Chapter Dental 8 - tmhp.com 2007/08_Dental.pdf · ... 8-25 8.4.2.7 Oral and Maxillofacial Surgery...

C h a p t e r

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8Dental
8.1 Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-2

8.2 Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-28.2.1 Tooth Identification (TID) and Surface Identification (SID) Systems . . . . . . . . . . . 8-28.2.2 Supernumerary Tooth Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-2

8.3 Benefits and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-38.3.1 Anesthesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-38.3.2 Dental Orthodontics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-48.3.3 Coverage/Policy Clarifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-8

8.4 Summary of Authorization Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-208.4.1 Prior Authorization Required. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-20

8.4.1.1 Diagnostic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-208.4.1.2 Restorative Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-218.4.1.3 Endodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-218.4.1.4 Periodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-218.4.1.5 Prosthodontic (Removable) Procedures . . . . . . . . . . . . . . . . . . . . . . . . . 8-218.4.1.6 Maxillofacial Prosthodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . 8-218.4.1.7 Implant Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-218.4.1.8 Prosthodontic (Fixed) Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-228.4.1.9 Oral and Maxillofacial Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-228.4.1.10 Orthodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-228.4.1.11 Adjunctive General Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-22

8.4.2 Prior Authorization Not Required. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-238.4.2.1 Diagnostic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-238.4.2.2 Preventive Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-238.4.2.3 Restorative Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-248.4.2.4 Endodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-248.4.2.5 Periodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-258.4.2.6 Prosthodontic (Removable) Procedures . . . . . . . . . . . . . . . . . . . . . . . . . 8-258.4.2.7 Oral and Maxillofacial Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-258.4.2.8 Adjunctive General Services Procedures . . . . . . . . . . . . . . . . . . . . . . . . 8-25

8.5 Dental Treatment in Hospitals and/or Ambulatory Surgical Centers . . . . . . . . . . . . . . 8-258.5.1 Dental Hospital Call . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-258.5.2 Dental Surgeries Performed in ASCs/HASCs. . . . . . . . . . . . . . . . . . . . . . . . . . 8-25

8.6 Doctor of Dentistry Services as a Limited Physician . . . . . . . . . . . . . . . . . . . . . . . . . 8-268.6.1 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-268.6.2 Cleft/Craniofacial Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-288.6.3 Evaluation and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-288.6.4 X-ray Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-288.6.5 Anesthesia by Dentist Physician. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-29

8.7 Claims Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-298.7.1 Dental Claim Electronic Billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-298.7.2 Dental Claim Paper Billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-298.7.3 Dental Emergency Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-298.7.4 Dental Claim Form Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-30

CPT only copyright 2005 American Medical Association. All rights reserved.

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Chapter 8

8.1 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 Services Program enrollment process, and comply with all applicable state laws and require-ments. Out-of-state dental providers must be located in the United States, within 50 miles of the Texas state border.

Refer to: Section 3.1, “Provider Enrollment,” on page 3-2 for more detailed information about CSHCN Services Program provider enrollment procedures.

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

Refer to: Appendix B, “ADA Dental Claim Form Example,” on page B-19.

8.2.1 Tooth Identification (TID) and Surface Identification (SID) SystemsClaims are denied if the procedure code is not compatible with TID and/or SID. Use the alpha characters to describe tooth surfaces or any combination of surfaces. Anterior teeth have facial and incisal surfaces only. Posterior teeth have buccal and occlusal surfaces only.

8.2.2 Supernumerary Tooth IdentificationEach identified permanent tooth and each identified primary tooth has its own identifiable supernu-merary number. This developed system can be found in the 2006 Current Dental Terminology (CDT) published by the ADA.

The TID for each identified supernumerary tooth will be used for paper and electronic claims and can only be billed with the following codes:

• For primary teeth only: D7111

• For both primary and permanent teeth the following codes are billable: D7140, D7210, D7220, D7230, D7240, D7241, D7250, D7285, D7286, and D7510

Permanent Teeth Upper ArchTooth # 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Super # 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66


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8.3 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 and authorization/prior authorization requirements 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 and 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 about covered procedure or diagnosis codes.

8.3.1 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 Services Program provider, may be reimbursed for anesthesia services provided to CSHCN Services Program 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 freestanding or hospital-based surgical center (POS 5) in accordance with all appli-cable rules for administration and supervision of anesthesia services.

CDT procedure codes for anesthesia services D9220, D9221, D9230, D9241, D9248, and D9610 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 8.6.5, “Anesthesia by Dentist Physician,” on page 8-29 for more information about anesthesia CPT procedure codes that are payable to a dentist physician.

Permanent Teeth Lower ArchTooth # 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 Super # 82 81 80 79 78 77 76 75 74 73 72 71 70 69 68 67

Primary Teeth Upper ArchTooth # A B C D E F G H I JSuper # AS BS CS DS ES FS GS HS IS JS

Primary Teeth Lower ArchTooth # T S R Q P O N M L KSuper # TS SS RS QS PS OS NS MS LS KS

CPT only copyright 2005 American Medical Association. All rights reserved. 8–3

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Chapter 8

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

Diagnosis Code Description

52400 Major anomalies of jaw size, unspecified anomaly

52401 Major anomalies of jaw size, maxillary hyperplasia

52402 Major anomalies of jaw size, mandibular hyperplasia

52403 Major anomalies of jaw size, maxillary hypoplasia

52404 Major anomalies of jaw size, mandibular hypoplasia

52405 Major anomalies of jaw size, macrogenia

52406 Major anomalies of jaw size, microgenia

52707 Excessive tuberosity of jaw

52409 Major anomalies of jaw size, other specified anomaly

52410 Anomalies of relationship of jaw to cranial base, unspecified anomaly

52411 Anomalies of relationship of jaw to cranial base, maxillary asymmetry

52412 Anomalies of relationship of jaw to cranial base, other jaw asymmetry

52419 Anomalies of relationship of jaw to cranial base, other specified anomaly

52451 Abnormal jaw closure

52452 Limited mandibular range of motion

52453 Deviation in opening and closing of the mandible

52454 Insufficient anterior guidance

52455 Centric occlusion maximum intercuspation discrepancy

52456 Non-working side interference

52457 Lack of posterior occlusal support

52459 Other dentofacial functional abnormalities

74900 Cleft palate, unspecified

74901 Cleft palate, unilateral, complete

74902 Cleft palate, unilateral, incomplete

74903 Cleft palate, bilateral, complete

74904 Cleft palate, bilateral, incomplete

74910 Cleft lip, unspecified

74911 Cleft lip, unilateral, complete

74912 Cleft lip, unilateral, incomplete

74913 Cleft lip, bilateral, complete

74914 Cleft lip, bilateral, incomplete

74920 Cleft palate with cleft lip, unspecified

74921 Cleft palate with cleft lip, unilateral, complete

74922 Cleft palate with cleft lip, unilateral, incomplete

74923 Cleft palate with cleft lip, bilateral, complete

74924 Cleft palate with cleft lip, bilateral, incomplete

74925 Other combinations of cleft palate with cleft lip


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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, providers must enter the local code in the Remarks section of the claim form.

For electronic submissions other than TDHconnect 3.0 software submissions, providers must 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 W-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 enter the DPC prefix, because 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 a delay of payment may be the result. For answers to questions about how to implement these processes, providers can contact TMHP-CSHCN at 1-800-568-2413 and select Option 2 to speak with a TMHP representative.

Local code D924X is no longer a benefit. 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:

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.

7540 Congenital musculoskeletal deformities of skull, face, and jaw

75555 Acrocephalosyndactyly

7560 Congenital 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.


D8080 Z2009orZ2011orZ2012

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



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

Local code 1009D 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 orthodontic diagnostic work up procedures are considered inclusive procedures. Procedure codes D0330, D0340, D0350, and D0470 will be denied when billed with a diagnostic work up procedure.

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 and the remarks code(s) for orthodontia services.

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


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

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


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

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

Remarks Code Removable 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

Remarks Code Fixed Appliances Description


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Chapter 8

8.3.3 Coverage/Policy ClarificationsThe following information provides procedure and diagnosis code clarification for CSHCN Services Program 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 provider identifier and also bills the equivalent CPT procedure code using the medical provider identifier:

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

ADA Procedure Codes

D0320 D5954 D5955 D5958 D5959

D6040 D6050 D7440 D7441 D7461

D7465 D7510 D7530 D7540 D7550

D7820 D7880 D7955 D7999

CPT Procedure Codes

2/F-21025 2/F-21026 2/F-21029 2/F-21030 2-21031

2-21032 2/8/F-21034 2/F-21040 2/8/F-21044 2/8-21045

2-21082 2-21083 2-21085 2-21110 2-21116

2/8/F-21123 2/8/F-21127 2/8-21188 2/F-21215 2/8/F-21230

Remarks Code Removable Appliances Description


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• 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 identifier) for the following procedure codes:

• Denying follow-up visit procedure codes listed below 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:

• Limiting full mouth X-rays with exam and subsequent reline of dentures to once every three years:

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

2/8/F-21240 2/8/F-21242 2/8/F-21243 2/8/F-21244 2/F-21245

2/F-21246 2/8-21255 2/F-21270 2/F-21295 2/F-21296

2/F-21480 2/F-21485 2/F-41800 2/F-41806 2-41822

2-41823 2-41825 2-41826 2/F-41827 2-41830

2-41850 4/I/T-70332

Procedure Codes

D0230 D0260 D4210 D4240 D4260

D4341 D7310 D7320 D9221

Procedure Codes

1-99211 1-99212 1-99213 1-99214 1-99215

1-99281 1-99282 1-99283 1-99284 1-99285

D4341 D4355

Procedure Codes

D5211 D5212 D5213 D5214 D5281

D5710 D5711 D5720 D5721 D5730

D5731 D5740 D5741 D5750 D5751

D5760 D5761

Procedure Codes

D0210 D0277 D5710 D5711 D5720

D5721 D5730 D5731 D5740 D5741

D5750 D5751 D5760 D5761


5200 Anodontia

5201 Supernumerary teeth

5202 Abnormalities of size and form of teeth

5203 Mottled teeth

5204 Disturbances of tooth formation

5205 Hereditary disturbances in tooth structure, not elsewhere classified

5206 Disturbances in tooth eruption

5207 Teething syndrome

5208 Other specified disorders of tooth development and eruption

5209 Unspecified disorder of tooth development and eruption

52100 Dental caries, unspecified

52101 Dental caries limited to enamel

52102 Dental caries extending into dentine

CPT Procedure Codes


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Chapter 8

52103 Dental caries extending into pulp

52104 Arrested dental caries

52105 Odontoclasia

52106 Dental caries pit and fissure

52107 Dental caries of smooth surface

52108 Dental caries of root surface

52109 Other dental caries

52110 Excessive attrition, unspecified

52120 Abrasion, unspecified

52130 Erosion, unspecified

52140 Pathological resorption, unspecified

5215 Hypercementosis

5216 Ankylosis of teeth

5217 Intrinsic posteruptive color changes

5218 Other specified diseases of hard tissues of teeth

5219 Unspecified disease of hard tissues of teeth

5220 Pulpitis

5221 Necrosis of the pulp

5222 Pulp degeneration

5223 Abnormal hard tissue formation in pulp

5224 Acute apical periodontitis of pulpal origin

5225 Periapical abscess without sinus

5226 Chronic apical periodontitis

5227 Periapical abscess with sinus

5228 Radicular cyst

5229 Other and unspecified diseases of pulp and periapical tissues

5230 Acute gingivitis

5231 Chronic gingivitis

52320 Gingival recession, unspecified

52321 Gingival recession, minimal

52322 Gingival recession, moderate

52323 Gingival recession, severe

52324 Gingival recession, localized

52325 Gingival recession, generalized

5233 Acute periodontitis

5234 Chronic periodontitis

5235 Periodontosis

5236 Accretions on teeth

5238 Other specified periodontal diseases

5239 Unspecified gingival and periodontal disease







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• Reviewing for medical necessity any visits/consults billed by a dentist for a diagnosis other than the following dental diagnosis codes:










52420 Unspecified anomaly of dental arch relationship

52430 Unspecified anomaly of tooth position

5244 Malocclusion, unspecified

52450 Dentofacial functional abnormality, unspecified

52460 Temporomandibular joint disorders, unspecified

52461 Temporomandibular joint disorders, adhesions and ankylosis (bony or fibrous)

52481 Anterior soft tissue impingement

52482 Posterior soft tissue impingement

52489 Other specified dentofacial anomalies

5249 Unspecified dentofacial anomalies

5250 Exfoliation of teeth due to systemic causes

52510 Acquired absence of teeth, unspecified

52511 Loss of teeth due to trauma

52512 Loss of teeth due to periodontal disease

52513 Loss of teeth due to caries

52519 Other loss of teeth

52520 Unspecified atrophy of edentulous alveolar ridge

5253 Retained dental root

5258 Other specified disorders of the teeth and supporting structures

5259 Unspecified disorder of the teeth and supporting structures

V5875 Aftercare following surgery of the teeth, oral cavity and digestive system, NEC

V722 Dental examination


0542 Herpetic gingivostomatitis

1120 Candidiasis of mouth

1400 Malignant neoplasm of upper lip, vermilion border

1401 Malignant neoplasm of lower lip, vermilion border

1403 Malignant neoplasm of upper lip, inner aspect

1404 Malignant neoplasm of lower lip, inner aspect

1405 Malignant neoplasm of lip, unspecified, inner aspect

1406 Malignant neoplasm of commissure of lip

1408 Malignant neoplasm of other sites of lip

1409 Malignant neoplasm of lip, unspecified, vermilion border



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1410 Malignant neoplasm of base of tongue

1411 Malignant neoplasm of dorsal surface of tongue

1412 Malignant neoplasm of tip and lateral border of tongue

1413 Malignant neoplasm of ventral surface of tongue

1414 Malignant neoplasm of anterior two-thirds of tongue, part unspecified

1415 Malignant neoplasm of junctional zone of tongue

1416 Malignant neoplasm of lingual tonsil

1418 Malignant neoplasm of other sites of tongue

1419 Malignant neoplasm of tongue, unspecified

1420 Malignant neoplasm of parotid gland

1421 Malignant neoplasm of submandibular gland

1422 Malignant neoplasm of sublingual gland

1428 Malignant neoplasm of other major salivary glands

1429 Malignant neoplasm of salivary gland, unspecified

1430 Malignant neoplasm of upper gum

1431 Malignant neoplasm of lower gum

1438 Malignant neoplasm of other sites of gum

1439 Malignant neoplasm of gum, unspecified

1440 Malignant neoplasm of anterior portion of floor of mouth

1441 Malignant neoplasm of lateral portion of floor of mouth

1448 Malignant neoplasm of other sites of floor of mouth

1449 Malignant neoplasm of floor of mouth, part unspecified

1450 Malignant neoplasm of cheek mucosa

1451 Malignant neoplasm of vestibule of mouth

1452 Malignant neoplasm of hard palate

1453 Malignant neoplasm of soft palate

1454 Malignant neoplasm of uvula

1455 Malignant neoplasm of palate, unspecified

1456 Malignant neoplasm of retromolar area

1458 Malignant neoplasm of other specified parts of mouth

1459 Malignant neoplasm of mouth, unspecified

1460 Malignant neoplasm of tonsil

1461 Malignant neoplasm of tonsillar fossa

1462 Malignant neoplasm of tonsillar pillars (anterior) (posterior)

1463 Malignant neoplasm of vallecula epiglottica

1464 Malignant neoplasm of anterior aspect of epiglottis

1465 Malignant neoplasm of junctional region of oropharynx

1466 Malignant neoplasm of lateral wall of oropharynx

1467 Malignant neoplasm of posterior wall of oropharynx

1468 Malignant neoplasm of other specified sites of oropharynx

1469 Malignant neoplasm of oropharynx, unspecified site

1490 Malignant neoplasm of pharynx, unspecified

1498 Malignant neoplasm of other sites within the lip and oral cavity

1602 Malignant neoplasm of maxillary sinus



Dental

8

1700 Malignant neoplasm of bones of skull and face, except mandible

1701 Malignant neoplasm of mandible

1730 Other malignant neoplasm of skin of lip

1733 Other malignant neoplasm of skin of other and unspecified parts of face

1950 Malignant neoplasm of head, face, and neck

2100 Benign neoplasm of lip

2101 Benign neoplasm of tongue

2102 Benign neoplasm of major salivary glands

2103 Benign neoplasm of floor of mouth

2104 Benign neoplasm of other and unspecified parts of mouth

2105 Benign neoplasm of tonsil

2106 Benign neoplasm of other parts of oropharynx

2107 Benign neoplasm of nasopharynx

2120 Benign neoplasm of nasal cavities, middle ear, and accessory sinuses

2130 Benign neoplasm of bones of skull and face

2131 Benign neoplasm of lower jaw bone

2160 Benign neoplasm of skin of lip

2163 Benign neoplasm of skin of other and unspecified parts of face

22801 Hemangioma of skin and subcutaneous tissue

2300 Carcinoma in situ of lip, oral cavity, and pharynx

2320 Carcinoma in situ of skin of lip

2323 Carcinoma in situ of skin of other and unspecified parts of face

2350 Neoplasm of uncertain behavior of major salivary glands

2380 Neoplasm of uncertain behavior of bone and articular cartilage

3501 Trigeminal neuralgia

3510 Bell’s palsy

470 Deviated nasal septum

4730 Chronic maxillary sinusitis

4781 Other diseases of nasal cavity and sinuses

5225 Periapical abscess without sinus

5227 Periapical abscess with sinus

5233 Acute periodontitis















8–14

Chapter 8


52420 Unspecified anomaly of dental arch relationship

52421 Angle’s Class I

52422 Angle’s Class II

52423 Angle’s Class III

52424 Open anterior occlusal relationship

52425 Open posterior occlusal relationship

52426 Excessive horizontal overlap

52427 Reverse articulation

52428 Anomalies of interarch distance

52429 Other anomalies of dental arch relationship

52450 Dentofacial functional abnormality, unspecified

52451 Abnormal jaw closure

52452 Limited mandibular range of motion

52453 Deviation in opening and closing of the mandible

52454 Insufficient anterior guidance

52455 Centric occlusion maximum intercuspation discrepancy

52456 Non-working side interference

52457 Lack of posterior occlusal support

52459 Other dentofacial functional abnormalities

52460 Temporomandibular joint disorders, unspecified

52461 Temporomandibular joint disorders, adhesions and ankylosis (bony or fibrous)

52462 Temporomandibular joint disorders, arthralgia of temporomandibular joint

52463 Temporomandibular joint disorders, articular disc disorder (reducing or non-reducing)

52464 Temporomandibular joint disorders, articular disc disorder (reducing or non-reducing)

52469 Temporomandibular joint disorders, other specified temporomandibular joint disorders

52470 Dental alveolar anomalies, unspecified alveolar anomaly

52471 Dental alveolar anomalies, alveolar maxillary hyperplasia

52472 Dental alveolar anomalies, alveolar mandibular hyperplasia

52473 Dental alveolar anomalies, alveolar maxillary hypoplasia

52474 Dental alveolar anomalies, alveolar mandibular hypoplasia

52475 Vertical displacement of alveolus and teeth

52476 Occlusal plane deviation

52479 Dental alveolar anomalies, other specified alveolar anomaly

52481 Anterior soft tissue impingement

52482 Posterior soft tissue impingement

52489 Other specified dentofacial anomalies

5249 Unspecified dentofacial anomalies

52510 Acquired absence of teeth, unspecified

52511 Loss of teeth due to trauma

52512 Loss of teeth due to periodontal disease

52513 Loss of teeth due to caries



Dental

8

52519 Other loss of teeth

5260 Developmental odontogenic cysts

5261 Fissural cysts of jaw

5262 Other cysts of jaws

5263 Central giant cell (reparative) granuloma

5264 Inflammatory conditions of jaw

5265 Alveolitis of jaw

52681 Exostosis of jaw

52689 Other specified diseases of the jaws

5269 Unspecified disease of the jaws

5272 Sialoadenitis

5273 Abscess of salivary gland

5274 Fistula of salivary gland

5275 Sialolithiasis

5276 Mucocele of salivary gland

5277 Disturbance of salivary secretion

5278 Other specified diseases of the salivary glands

5279 Unspecified disease of the salivary glands

5281 Cancrum oris

5282 Oral aphthae

5283 Cellulitis and abscess of oral soft tissues

5284 Cysts of oral soft tissue

5285 Diseases of lips

5286 Leukoplakia of oral mucosa, including tongue

5287 Other disturbances of oral epithelium, including tongue

52871 Minimal keratinized residual ridge mucosa

52872 Excessive keratinized residual ridge mucosa

52879 Other disturbances of oral epithelium, including tongue

5290 Glossitis

5291 Geographic tongue

5292 Median rhomboid glossitis

5293 Hypertrophy of tongue papillae

5294 Atrophy of tongue papillae

5295 Plicated tongue

5296 Glossodynia

5298 Other specified conditions of the tongue

6820 Cellulitis and abscess of face

6828 Cellulitis and abscess of other specified sites

6829 Cellulitis and abscess of unspecified sites

70900 Dyschromia, unspecified

71509 Osteoarthrosis, generalized, involving multiple sites

71518 Osteoarthrosis, localized, primary, involving other specified sites

71528 Osteoarthrosis, localized, secondary, involving other specified sites

71618 Traumatic arthropathy involving other specified sites



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Chapter 8

71690 Unspecified arthropathy, site unspecified

73810 Other acquired deformity of head, unspecified deformity

73811 Other acquired deformity of head, zygomatic hyperplasia

73812 Other acquired deformity of head, zygomatic hypoplasia

73819 Other acquired deformity of head, other specified deformity

74441 Branchial cleft sinus or fistula

74442 Branchial cleft cyst

74900 Cleft palate, unspecified

74901 Cleft palate, unilateral, complete

74902 Cleft palate, unilateral, incomplete

74903 Cleft palate, bilateral, complete

74904 Cleft palate, bilateral, incomplete

74910 Cleft lip, unspecified

74911 Cleft lip, unilateral, complete

74912 Cleft lip, unilateral, incomplete

74913 Cleft lip, bilateral, complete

74914 Cleft lip, bilateral, incomplete

74920 Cleft palate with cleft lip, unspecified

74921 Cleft palate with cleft lip, unilateral, complete

74922 Cleft palate with cleft lip, unilateral, incomplete

74923 Cleft palate with cleft lip, bilateral, complete

74924 Cleft palate with cleft lip, bilateral, incomplete

74925 Other combinations of cleft palate with cleft lip

7500 Tongue tie

75029 Other specified congenital anomalies of pharynx

7560 Congenital anomalies of skull and face bones

7810 Abnormal involuntary movements

78199 Other symptoms involving nervous and musculoskeletal systems

8020 Closed fracture of nasal bones

8021 Open fracture of nasal bones

80220 Closed fracture of unspecified site of mandible

80221 Closed fracture of condylar process of mandible

80222 Closed fracture of subcondylar process of mandible

80223 Closed fracture of coronoid process of mandible

80224 Closed fracture of unspecified part of ramus of mandible

80225 Closed fracture of angle of jaw

80226 Closed fracture of symphysis of body of mandible

80227 Closed fracture of alveolar border of body of mandible

80228 Closed fracture of other and unspecified part of body of mandible

80229 Closed fracture of multiple sites of mandible

80230 Open fracture of unspecified site of mandible

80231 Open fracture of condylar process of mandible

80232 Open fracture of subcondylar process of mandible

80233 Open fracture of coronoid process of mandible



Dental

8

80234 Open fracture of unspecified part of ramus of mandible

80235 Open fracture of angle of jaw

80236 Open fracture of symphysis of body of mandible

80237 Open fracture of alveolar border of body of mandible

80238 Open fracture of body of mandible, other and unspecified

80239 Open fracture of multiple sites of mandible

8024 Closed fracture of malar and maxillary bones

8025 Open fracture of malar and maxillary bones

8026 Closed fracture of orbital floor (blow-out)

8027 Open fracture of orbital floor (blow-out)

8028 Closed fracture of other facial bones

8029 Open fracture of other facial bones

80300 Other closed skull fracture without mention of intracranial injury, with unspec-ified state of consciousness

80301 Other closed skull fracture without mention of intracranial injury, with no loss of consciousness

80302 Other closed skull fracture without mention of intracranial injury, with brief (less than one hour) loss of consciousness

80303 Other closed skull fracture without mention of intracranial injury, with moderate (1–24 hours) loss of consciousness

80304 Other closed skull fracture without mention of intracranial injury, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level

80305 Other closed skull fracture without mention of intracranial injury, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level

80306 Other closed skull fracture without mention of intracranial injury, with loss of consciousness of unspecified duration

80309 Other closed skull fracture without mention of intracranial injury, with concussion, unspecified

80310 Other closed skull fracture with cerebral laceration and contusion, with unspec-ified state of consciousness

8481 Jaw sprain

87320 Open wound of nose, unspecified site, uncomplicated

87321 Open wound of nasal septum, uncomplicated

87322 Open wound of nasal cavity, uncomplicated

87323 Open wound of nasal sinus, uncomplicated

87329 Open wound of multiple sites, uncomplicated

87330 Open wound of nose, unspecified site, complicated

87331 Open wound of nasal septum, complicated

87332 Open wound of nasal cavity, complicated

87333 Open wound of nasal sinus, complicated

87339 Open wound of multiple sites, complicated

87340 Open wound of face, unspecified site, uncomplicated

87341 Open wound of cheek, uncomplicated

87342 Open wound of forehead, uncomplicated

87343 Open wound of lip, uncomplicated



8–18

Chapter 8

• Reviewing procedures billed with a noncovered dental restoration/rehabilitation diagnosis for clients older than 21 years of age:

87344 Open wound of jaw, uncomplicated

87349 Open wound of other and multiple sites, uncomplicated

87350 Open wound of face, unspecified site, complicated

87351 Open wound of cheek, complicate

87352 Open wound of forehead, complicated

87353 Open wound of lip, complicated

87354 Open wound of jaw, complicated

87359 Open wound of other and multiple sites, complicated

87360 Open wound of mouth, unspecified site, uncomplicated

87361 Open wound of buccal mucosa, uncomplicated

87362 Open wound of gum (alveolar process), uncomplicated

87363 Open wound of tooth (broken), uncomplicated

87364 Open wound of tongue and floor of mouth, uncomplicated

87365 Open wound of palate, uncomplicated

87369 Open wound of other and multiple sites, uncomplicated

87370 Open wound of mouth, unspecified site, complicated

87371 Open wound of buccal mucosa, complicated

87372 Open wound of gum (alveolar process), complicated

87373 Open wound of tooth (broken), complicated

87374 Open wound of tongue and floor of mouth, complicated

87375 Open wound of palate, complicated

87379 Open wound of other and multiple sites, complicated

8738 Other and unspecified open wound of head without mention of complication

8739 Other and unspecified open wound of head, complicated

8744 Open wound of pharynx, without mention of complication

8745 Open wound of pharynx, complicated

9062 Late effect of superficial injury

920 Contusion of face, scalp, and neck except eye(s)

9350 Foreign body in mouth

95901 Other and unspecified injury to head

95909 Other and unspecified injury to face and neck


52100 Dental caries, unspecified

52101 Dental caries limited to enamel

52102 Dental caries extending into dentine

52103 Dental caries extending into pulp

52104 Arrested dental caries

52105 Odontoclasia

52109 Other dental caries

52512 Excessive attrition, extending into dentine

52513 Excessive attrition, extending into pulp



Dental

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

• 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 5-88240, 5-88241, 5-88271, 5-88272, 5-88723, 5-88724, 5-88275, D1330, D9951, and 1-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 3 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, D2790 D2791, D2792, and D2794.

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


317 Mild mental retardation

3180 Moderate mental retardation

3181 Severe mental retardation

3182 Profound mental retardation

319 Unspecified mental retardation

Procedure Codes

D2140 D2150 D2160 D2161 D2330

D2331 D2332 D2335 D2391 D2392

D2393 D2394 D2542 D2650 D2651

D2652 D2662 D2663 D2664 D2780

D2781 D2782 D2783 D2930 D2932

D2934

Procedure Codes

D2140 D2150 D2160 D2161 D2330

D2331 D2332 D2335 D2390 D2391

D2392 D2393 D2394 D2542 D2650

D2651 D2652 D2662 D2663 D2664

D2931 D2932 D2933 D2934

Procedure Codes

D2140 D2150 D2160 D2161 D2330

D2331 D2332 D2335 D2390 D2391

D2392 D2393 D2394 D2542 D2650

D2651 D2652 D2662 D2663 D2664

D2931 D2932 D2933 D2934


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Chapter 8

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

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

8.4 Summary of Authorization RequirementsDental services listed in Section 8.4.1 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. Authori-zation is not required for preventative dental services.

Dental radiographs document medical necessity for all therapeutic procedure codes. When radiographs are necessary but cannot be obtained, intraoral photographs should be obtained instead. These radio-graphs or intraoral photographs must be maintained in the client’s record as documentation of medical necessity.

Radiographs or intraoral photographs must be taken before commencing treatment and must be of diagnostic quality or sufficient quality for a prudent dentist to make an appropriate diagnosis. Digital radiographs are not considered appropriate documentation of medical necessity.

The number of radiographic films required for a complete intraoral series is dependent on the age of the client. An intraoral series requires at least eight films. Adults and children over 12 years of age require 12 to 20 films to be considered an intraoral series. A panoramic film (procedure code D0330) plus a minimum of four bitewing films (procedure code D0274) may be considered equivalent to a complete intraoral series including bitewings (procedure code D0210).

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 B, “Request for Dental Authorization or Orthodontia Prior Authorization,” on page B-28, for an example of this form.

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

8.4.1 Prior Authorization RequiredProcedure codes and details concerning authorization requirements are listed below under their respective titles.

8.4.1.1 Diagnostic Procedures

Use procedure code D0999 when billing for unspecified diagnostic procedures.

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


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8.4.1.2 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.

8.4.1.3 Endodontic Procedures

Use procedure codes D3346, D3347, D3348, D3460, D3470, and D3999.

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.

8.4.1.4 Periodontic Procedures

Use the following procedure codes for periodontic procedures:

8.4.1.5 Prosthodontic (Removable) Procedures

Use the following procedure codes for prosthodontic (removable) procedures:

8.4.1.6 Maxillofacial Prosthodontic Procedures

Use the following procedure codes for maxillofacial prosthodontic procedures:

8.4.1.7 Implant Procedures

Use the following procedure codes for implant 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


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Chapter 8

8.4.1.8 Prosthodontic (Fixed) Procedures

Use the following procedure codes for prosthodontic (fixed) procedures:

8.4.1.9 Oral and Maxillofacial Surgery

Use the following procedure codes for oral and maxillofacial surgery procedures:

8.4.1.10 Orthodontic Procedures

Refer to: Section 8.3.2, “Dental Orthodontics,” on page 8-4.

8.4.1.11 Adjunctive General Services

Use 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 enrolled cleft/craniofacial teams or enrolled affiliated providers. See Section 3.1.8, “Specialty Team/Center Enrollment,” on page 3-3 and Section 17.1.4, “Specialty Team/Center,” on page 17-4, for additional information.

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

Procedure Codes

D7260 D7272 D7280 D7285 D7286

D7290 D7291 D7310 D7320 D7340

D7350 D7410 D7411 D7412 D7413

D7414 D7440 D7441 D7450 D7451

D7460 D7461 D7472 D7530 D7540

D7550 D7560 D7820 D7880 D7899

D7955 D7960 D7970 D7971 D7972

D7980 D7983 D7997 D7999

Procedure Codes

D9220 D9221 D9310 D9420 D9610

D9630 D9920 D9940 D9950 D9952

D9974 D9999


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

8.4.2.1 Diagnostic Procedures

The following diagnostic procedures do not require authorization or prior authorization:

8.4.2.2 Preventive Procedures

The following are billable preventive procedure codes:

Tobacco counseling (D1320) and dental nutrition counseling (D1310) are not benefits of the CSHCN Services Program as separate procedures.

Dental SealantsDental sealants may be 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. The tooth must be at risk for dental decay and be free of proximal caries and restorations on the surface to be sealed. Each tooth must be billed separately using procedure code D1351. Reimbursement will be on a per-tooth basis, regardless of the number of surfaces sealed. Tooth numbers and surfaces must be indicated on the claim form. Replacement sealants are not reimbursed.

If, upon claims processing or retrospective review, the finding of the claim/narrative/documen-tation/charting, by a provider, of terms/acronyms indicating preventive resin or combination of similar words, the procedure will be reimbursed as a dental sealant only and not for any of the restorative procedures.

Dental ProphylaxisThe following dental prophylaxis services are a benefit of the CSHCN Services Program:

The following preventive dental codes will not be payable on the same date of service as any D4000 series (periodontal) procedure codes:

Oral Hygiene Instruction (OHI)Procedure code D1330 for OHI may be a benefit of the CSHCN Services Program when the services are above and beyond the routine brushing and flossing instructions included in the prophylaxis procedure codes and when additional time and expertise have been directed toward the client’s care. OHI (procedure code D1330) is limited to once per year by any provider.

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

Procedure Codes

D1110 D1120 D1201 D1203 D1204

D1205 D1330 D1351 D1510 D1515

D1520 D1525 D1550

Procedure Codes

D1110 D1120 D1201 D1203

D1204 D1205 D1330

Procedure Codes

D1110 D1120 D1201 D1203

D1204 D1205 D1351


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Chapter 8

OHI is denied when billed on the same day as dental prophylaxis (procedure codes D1110 and D1120) and topical fluoride treatments with prophylaxis (procedure codes D1201 and D1205) by the same provider.

Space MaintainersSpace maintainers are designed to prevent tooth movement and may be a benefit of the CSHCN Services Program in the following situations:

• After premature loss of deciduous/primary tooth first and/or second molar(s), TID: A, B, I, J, K, L, S, and T for clients 1 through 12 years of age

• After loss of a permanent first molar(s) (TID 3, 14, 19 and 30) for clients 3 through 20 years of age

Note: Premature loss is defined as loss of the tooth prior to the expected or normal life of the tooth. For a deciduous/primary molar, this is before eruption of the comparable permanent tooth.

One space maintainer per tooth ID may be reimbursed per lifetime, per client. Replacement space maintainers may be considered on appeal with documentation supporting medical/dental necessity.

Space maintainers may be reimbursed with procedure codes D1510, D1515, D1520, and D1525.

When procedure codes D1510 or D1515 have been previously reimbursed, the recementation of space maintainers may be considered for reimbursement to either the same or a different CSHCN Services Program dental provider when billed with procedure code D1550.

8.4.2.3 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.

Use the following procedure codes when billing restorative procedures:

8.4.2.4 Endodontic Procedures

Use the following procedure codes when billing endodontic procedures:

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


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8.4.2.5 Periodontic Procedures

Use the following procedure codes when billing periodontic procedures:

8.4.2.6 Prosthodontic (Removable) Procedures

Use the following procedure codes when billing prosthodontic procedures:

8.4.2.7 Oral and Maxillofacial Surgery

Use the following procedure codes when billing oral and maxillofacial surgeries:

8.4.2.8 Adjunctive General Services Procedures

Use the following procedure codes when billing adjunctive general services:

8.5 Dental Treatment in Hospitals and/or Ambulatory Surgical CentersAll inpatient hospital admissions require prior authorization.

8.5.1 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. 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. All client records are subject to retrospective review.

8.5.2 Dental Surgeries Performed in ASCs/HASCsExcept for those procedures that require prior authorization, admission to freestanding ambulatory surgical centers (ASCs) or outpatient hospital ambulatory surgical centers (HASCs) for the purpose of performing dentistry services must be authorized by TMHP.

Procedure Codes

D4210 D4211 D4240 D4241 D4260

D4261 D4273 D4275 D4320 D4321

D4341 D4342 D4355 D4381 D4910

D4920

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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Chapter 8

Anesthesiologists should bill using procedure code 7-00170. Facilities (ASCs or HASCs) should bill using procedure code F-41899.

8.6 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.

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 3.1.8.2, “Requirements for Cleft/Craniofacial (C/C) Center Team Enrollment,” on page 3-4, Section 8.6.2, “Cleft/Craniofacial Surgery,” on page 8-28, and Section 17.1.4, “Specialty Team/Center,” on page 17-4, for more detailed 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 payer requirements are met.

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

Procedure Codes

2-10060 2-10061 2-10120 2-10121

2-10140 2-10160 2-10180 2-11000

2-11001 2-11040 2-11044 2-11440

2-11441 2-11442 2-11443 2-11444

2-11446 2-11640 2-11646 2-12011

2-12013 2-12014 2-12015 2-12016

2-12017 2/8-12018 2-12051 2-12052

2-12053 2-12054 2-12055 2-12056

2/8-12057 2-13131* 2-13132* 2/8–13133*

2-13150 2-13151 2-13152 2/8-13153

2-14040* 2-14060 2-14061 2-15000

2-15115 2-15120 2-15121 2-15240

2-15400 2-15850 2-15852 2-20000

2-20005 2-20200 2–20205 2-20220

2-20240 2-20520 2-20600 2-20605

2-20670 2/8-20680 2-20693 2-20694

2-20900 2/8-20902 2-20912 2-21010

2-21015 2-21025 2-21026 2-21029

2-21030 2-21031 2--21032 2/8-21034

2-21040 2/8-21044 2/8-21045 2/8-21050

2/8-21060 2-21070 2-21116 2/8-21240

2/8-21242 2/8-21243 2-21310 2/8-21343

2/8-21344 2-21345 2-21346 2/8-21347

2/8-21348 2-21355 2/8-21356 2/8-21360

* Payable only for repairs to the forehead, cheeks, chin, mouth, and neck.


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2/8-21365 2/8-21366 2/8-21385 2-21386

2-21387 2/8-21390 2/8-21395 2-21400

2-21401 2-21406 2/8-21407 2/8-21408

2-21421 2/8-21422 2/8-21423 2/8-21431

2/8-21432 2/8-21433 2/8-21435 2/8-21436

2-21440 2-21445 2-21450 2-21451

2-21452 2-21453 2-21454 2/8-21461

2/8-21462 2/8-21465 2/8-21470 2-21480

2-21485 2/8-21490 2-29800 2-29804

2-30130 2-30140 2-30400 2-30450

2-30520 2-30580 2-30600 2-30630

2-30801 2-30802 2-30930 2-31020

2-31030 2-40490 2-40500 2-40510

2-40520 2-40530 2-40650 2-40702

2-40800 2-40801 2-40804 2-40805

2-40806 2-40808 2-40810 2-40812

2-40814 2-40816 2-40819 2-40820

2-40830 2-40831 2-40840 2-40842

2-40843 2-40844 2-40845 2-41000

2-41005 2-41006 2-41007 2-41008

2-41009 2-41010 2-41015 2-41016

2-41017 2-41018 2-41100 2-41105

2-41108 2-41110 2-41112 2-41113

2-41114 2-41115 2-41116 2/8-41130

2-41250 2-41251 2-41252 2-41520

2-41800 2-41806 2-41822 2-41823

2-41827 2-41830 2-41850 2-42000

2-42100 2-42104 2-42106 2-42107

2/8-42120 2-42160 2-42180 2-42182

2-42281 2-42300 2-42305 2-42310

2-42320 2-42330 2-42335 2-42340

2-42400 2-42405 2/8-42410 2/8-42415

2/8-42425 2/8-42440 2-42505 2-42550

2-42600 2-42650 2-42660 2-42665

2-42700 2-42720 2-42725 2-42810

2-42900 2-42960 2-42970 2-64400

2-64600 2-64722 2-64736 2/8-64740

5/I/T-88305 5/I/T-88331 5/I/T-88332 2-92511

Procedure Codes

* Payable only for repairs to the forehead, cheeks, chin, mouth, and neck.


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8.6.2 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 cleft/craniofacial team.

Refer to: Section 3.1.8.2, “Requirements for Cleft/Craniofacial (C/C) Center Team Enrollment,” on page 3-4, Section 8.6.2, “Cleft/Craniofacial Surgery,” on page 8-28, and Section 17.1.4, “Specialty Team/Center,” on page 17-4 for more information.

All of the following cleft/craniofacial surgery procedures must be prior authorized:

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

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

Procedure Codes

2-21079 2-21080 2-21081 2-21082 2-21083

2-21084 2-21085 2-21086 2-21087 2-21088

2-21089 2-21100 2-21110 2/8-21120 2/8-21121

2/8-21122 2/8-21123 2/8-21125 2/8-21127 2/8-21137

2/8-21138 2/8-21139 2/8-21141 2/8-21142 2/8-21143

2/8-21145 2/8-21146 2/8-21147 2/8-21150 2/8-21151

2/8-21154 2/8-21155 2/8-21159 2/8-21160 2/8-21172

2/8-21175 2/8-21179 2/8-21180 2/8-21181 2/8-21182

2/8-21183 2/8-21184 2/8-21188 2/8-21193 2/8-21194

2/8-21195 2/8-21196 2/8-21198 2/8-21199 2/8-21206

2/21208 2/8-21209 2/8-21210 2-21215 2/8-21230

2/21235 2/8-21244 2-21245 2-21246 2/8-21247

2-21248 2-21249 2/8-21255 2/8-21256 2/8-21260

2/8-21261 2/8-21263 2/8-21267 2/8-21268 2-21270

2-21275 2-21280 2-21282 2-21295 2-21296

2/8-21299 2-30460 2-30462 2-30520 2-40650

2-40652 2-40654 2-40700 2-40701 2-40702

2-40720 2-42200 2-42205 2/8-42210 2-42215

2-42220 2-42225 2-42226 2-42227 2-42235

2-42260

Procedure Codes

1-99201 1-99202 1-99203 1-99204 1-99205

1-99211 1-99212 1-99213 1-99214 1-99215

1-99218 1-99219 1-99220 1-99221 1-99222

1-99223 1-99231 1-99232 1-99233 1-99238

3-99241 3-99242 3-99243 3-99244 3-99245

3-99251 3-99252 3-99253 3-99254 3-99255

1-99281 1-99282 1-99283 1-99284 1-99285

Procedure Codes

4/I/T-70100 4/I/T-70110 4/I/T-70120 4/I/T-70130 4/I/T-70140

4/I/T-70150 4/I/T-70160 4/I/T-70170 4/I/T-70190 4/I/T-70200


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8.6.5 Anesthesia by Dentist PhysicianIn addition to the CDT codes discussed under “Benefits and Limitations” in this chapter, anesthesia CPT procedure codes 1-99100, 1-99116, 1-99135, and 1-99140 are payable to a dentist physician.

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


8.7.1 Dental Claim Electronic BillingProviders billing electronically must submit dental claims in American National Standards Institute (ANSI) ASC X12 837D format. 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.

8.7.2 Dental Claim Paper BillingAll participating CSHCN Services Program dental providers must use the ADA Dental Claim Form (Copyright 2002, American Dental Association) for paper claim submissions to the CSHCN Services Program and can obtain copies of this form 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-digit provider identifier. The billing provider’s full name and address must be entered in Block 48 of the ADA Dental Claim Form, and the nine-digit provider identifier must be entered in Block 49. A claim without a provider name, address, or provider identifier cannot be processed.


8.7.3 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.

4/I/T-70250 4/I/T-70260 4/I/T-70300 4/I/T-70310 4/I/T-70320

4/I/T-70328 4/I/T-70330 4/I/T-70332 4/I/T-70336 4/I/T-70350

4/I/T-70355 4/I/T-70370 4/I/T-70371 4/I/T-70380 4/I/T-70390

4/I/T-73100 4/I/T-76375

Procedure Codes


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8.7.4 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. Complete the dental claim form according to the instructions to facilitate prompt and accurate reimbursement and reduce followup inquiries. Providers can review the “ADA Dental Claim Form Example,” on page B-19, and the “Instructions for Completing the ADA Dental Claim Form,” on page B-16.


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