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14.2.3.3 Submitting Local Codes for Orthodontic Procedures
To ensure appropriate claims processing, the local code reflecting the specific service is required on the claim.
For electronic submissions other than TexMedConnect submissions, providers must follow the steps below to ensure the correct local code is accurately applied 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 TexMedConnect, 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. TexMedConnect submitters are not required to enter the DPC prefix, because it is automatically placed in the appropriate field on the TexMedConnect electronic claim.
For paper claim submissions, providers must enter the local code in the Remarks section of the claim form.
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.
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.
When a diagnostic workup is not approved, individual components may be considered for separate reimbursement. Use the following procedure codes:
Procedure code D8680 includes all retainers necessary to treat the client. Use the following remarks codes according to the services provided:
Procedure code D8050 includes a crossbite workup and removable appliance. Use the following remarks codes according to the services provided:
Procedure code D8060 includes a crossbite workup and the fixed appliance. Use the following remarks codes according to the services provided:
The orthodontic diagnostic work up procedures are considered inclusive procedures. Procedure codes D0330, D0340, D0350, and D0470 are 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 American Dental Association (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 codes may result in claim processing delays.
Note: Prior authorization must be requested using both the CDT procedure code and the remarks codes for orthodontia services.
Use the following remarks codes in the Remarks field for fixed appliances (procedure code D8220):
Use the following remarks codes in the Remarks field for removable appliances (procedure code D8210):
The following procedure codes are used to bill orthodontic services:
Only one rebonding or recementing or repair, as required, of fixed retainers per arch, per lifetime for each retainer may be reimbursed.
Procedure code D8693 is limited to clients 6 years of age or older.
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