CSHCN Services Program 2010 > Dental > Benefits, Limitations, and Authorization Requirements

   
 

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:

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.

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.

CDT Procedure Code
Remarks Code
Description

D8080

Z2008

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

D0330

Z2010

Diagnostic workup, not approved

D0340

D0350

D0470

Procedure code D8680 includes all retainers necessary to treat the client. Use the following remarks codes according to the services 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 services 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 services provided:

Remarks Code
Description

8120D

Crossbite therapy, fixed appliance

Z2018

Crossbite, workup

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 paper 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):

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

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

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

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

The following procedure codes are used to bill orthodontic services:

ADA Procedure Codes

D5951

D5952

D5953

D5954

D5955

D5958

D5959

D5960

D7280

D7997

D8050

D8060

D8080

D8210

D8220

D8660

D8670

D8680

D8690

D8693

D8999

The rebonding, recementing, or repair (procedure code D8693) is limited to one per arch, per lifetime. Procedure code D8693 is limited to clients 6 years of age or older.


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