CSHCN Services Program 2010 > Dental > Benefits, Limitations, and Authorization Requirements
14.2.3 Orthodontia Services
Orthodontia services are benefits of the CSHCN Services Program for clients with the following diagnosis codes of cleft-craniofacial anomalies:
Diagnosis Code
Description
52400
Unspecified major anomaly of jaw size
52401
Maxillary hyperplasia
52402
Mandibular hyperplasia
52403
Maxillary hypoplasia
52404
Mandibular hypoplasia
52405
Macrogenia
52406
Microgenia
52407
Excessive tuberosity of jaw
52409
Other specified major anomaly of jaw size
52410
Unspecified anomaly of relationship of jaw to cranial base
52411
Maxillary asymmetry
52412
Other jaw asymmetry
52419
Other unspecified anomaly of relationship of jaw to cranial base
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
Dentofacial functional abnormality, nonworking side interference
52457
Lack of posterior occlusal support
52459
Other dentofacial functional abnormalities
74900
Unspecified cleft palate
74901
Unilateral cleft palate, complete
74902
Unilateral cleft palate, incomplete
74903
Bilateral cleft palate, complete
74904
Bilateral cleft palate, incomplete
74910
Unspecified cleft lip
74911
Unilateral cleft lip, complete
74912
Unilateral cleft lip, incomplete
74913
Bilateral cleft lip, complete
74914
Bilateral cleft lip, incomplete
74920
Unspecified cleft palate with cleft lip
74921
Unilateral cleft palate with cleft lip, complete
74922
Unilateral cleft palate with cleft lip, incomplete
74923
Bilateral cleft palate with cleft lip, complete
74924
Bilateral cleft palate with cleft lip, incomplete
74925
Other combinations of cleft palate with cleft lip
7540
Congenital musculoskeletal deformities of skull, face, and jaw
75555
Acrocephalosyndactyly
7560
Congenital anomalies of skull and face bones
Orthodontia for cosmetic purposes only is not a benefit of the CSHCN Services Program.All removable or fixed orthodontic appliances must be billed with procedure codes D8210 or D8220.
Texas Medicaid & Healthcare Partnership CPT only copyright 2009 American Medical Association. All rights reserved.