7.3.2 Dental Orthodontics

Chapter 7 Dental 7.1 Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-2...
Author: Ada Floyd
25 downloads 3 Views 752KB Size
Chapter

7

Dental

7.1 Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-2 7.2 Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-2 7.3 Benefits and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-2 7.3.1 Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-2 7.3.2 Dental Orthodontics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-3 7.3.3 Coverage/Policy Clarifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-7 7.4 Summary of Authorization Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-9 7.4.1 Prior Authorization Required. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-9 7.4.1.1 Diagnostic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-9 7.4.1.2 Restorative Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-9 7.4.1.3 Endodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-9 7.4.1.4 Periodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-10 7.4.1.5 Prosthodontic (Removable) Procedures . . . . . . . . . . . . . . . . . . . . . . . . . 7-10 7.4.1.6 Maxillofacial Prosthodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . 7-10 7.4.1.7 Implant Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-10 7.4.1.8 Prosthodontic (Fixed) Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-10 7.4.1.9 Oral and Maxillofacial Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-11 7.4.1.10 Orthodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-11 7.4.1.11 Adjunctive General Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-11 7.4.2 Prior Authorization Not Required. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-11 7.4.2.1 Diagnostic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-11 7.4.2.2 Preventive Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-11 7.4.2.3 Restorative Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-12 7.4.2.4 Endodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-12 7.4.2.5 Periodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-12 7.4.2.6 Prosthodontic (Removable) Procedures . . . . . . . . . . . . . . . . . . . . . . . . . 7-13 7.4.2.7 Oral and Maxillofacial Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-13 7.4.2.8 Orthodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-13 7.4.2.9 Adjunctive General Services Procedures . . . . . . . . . . . . . . . . . . . . . . . . 7-13 7.5 Dental Treatment in Hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-13 7.5.1 Dental Hospital Call . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-13 7.5.2 Dental Surgeries Performed in ASC/HASC . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-13 7.6 Doctor of Dentistry Services as a Limited Physician . . . . . . . . . . . . . . . . . . . . . . . . . 7-13 7.6.1 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-14 7.6.2 Cleft/Craniofacial Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-15 7.6.3 Evaluation and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-15 7.6.4 X-ray Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-15 7.6.5 Anesthesia by Dentist Physician. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-15 7.7 Claims Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-15 7.7.1 Dental Claim Electronic Billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-15 7.7.2 Dental Claim Paper Billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-16 7.7.3 Dental Emergency Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-16 7.7.4 Dental Claim Form Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-16

7

Chapter 7

7.1 Enrollment To 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 Reimbursement Reimbursement 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 Limitations The 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 Anesthesia Each 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-intravenous (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.

7–2

Dental

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

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.

7

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: 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.

7–3

Chapter 7

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. CDT Procedure Code

Remarks Code

Description

D8080

Z2009 or Z2011 or Z2012

Diagnostic workup, approved or Orthodontic appliance, upper (braces) or Orthodontic appliance, lower (braces)

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

Remarks Code

Description

Z2010

Diagnostic workup, not approved

D0330 D0340 D0350 D0470 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: Remarks Code

Description

1033D

Mandibular, fixed, 2x4 retainer

1034D

Mandibular, fixed, 3x3 retainer

1035D

Mandibular, fixed, 4x4 retainer

Z2014

Orthodontic retainer, upper

Z2015

Orthodontic retainer, lower

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

Description

8110D

Crossbite therapy, removable appliance

Z2018

Crossbite, workup

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

Description

8120D

Crossbite therapy, fixed appliance

Z2018

Crossbite, workup

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.

7–4

Dental

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

7

7–5

Chapter 7

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

7–6

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

Dental

7.3.3 Coverage/Policy Clarifications The 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: 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

• 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:

7

Procedure Codes D0230

D0260

D4210

D4240

D4341

D7310

D7320

D9221

D4260

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

7–7

Chapter 7

Diagnosis Codes 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

• 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: Procedure Codes D2140

D2150

D2160–2161

D2330–2332

D2335

D2391–D2394

D2542

D2650–D2652

D2662–D2664

D2780–D2783

D2930

D2932

D2934

• 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: Procedure Codes D2140

D2150

D2160–D2161

D2330–D2332

D2335

D2390

D2391–D2394

D2542

D2650–D2652

D2662–D2664

D2931–D2934 • 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: Procedure Codes D2140

D2150

D2160–D2161

D2330–D2332

D2335

D2390

D2391–D2394

D2542

D2650–D2652

D2662–D2664

D2931–D2934 • 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.

7–8

Dental

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

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

POS

Procedure Code

POS

4–76375

1, 5

T–76375

1

I–76375

1, 3, 5

7.4 Summary of Authorization Requirements

7

Dental 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 Required The following procedure codes must be prior authorized:

7.4.1.1 Diagnostic Procedures Use procedure code D0999 when billing for diagnostic procedures. 7.4.1.2 Restorative Procedures Prior 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 Procedures Use procedure codes D3346 through D3348, D3460, D3470, and D3999.

7–9

Chapter 7

7.4.1.4 Periodontic Procedures Use the following procedure codes for periodontic procedures: Procedure Codes D4245

D4249

D4266

D4267

D4270

D4271

D4273

D4274

D4276

D4999

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

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

7.4.1.7 Implant Procedures Use the following procedure codes for implant procedures: Procedure Codes D6010

D6040

D6050

D6055

D6056

D6057

D6080

D6090

D6095

D6100

D6199

7.4.1.8 Prosthodontic (Fixed) Procedures Use the following procedure codes for prosthodontic (fixed) procedures: Procedure Codes

7–10

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

Dental

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

7.4.1.10 Orthodontic Procedures Refer to: Section 7.3.2, “Dental Orthodontics,” on page 7-3. 7.4.1.11 Adjunctive General Services Use the following procedure codes for adjunctive general services: 7

Procedure Codes D9220

D9221

D9310

D9420

D9610

D9630

D9920

D9940

D9950

D9952

D9974

D9999

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 Required The following procedure codes do not require authorization or prior authorization and may be used when submitting claims:

7.4.2.1 Diagnostic Procedures 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

7.4.2.2 Preventive Procedures Dental Sealants Dental 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 7–11

Chapter 7

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: Procedure Codes D1110

D1120

D1201

D1203

D1204

D1205

D1330

D1351

D1510

D1515

D1520

D1525

D1550

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

7.4.2.4 Endodontic Procedures Procedure Codes D3110

D3120

D3220

D3230

D3240

D3310

D3320

D3330

D3351

D3352

D3353

D3410

D3421

D3425

D3426

D3430

D3450

D3910

D3920

D3950

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

7–12

D4210

D4211

D4240

D4241

D4260

D4261

D4265

D4273

D4275

D4320

D4321

D4341

D4342

D4355

D4381

D4910

D4920

Dental

7.4.2.6 Prosthodontic (Removable) Procedures Procedure Codes D5410

D5411

D5421

D5422

D5610

D5620

D5630

D5640

D5650

D5660

D5670

D5671

D5730

D5731

D5740

D5741

D5750

D5751

D5760

D5761

7.4.2.7 Oral and Maxillofacial Surgery Procedure Codes D7111

D7140

D7240

D7241

D7250

D7261

D7270

D7282

D7510

D7520

D7670

D7910

D7911

D7912

D7972

7.4.2.8 Orthodontic Procedures All orthodontic procedures require prior authorization. Refer to: Section 7.3.2, “Dental Orthodontics,” on page 7-3. 7

7.4.2.9 Adjunctive General Services Procedures Procedure Codes D8660

D9110

D9210

D9211

D9212

D9215

D9230

D9430

D9440

D9910

D9930

D9951

7.5 Dental Treatment in Hospitals All inpatient hospital admissions require prior authorization.

7.5.1 Dental Hospital Call A 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/HASC Anesthesiologists 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 Physician The 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.

7–13

Chapter 7

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 Surgery The 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.

7–14

Dental

7.6.2 Cleft/Craniofacial Surgery The 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: 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

7.6.3 Evaluation and Management The following evaluation and management service procedure codes are payable to a dentist physician: Procedure Codes

7

99201–99205

99211–99215

99218–99223

99231–99233

99241–99245

99251–99255

99261–99263

99281–99285

99238

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

7.6.5 Anesthesia by Dentist Physician In 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: Procedure Codes 00100–00102

00160–00164

00170–00172

99116

99135

99140

00190–00192

99100

7.7 Claims Information Providers billing for dental services may bill electronically or use the ADA Dental Claim Form. Refer to: The ADA Dental Claim Form Example on page C-19.

7.7.1 Dental Claim Electronic Billing Providers 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. 7–15

Chapter 7

7.7.2 Dental Claim Paper Billing All participating CSHCN dental providers must use the ADA Dental Claim Form for paper claim submissions 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. Refer to: The ADA Dental Claim Form Example on page C-19.

7.7.3 Dental Emergency Claims The 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 Instructions The 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.

7–16