . 7-137.6.1 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-147.6.2 Cleft/Craniofacial Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-157.6.3 Evaluation and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-157.6.4 X-ray Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-157.6.5 Anesthesia by Dentist Physician. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-15

7.7 Claims Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-157.7.1 Dental Claim Electronic Billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-157.7.2 Dental Claim Paper Billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-167.7.3 Dental Emergency Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-167.7.4 Dental Claim Form Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-16

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7.1 EnrollmentTo enroll in the CSHCN Services Program, dental providers must be actively enrolled in the Texas Medicaid Program, have a valid Provider Agreement with the CSHCN Services Program, have completed the CSHCN enrollment process, and comply with all applicable state laws and requirements.

7.2 ReimbursementReimbursement for dental services is the lower of the billed amount or the amount allowed by the Texas Medicaid Program. All participating CSHCN dental providers are required to submit the American Dental Association (ADA) Dental Claim Form for paper claim submissions to the CSHCN Services Program. Obtain these forms by contacting ADA at 1-800-947-4746.

Refer to: The ADA Dental Claim Form Example on page C-19.

7.3 Benefits and LimitationsThe CSHCN Services Program provides coverage for dental services to program eligible clients. Coverage of dental services is limited to what is necessary to prevent, treat, or correct dental and oral complications. Additional specific information regarding benefits and limitations for orthodontia, dental orthodontics, dental policy clarifications, and dental sealants follows.

Specific procedure or diagnosis codes related to program benefits and coverage may be listed in this chapter. These listings are intended to provide helpful information, but should not be considered all-inclusive. From time to time, codes are added, deleted, or revised. Coverage and coding information is updated in the CSHCN Provider Bulletin. Call the TMHP-CSHCN Contact Center at 1-800-568-2413 with questions regarding covered procedure or diagnosis codes.

7.3.1 AnesthesiaEach dentist licensed by the Texas State Board of Dental Examiners (TSBDE) practicing in Texas who has obtained a permit from the TSBDE to administer anesthesia in accordance with the rules of the TSBDE, and who is enrolled as a CSHCN provider, may be reimbursed for anesthesia services provided to CSHCN clients having dental/oral and maxillofacial surgical procedures. These services must be performed in the dental office (place of service [POS] 1),inpatient hospital (POS 3), or free-standing or hospital-based surgical center (POS 5) in accordance with all applicable rules for administration and supervision of anesthesia services.

Current Dental Terminology (CDT) procedure codes for anesthesia services D9220, D9221, D9230, D9241, and D9248 are covered benefits.

Except for procedure code D9221, only one anesthesia procedure may be reimbursed per day for the same client.

Procedure code D9248 is a benefit when provided in the office setting. Any dentist providing non-intra-venous (IV) conscious sedation must comply with all TSBDE rules and American Academy of Pediatric Dentistry (AAPD) guidelines, including maintaining a current permit to provide non-IV conscious sedation. Documentation supporting medical necessity and appropriateness for the use of non-IV conscious sedation must be maintained in the client’s record and is subject to retrospective review.

Reimbursement for non-IV conscious sedation is limited to:

• Clients 1 through 20 years of age.

• One non-IV conscious sedation service per client per day.

• Two non-IV conscious sedation services per 12 months per client without prior authorization.

A provider must obtain prior authorization to perform more than two non-IV conscious sedation services for the same client in a 12-month period.

Refer to: Section 7.6.5, “Anesthesia by Dentist Physician,” on page 7-15 for more information about anesthesia CPT procedure codes that are payable to a dentist physician.

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7.3.2 Dental OrthodonticsOrthodontic procedures require prior authorization and may be reimbursed for the following diagnosis codes:

All removable or fixed orthodontic appliances must be billed with CDT procedure codes D8210 or D8220. To ensure appropriate claims processing, the local code reflecting the specific service is also required. For paper claim submissions, enter the local code in the Remarks section of the claim form.

For electronic submissions other than TDHconnect 3.0 software submissions, follow the steps below to ensure TMHP accurately applies the correct local code to the appropriate claim detail:

1) Submit the DPC prefix in the first three bytes of NTE02 at the 2400 loop. Submit the DPC prefix only once.

2) Submit the remark code (local code) in bytes 4–8, based on the order of the claim detail. Do not enter any spaces or punctuation between remark codes, unless to designate that the detail is not billed with D8210 or D8220:

Example: For a claim with three details, where details 1 and 3 are submitted with procedure code D8210 and detail 2 is not, enter the following information in the NTE02 at the 2400 loop:

DPC1014D 1046D(The space shows that detail 2 needs no local code.)

Example: If all three details require a local code, enter DPC and the appropriate local codes in sequence without any spaces between the codes:

DPC1024D1055D1056D(The absence of spaces indicates that local codes are needed for all three details.)

To submit using TDHconnect 3.0 software, enter the local code into the Remarks Code field, located under the Details header. The Remarks Code field is the field following the Procedure Code field. TDHconnect 3.0 submitters are not required to manually enter the DPC prefix, as it is automatically placed in the appropriate field on the TDHconnect 3.0 electronic claim.

Failure to follow the above steps does not cause the claim to deny; however, manual intervention is required to process the claim, and may result in a delay of payment. For answers to questions about how to implement these processes, contact TMHP-CSHCN at 1-800-568-2413 and select Option 2 to speak with a TMHP representative.

Local code D924X, Intravenous sedation, is no longer a benefit. Providers should use procedure code D9241 instead. All other orthodontic procedure codes that were local codes used for prior authorization and reimbursement have been converted to CDT (national) procedure codes.

The following procedures are not included in comprehensive treatment:

Diagnosis Code Description

52400–52409 Major anomalies of jaw size

52410–52419 Anomalies of relationship of jaw to cranial base

52451–52459 Dentofacial functional abnormalities

74900–74925 Cleft palate and cleft lip

7540 Certain congenital musculoskeletal deformities of skull, face, and jaw

75555 Acrocephalosyndactyly

7560 Anomalies of skull and face bones

CDT Procedure Code Remarks Code Description

D8660 Z2008 Initial orthodontic visit

D8670 Z2013 Orthodontic adjustments, per month

*D7997 Z2016 Premature appliance removal, per arch

*May only be paid to a provider not billing for comprehensive treatment.

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Procedure code D8080 is a comprehensive code and includes a diagnostic workup as well as all upper and lower orthodontic appliances (braces) necessary to treat the client. Use remarks codes Z2009, Z2011, or Z2012.

When a diagnostic workup is not approved, individual components may be considered for separate reimbursement. Use the following procedure codes:

Local code 1009D, Brackets, was replaced with CDT procedure code D8690.

Procedure code D8680 includes all retainers necessary to treat the client. Use the following remarks codes according to the service(s) provided:

Procedure code D8050 includes a crossbite workup and removable appliance. Use the following remarks codes according to the service(s) provided:

Procedure code D8060 includes a crossbite workup and the fixed appliance. Use the following remarks codes according to the service(s) provided:

The following tables display the special fixed and removable orthodontic appliances. Under the current provisions of the Health Insurance Portability and Accountability Act (HIPAA), all fixed appliances are designated as procedure code D8220, and all removable appliances are designated as procedure code D8210. These are entered as a line item on the ADA Dental Claim Form with the appropriate fee. However, the remarks codes (former local procedure codes), as appropriate and listed below, also need to be entered on the authorization request form and in the Remarks field of the dental claim form (paper and electronic) to ensure correct authorization, accurate records, and reimbursement. Failure to bill the correct procedure code(s) may result in claim processing delays.

Note: Prior authorization must be requested using both the CDT procedure code(s) and the remarks code(s) for orthodontia services.


D8080 Z2009orZ2011orZ2012

Diagnostic workup, approvedorOrthodontic appliance, upper (braces)orOrthodontic appliance, lower (braces)


D0330

Z2010 Diagnostic workup, not approvedD0340

D0350

D0470

Remarks Code Description

1033D Mandibular, fixed, 2x4 retainer



Z2014 Orthodontic retainer, upper

Z2015 Orthodontic retainer, lower


8110D Crossbite therapy, removable appliance

Z2018 Crossbite, workup


8120D Crossbite therapy, fixed appliance

Z2018 Crossbite, workup

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Use the following remarks codes in the Remarks field for fixed appliances (procedure code D8220):

Remarks Code Fixed Appliances Description

1000D Appliance for horizontal projections

1001D Appliance for recurved springs

1002D Arch wires for crossbite correction, for total treatment

1003D Banded maxillary expansion appliance

1008D Bonded expansion device

1012D Crib

1015D Distalizing appliance with springs

1016D Expansion device

1018D Fixed expansion device

1019D Fixed lingual arch

1020D Fixed mandibular holding arch

1021D Fixed rapid palatal expander

1025D Herbst appliance, fixed or removable

1026D Interocclusal cast cap surgical splints

1028D Jasper jumpers

1029D Lingual appliance with hooks

1030D Mandibular anterior bridge

1031D Mandibular bihelix, similar to a quad helix for mandibular expansion to attempt nonextraction treatment

1036D Mandibular lingual, 6x6, arch wire

1042D Maxillary lingual arch with spurs

1043D Maxillary and mandibular distalizing appliance

1044D Maxillary quad helix with finger springs

1045D Maxillary and mandibular retainer with pontics

1049D Modified quad helix appliance

1050D Modified quad helix appliance, with appliance

1051D Nance stent

1052D Nasal stent

1057D Palatal bar

1059D Quad helix appliance held with transpalatal arch horizontal projections

1060D Quad helix maintainer

1061D Rapid palatal expander (RPE), i.e., quad helix, haas, or menne

1068D Stapled palatal expansion appliance

1072D Thumb sucking appliance, requires submission of models

1076D Transpalatal arch

1077D Two bands with transpalatal arch and horizontal projections forward

1078D W-appliance

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Use the following remarks codes in the Remarks field for removable appliances (procedure code D8210):

Remarks Code Fixed Appliances Description

1004D Bite plate/bite plane

1005D Bionator

1006D Bite block

1007D Bite plate with push springs

1010D Chateau appliance (face mask, palatal expander, and hawley)

1011D Coffin spring appliance

1013D Dental obturator, definitive (obturator)

1014D Dental obturator, surgical (obturator, surgical stayplate, immediate temporary obturator)

1017D Face mask (protraction mask)

1022D Frankel appliance

1023D Functional appliance for reduction of anterior open bite and crossbite

1024D Head gear (face bow)

1027D Intrusion arch

1032D Mandibular lip bumper

1037D Mandibular removable expander with bite plane (crozat)

1038D Mandibular ricketts rest position splint

1039D Mandibular splint

1040D Maxillary anterior bridge

1041D Maxillary bite-opening appliance with anterior springs

1046D Maxillary Schwarz

1047D Maxillary splint

1048D Mobile intraoral arch (MIA), similar to a bihelix for nonextraction treatment

1053D Occlusal orthotic device

1054D Orthopedic appliance

1055D Other mandibular utilities

1056D Other maxillary utilities

1062D Removable bite plane

1063D Removable mandibular retainer

1064D Removable maxillary retainer

1065D Removable prosthesis

1066D Sagittal appliance, 2-way

1067D Sagittal appliance, 3-way

1069D Surgical arch wires

1070D Surgical splints (surgical stent/wafer)

1071D Surgical stabilizing appliance

1073D Tongue thrust appliance, requires submission of models

1074D Tooth positioner, full maxillary and mandibular

1075D Tooth positioner with arch

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7.3.3 Coverage/Policy ClarificationsThe following information provides procedure and diagnosis code clarification for CSHCN dental and orthodontia policies. CSHCN Services Program policy requires the following:

• Reviewing claims for procedure codes when a dental provider submits an ADA procedure code under the dental Texas Provider Identifier (TPI) and also bills the equivalent CPT procedure code using the medical TPI:

• Reviewing duplicate dental services that are submitted on different claims (same procedure, tooth ID, surface ID, place of service, date of service, and same provider TPI) for the following procedure codes:

• Denying follow-up visit procedure codes 99052, 99054, 99211 through 99215, 99281 through 99285, D4341, and D4355 if billed within 90 days of radiation treatment provided by the same provider.

• Reviewing partials and/or relines within one year of original denture/reline; procedure codes D5211 through D5214, D5281, D5710 through D5711, D5720 through D5721, D5730 through D5731, D5740 through D5741, D5750 through D5751, and D5760 through D5761.

• Limiting full mouth X-rays with exam and subsequent reline of dentures to once every three years; procedure codes D0210, D0277, D5710 through D5711, D5720 through D5721, D5730 through D5731, D5740 through D5741, D5750 through D5751, and D5760 through D5761.

• Reviewing all inpatient claims billed with one of the following oral surgery diagnosis codes:

• Reviewing for medical necessity visits/consults billed by a dentist for a diagnosis other than a dental diagnosis as follows:

Procedure Codes

21025–21026 21029–21032 21034 21040 21044–21045

21082–21083 21085 21110 21116 21123

21127 21188 21215 21230 21240

21242–21246 21255 21270 21295–21296 21480

21485 41800 41805–41806 41822–41823 41825–41827

41830 41850 70332 D0320 D5954–D5955

D5958–D5959 D6040 D6050 D7440–D7441 D7461

D7465 D7510 D7530 D7540 D7550

D7820 D7880 D7955 D7999

Procedure Codes

D0230 D0260 D4210 D4240 D4260

D4341 D7310 D7320 D9221

Diagnosis Codes

5200-5209 52100-52109 52110 52120 52130

52140 5215 5216 5217 5218

5219 5220-5229 5230-5239 52400-52409 52410-52419

52420 52430 5244 52450 52460

52461 52481-52489 5249 5250 52510–52519

52520 5253 5258 5259 V5875

V722

Diagnosis Codes

0542 1120 1400-1469 1490 1498

1602 1700-1701 1730 1733 1950

2100–2107 2120 2130–2131 2160 2163

22801 2300 2320 2323 2350

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• Reviewing procedures billed with a noncovered dental restoration/rehabilitation diagnosis for clients older than 21 years of age: diagnosis codes 52100 through 52105, 52109, and 52512 through 52513.

• Reviewing procedures billed with a noncovered mental retardation diagnosis for clients 0 through 20 years of age: diagnosis codes 317 through 319.

• Limiting the paid amount for restorations and stainless steel crowns on primary teeth to ensure that the total amount paid does not exceed the payment allowed on each tooth for tooth IDs A through T and 99:

• Limiting the paid amount for restorations and stainless steel crowns on anterior teeth to ensure that the total amount paid does not exceed the payment allowed on each tooth for tooth IDs 06 through 11, 22 through 27, and 99:

• Limiting the paid amount for restorations and stainless steel crowns on permanent posterior teeth to ensure that the total amount paid does not exceed the payment allowed on each tooth for tooth IDs 1 through 5, 12 through 21, 28 through 32, and 99:

• Denying procedures billed more than once per year, per client by any provider: procedure codes 8240 through 88241, 88271 through 88275, D1330, D9951, and J9219.

• Limiting the paid amount for X-rays per date of service, billed on the same claim by any provider to ensure that the amount paid for X-rays per case does not exceed the payment for the all inclusive X-ray procedure: procedure codes D0210, D0220, D0230, D0240, D0270, D0272, D0274, D0277, and D0330.

• Reviewing procedures that are limited to once in a lifetime (dental exams/panorex codes for clients from 0 through 20 years of age): procedure code D0330.

• Limiting posterior crowns to four per lifetime, any type, any provider: procedure codes D2710, D2720, D2722, D2740, D2750, D2751, D2752, and D2790 through D2794.

• Limiting anterior crowns to two per lifetime, any type, any provider: procedure code D2751.

• Reviewing sealants billed on a previously restored surface or on a tooth previously crowned or extracted.

2380 3501 3510 470 4730

4781 5225 5227 5233 52400–52429

5245–5249 52510-52519 5260–5269 5272–5279 5281–52879

5290–5298 6820 6828–6829 70900 71509

71518 71528 71618 71690 73810–73819

74441–74442 74900–7500 75029 7560 7810

78199 8020–80310 8481 87320–8739 8744–8745

9062 920 9350 95901–95909

Procedure Codes

D2140 D2150 D2160–2161 D2330–2332 D2335

D2391–D2394 D2542 D2650–D2652 D2662–D2664 D2780–D2783

D2930 D2932 D2934

Procedure Codes

D2140 D2150 D2160–D2161 D2330–D2332 D2335

D2390 D2391–D2394 D2542 D2650–D2652 D2662–D2664

D2931–D2934

Procedure Codes

D2140 D2150 D2160–D2161 D2330–D2332 D2335

D2390 D2391–D2394 D2542 D2650–D2652 D2662–D2664

D2931–D2934

Diagnosis Codes

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• The following CPT procedure codes are benefits of the CSHCN Services Program for physicians and dentists when provided in the following payable POS:

• The following CPT procedure codes are payable to dental provider types 27 (Dentist DDS and DMD) and 96 (Dentistry Group):

7.4 Summary of Authorization RequirementsDental services listed in Section 7.4.1 require prior authorization. All orthodontia must also be prior authorized as specified in preceding sections of this chapter. The CSHCN Services Program does not require the submission of X-rays, models, etc., for prior authorized services. All prior authorization requests must include specific rationale for the requested service including documentation of medical necessity. Additional documentation, including current periapical radiographs, must be maintained in the client's medical/dental record and submitted to the CSHCN Services Program on request.

Reimbursement for appliance adjustments is limited to one per month, per client. Newborn appliances and surgical archwires do not require authorization and may be adjusted more than once per month.

Note: Fax transmittal confirmations are not accepted as proof of timely authorization submission.

Refer to: Appendix C, “Request for Dental Authorization or Orthodontia Prior Authorization,” on page C-28, for an example of this form.

Tip: Photocopy this form and retain the original for future use.

7.4.1 Prior Authorization RequiredThe following procedure codes must be prior authorized:

7.4.1.1 Diagnostic ProceduresUse procedure code D0999 when billing for diagnostic procedures.

7.4.1.2 Restorative ProceduresPrior authorization is required for inlay/onlay restorations and crowns-single restorations only (permanent teeth only), in excess of four in a lifetime, any provider. For example, if a client received three inlays (procedure code D2610), and one crown (procedure code D2710), prior authorization is necessary for any further inlay/onlay restorations or crowns—single restorations only. Use procedure code D2999 when billing for restorative procedures not adequately described by a code.

7.4.1.3 Endodontic ProceduresUse procedure codes D3346 through D3348, D3460, D3470, and D3999.

Procedure Code POS Procedure Code POS

2–20520 1, 3, 5 5–88331 1, 3, 5, 6

4–70380 1, 5 I–88331 3, 5

I–70380 1, 3, 5 T–88331 6

T–70380 1 5–88332 1, 3, 5, 6

5–88305 1, 3, 5, 6 I–88332 3, 5

I–88305 3, 5 T–88332 6

T–88305 6

Procedure Code POS Procedure Code POS

4–76375 1, 5 T–76375 1

I–76375 1, 3, 5

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7.4.1.4 Periodontic ProceduresUse the following procedure codes for periodontic procedures:

7.4.1.5 Prosthodontic (Removable) ProceduresUse the following procedure codes for prosthodontic (removable) procedures:

7.4.1.6 Maxillofacial Prosthodontic ProceduresUse the following procedure codes for maxillofacial prosthodontic procedures:

7.4.1.7 Implant ProceduresUse the following procedure codes for implant procedures:

7.4.1.8 Prosthodontic (Fixed) ProceduresUse the following procedure codes for prosthodontic (fixed) procedures:

Procedure Codes

D4245 D4249 D4266 D4267 D4270

D4271 D4273 D4274 D4276 D4999

Procedure Codes

D5110 D5120 D5130 D5140 D5211–D5212

D5213–D5214 D5281 D5510 D5520 D5710

D5711 D5720 D5721 D5810 D5811

D5820 D5821 D5850 D5851 D5860

D5861 D5862 D5899

Procedure Codes

D5911 D5912 D5913 D5914 D5915

D5916 D5919 D5922 D5923 D5924

D5925 D5926 D5927 D5928 D5929

D5931 D5932 D5933 D5934 D5935

D5936 D5937 D5951 D5952 D5953

D5954 D5955 D5958 D5959 D5960

D5982 D5983 D5984 D5985 D5986

D5987 D5988 D5999

Procedure Codes

D6010 D6040 D6050 D6055 D6056

D6057 D6080 D6090 D6095 D6100

D6199

Procedure Codes

D6210 D6211 D6212 D6240 D6241

D6242 D6245 D6250 D6251 D6252

D6545 D6548 D6720 D6721 D6722

D6740 D6750 D6751 D6752 D6780

D6781 D6782 D6783 D6790 D6791

D6792 D6920 D6930 D6940 D6950

D6970 D6971 D6972 D6973 D6975

D6976 D6977 D6980 D6999

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7.4.1.9 Oral and Maxillofacial SurgeryUse the following procedure codes for oral and maxillofacial surgery procedures:

7.4.1.10 Orthodontic ProceduresRefer to: Section 7.3.2, “Dental Orthodontics,” on page 7-3.

7.4.1.11 Adjunctive General ServicesUse the following procedure codes for adjunctive general services:

Note: Invasive procedures for clients with cleft palate/lip and/or craniofacial anomalies must be prior authorized and performed by approved cleft/craniofacial teams or approved affiliated providers. See Section 3.1.7, “Specialty Team/Center Approval,” on page 3-4, and Section 16.1.4, “Specialty Team/Center,” on page 16-4, for additional information.

7.4.2 Prior Authorization Not RequiredThe following procedure codes do not require authorization or prior authorization and may be used when submitting claims:

7.4.2.1 Diagnostic Procedures

7.4.2.2 Preventive ProceduresDental SealantsDental sealants are a benefit for clients under 21 years of age. Sealants may be applied to the occlusal, buccal, and lingual pits and fissures of any tooth that is at risk for dental decay and is free of proximal caries and restorations on the surface to be sealed. Indicate the tooth numbers and surfaces on the claim form. To bill for more than one tooth in a quadrant, bill each tooth separately using procedure code D1351. Reimbursement is based on Medicaid pricing. Replacement sealants are not reimbursed. If a dentist has applied two or more sealants in a particular quadrant and has been paid the maximum quadrant fee, any other sealants applied in that quadrant are not paid during the six months following the application of those sealants. However, recognizing that it is good dental practice to seal teeth as soon as possible upon eruption, if a dentist seals a newly erupted permanent molar in that quadrant

Procedure Codes

D7260 D7272 D7280 D7285 D7286

D7290 D7291 D7310 D7320 D7340

D7350 D7410 D7411 D7413 D7414

D7440 D7441 D7450 D7451 D7460

D7461 D7472 D7530 D7540 D7550

D7560 D7820 D7880 D7899 D7950

D7955 D7960 D7970 D7971 D7972

D7980 D7983 D7997 D7999

Procedure Codes

D9220 D9221 D9310 D9420 D9610

D9630 D9920 D9940 D9950 D9952

D9974 D9999

Procedure Codes

D0120 D0140 D0150 D0160 D0170

D0210 D0220 D0230 D0240 D0250

D0260 D0270 D0272 D0274 D0277

D0290 D0310 D0320 D0321 D0322

D0330 D0340 D0350 D0460 D0470

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during this six-month period, it may be paid (on appeal only) the full single-tooth amount. The tooth number(s) and surfaces must be indicated on the claim form. The following are billable preventive procedure codes:

7.4.2.3 Restorative ProceduresNote: Prior authorization is required for inlay/onlay restorations and single crown restorations (permanent teeth only) in excess of four in a lifetime, any provider.

7.4.2.4 Endodontic Procedures

Procedure code D3460 is a benefit for clients 16 years of age and older when regular treatment has failed. Prior authorization is required. Documentation of medical necessity must include the following: the anatomy is such that no other fixed or removable prosthodontic alternatives are available (e.g., anodontia, a result of trauma, or birth defect) and regular treatment failure.

7.4.2.5 Periodontic Procedures

Procedure Codes

D1110 D1120 D1201 D1203 D1204

D1205 D1330 D1351 D1510 D1515

D1520 D1525 D1550

Procedure Codes

D2140 D2150 D2160 D2161 D2330

D2331 D2332 D2335 D2390 D2391

D2392 D2393 D2394 D2410 D2420

D2430 D2510 D2520 D2530 D2542

D2543 D2544 D2610 D2620 D2630

D2642 D2643 D2644 D2650 D2651

D2652 D2662 D2663 D2664 D2710

D2720 D2721 D2722 D2740 D2750

D2751 D2752 D2780 D2781 D2782

D2783 D2790 D2791 D2792 D2794

D2910 D2915 D2920 D2930 D2931

D2932 D2933 D2934 D2940 D2950

D2951 D2952 D2953 D2954 D2955

D2957 D2960 D2961 D2962 D2980

Procedure Codes

D3110 D3120 D3220 D3230 D3240

D3310 D3320 D3330 D3351 D3352

D3353 D3410 D3421 D3425 D3426

D3430 D3450 D3910 D3920 D3950

Procedure Codes

D4210 D4211 D4240 D4241 D4260

D4261 D4265 D4273 D4275 D4320

D4321 D4341 D4342 D4355 D4381

D4910 D4920

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7.4.2.6 Prosthodontic (Removable) Procedures

7.4.2.7 Oral and Maxillofacial Surgery

7.4.2.8 Orthodontic ProceduresAll orthodontic procedures require prior authorization.

Refer to: Section 7.3.2, “Dental Orthodontics,” on page 7-3.

7.4.2.9 Adjunctive General Services Procedures

7.5 Dental Treatment in HospitalsAll inpatient hospital admissions require prior authorization.

7.5.1 Dental Hospital CallA dental hospital call may be reimbursed for clients requiring medically necessary anesthesia and/or dental treatment in the inpatient or outpatient hospital setting. Use procedure code D9420.

Documentation supporting the medical necessity of a dental hospital call must be retained in the patient’s record and is subject to retrospective review. This documentation includes any medical, physical (e.g. traumatic event), mental, or behavioral disability, and a description of the service performed that required the hospital call. Client records are subject to retrospective review.

Except for those procedures requiring prior authorization, admission to ambulatory surgical centers (outpatient and freestanding) for the purpose of performing dentistry services must be authorized by TMHP.

7.5.2 Dental Surgeries Performed in ASC/HASCAnesthesiologists should bill procedure code 00170. Ambulatory Surgical Centers/Hospital Ambulatory Surgical Centers (ACSs/HASCs) should bill procedure code 41899.

7.6 Doctor of Dentistry Services as a Limited PhysicianThe CSHCN Services Program covers services provided by a doctor of dentistry (DDS, DMD, or DDM) if the services are covered and furnished within the dentist’s scope of practice as defined by Texas state law. To participate in the CSHCN Services Program as a dentist practicing as a limited physician, a dentist (DDS, DMD, or DDM) must be enrolled separately as a dentist practicing as a limited physician.

Procedure Codes

D5410 D5411 D5421 D5422 D5610

D5620 D5630 D5640 D5650 D5660

D5670 D5671 D5730 D5731 D5740

D5741 D5750 D5751 D5760 D5761

Procedure Codes

D7111 D7140 D7240 D7241 D7250

D7261 D7270 D7282 D7510 D7520

D7670 D7910 D7911 D7912 D7972

Procedure Codes

D8660 D9110 D9210 D9211 D9212

D9215 D9230 D9430 D9440 D9910

D9930 D9951

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For treatment of clients with cleft/craniofacial anomalies, dental providers must conform to the CSHCN Services Program rules for cleft/craniofacial specialty team/center enrollment and be members of or affiliated with a cleft/craniofacial center team.

Refer to: Section 3.1.7.2, “Requirements for Cleft/Craniofacial (C/C) Center Team Approval,” on page 3-4, Section 7.6.2, “Cleft/Craniofacial Surgery,” on page 7-15, and Section 16.1.4, “Specialty Team/Center,” on page 16-4, for more information.

If a client has third party insurance coverage available that requires reconstructive facial surgery involving the bony skeleton of the face, including midface osteotomies and cleft lip and palate repairs performed by a physician, the CSHCN Services Program cannot consider a claim for payment unless all third party payor requirements are met.

7.6.1 SurgeryThe following surgery CPT procedure codes are payable to a dentist enrolled in the CSHCN Services Program as a dentist physician:

Procedure Codes

10060–10061 10140 10160 10180 11000–11001

11040 11044 11440–11446 11640 11646

12011–12018 12051–12057 13131–13133* 13150–13153 14040*

14060–14061 15000 15120–15121 15240 15400

15850 15852 20000–20005 20200–20205 20220

20240 20520 20600–20605 20670–20680 20693–20694

20900–20902 20912 21010 21015 21025–21026

21029–21032 21034 21040 21044–21045 21050

21060 21070 21116 21240–21243 21310

21343–21348 21355–21366 21385–21395 21400–21401 21406–21408

21421–21423 21431–21436 21440 21445 21450–21453

21454–21470 21480–21485 21490 29800–29804 30130

30140 30400 30450 30520 30580–30600

30630 30801–30802 30930 31020–31030 40490

40500 40510–40520 40530 40650 40702

40800–40801 40804–40806 40808 40810–40816 40819

40820 40830–40831 40840–40845 41000–41010 41015–41018

41100–41105 41108 41110–41116 41130 41250–41252

41520 41800 41806 41822–41823 41827

41830 41850 42000 42100 42104–42107

42120 42160 42180–42182 42300–42305 42310–42320

42325–42326 42330–42340 42400–42405 42410–42415 42425

42440 42505 42550 42600 42650

42660 42665 42700–42725 42810 42900

42960 42970 64400 64600 64722

64736 64740 88305 88331–88332 92511

* Procedure codes 13131–13133 and 14040 are payable only for repairs to the forehead, cheeks, chin, mouth, and neck.

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7.6.2 Cleft/Craniofacial SurgeryThe following surgery codes are payable to a dentist physician only if the dentist physician also is enrolled as a member of or affiliated with a CSHCN-approved cleft/craniofacial team. These procedures must be prior authorized:

7.6.3 Evaluation and ManagementThe following evaluation and management service procedure codes are payable to a dentist physician:

7.6.4 X-ray ProceduresThe following diagnostic X-ray procedure codes are payable to a dentist physician:

7.6.5 Anesthesia by Dentist PhysicianIn addition to the CDT codes discussed under Benefits and Limitations in this chapter, the following anesthesia CPT procedure codes are payable to a dentist physician:

7.7 Claims InformationProviders billing for dental services may bill electronically or use the ADA Dental Claim Form.


7.7.1 Dental Claim Electronic BillingProviders billing electronically must submit dental claims in NSF or X.12 837D formats. Specifications are available to providers developing in-house systems, software developers, and vendors. Because each software package is different, field locations may vary. Providers should contact the software developer or vendor for information about their software. Providers or software vendors may direct questions about development requirements to the TMHP Electronic Data Interchange (EDI) Help Desk at 1-888-863-3638.

Procedure Codes

21076–21077 21079–21089 21100 21120–21123 21125–21127

21137–21139 21141–21160 21172–21184 21188 21193–21196

21198–21199 21206 21208–21215 21230–21235 21244–21249

21255–21256 21260–21263 21267–21268 21270 21275

21280–21282 21295–21296 21299 21497 30460–30462

30520 40527 40650–40654 40700–40720 40761

42145 42200–42227 42235 42260 42280–42281

61550–61559 62115–62117 67950 67961–67975

Procedure Codes

99201–99205 99211–99215 99218–99223 99231–99233 99238

99241–99245 99251–99255 99261–99263 99281–99285

Procedure Codes

70100–70110 70120–70130 70140–70150 70160 70170

70190–70200 70250–70260 70300–70320 70328–70330 70332

70336 70350 70355 70370 70371

70380 70390 76375

Procedure Codes

00100–00102 00160–00164 00170–00172 00190–00192 99100

99116 99135 99140

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7.7.2 Dental Claim Paper BillingAll participating CSHCN dental providers must use the ADA Dental Claim Form for paper claim submis-sions to the CSHCN Services Program and can obtain these forms by contacting the ADA at 1-800-947-4746. Any paper dental claim submitted using any other version of the dental claim form may not be processed and will be returned to the submitter.

Claims must contain the billing provider’s full name, address, and/or nine-character TPI. The billing provider’s full name and address must be entered in Block 48 of the ADA Dental Claim Form, and the nine-character TPI must be entered in Block 49. A claim without a provider name, address, or TPI cannot be processed.


7.7.3 Dental Emergency ClaimsThe Emergency Indicator field has been removed from the HIPAA approved 837D electronic transaction. Dental providers submitting electronic claims in the 837D format must use modifier ET to report emergency services. Modifier ET must be placed in the SVC01 section of the 837D format.

Additionally, the Comments field should be used to document the specific nature of the emergency. The Comments field in the HIPAA approved 837D electronic transaction is 80 bytes long.

To indicate a dental emergency on a paper claim submission (ADA Dental Claim Form), check Block 45, Treatment Resulting From (check the applicable box), and check the Other Accident box for emergency claim reimbursement. If the Other Accident box is checked, information about the emergency must be provided in Block 35, Remarks.

7.7.4 Dental Claim Form InstructionsThe Dental Claim Form Instructions describe the information that must be entered in each of the block numbers of the ADA Dental Claim Form. Thoroughly complete the dental claim form according to the instructions to facilitate prompt and accurate reimbursement and reduce followup inquiries. Review the ADA Dental Claim Form Example on page C-19, and the Instructions for Completing the ADA Dental Claim Form on page C-16.

chapter dental 7 - tmhp 2006/07_dental.pdforthodontic procedures require prior authorization and may...

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