If performing fluoride treatments, procedure codes D1203 and D1204 must be submitted on the same date of service as the cleaning (D1110 and D1120).

D1110*

Limited to one prophylaxis per client per six-month period (includes oral health instructions). If billed on emergency claim, procedure code will be denied. A 13-20

D1120*

Limited to one prophylaxis per client per six-month period (includes oral health instructions). If billed on emergency claim, procedure code will be denied. A 1-12

D1203*

Includes oral health instructions. A 1-12, N, CCP

D1204*

Includes oral health instructions. A 13-20, N, CCP

D1206*

Includes oral health instructions. A 1-20, N, CCP

D1320

A client requiring tobacco counseling may be referred to a THSteps primary care provider.

D1330

Requires documentation of the type of instructions, number of appointments, and content of instructions. This procedure is payable only for medically necessary situations that are non-routine. This procedure refers to services above and beyond routine brushing and flossing instruction and requires that additional time and expertise have been directed toward the client's care.
Oral hygiene instruction is denied when billed on the same day as dental prophylaxis (D1110, D1120) and/or topical fluoride treatments (D1203, D1204, and D1206) by the same provider. Procedure code D1330 is limited to once per client, per year by any provider. A 1-20, N, CCP

D1351*

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 free of restorations on the surface to be sealed. Sealants are a benefit when applied to deciduous (baby or primary) teeth or permanent teeth. Replacement sealants will not be reimbursed. Indicate the tooth numbers and surfaces on the claim form. Reimbursement will be considered on a per-tooth basis, regardless of the number of surfaces sealed. A 1-20

When a client needs a space maintainer and exceeds the listed age limitation, the service can be a benefit under CCP. The provider must justify medical necessity with radiograph(s) and/or a narrative on the prior authorization request and receive prior authorization for consideration of payment of the service.

Limitation for space maintainers is to hold the space for the loss of one of the first or second primary molars (#A, #B, #I, #J, #K, #L, #S, and #T) or the loss of a permanent first molar (#3, #14, #19, and #30). There is no payment for replacement if it was previously paid for by Medicaid/THSteps. Fees for space maintainers include maintenance and repair. One space maintainer is reimbursed per TID, per client, per lifetime. When procedure code D1510 or D1515 have been previously reimbursed, the recementation of space maintainers may be considered for reimbursement to either the same or different THSteps dental provider when billed with procedure code D1550.

D1510*

A 1-20 (#A, #B, #I, #J, #K, #L, #S, #T), MTID
A 3-20 (#3, #14, #19, #30), MTID

D1515*

A 1-20 (#A, #B, #I, #J, #K, #L, #S, #T), MTID
A 3-20 (#3, #14, #19, #30), MTID

D1520*

A 1-20 (#A, #B, #I, #J, #K, #L, #S, #T), MTID
A 3-20 (#3, #14, #19, #30), MTID

D1525*

A 1-20 (#A, #B, #I, #J, #K, #L, #S, #T), MTID
A 3-20 (#3, #14, #19, #30), MTID

D1550

A 3-12 (#A, #B, #I, #J, #K, #L, #S, #T), MTID
A 3-20 (#3, #14, #19, #30), MTID

D1555*

Replacement space maintainers may be considered upon appeal with documentation supporting medical necessity.