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
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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.
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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.
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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.
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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
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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
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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.
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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.
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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
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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: 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.
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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 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.
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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