TMPPM 2010 > Children's Services Handbook > Texas Health Steps (THSteps) Dental > Services/Benefits, Limitations, and Prior Authorization > Diagnostic Services

    
 

5.3.11 Diagnostic Services

Diagnostic services should be performed for all clients, starting within the first 6 months of the eruption of the first primary tooth, but no later than 1 year of age.

Procedure Code
Limitations
Maximum Fee

Clinical Oral Evaluations

Procedure codes D0140, D0160, D0170, and D0180 are limited dental codes and may be paid in addition to a comprehensive oral exam (procedure code D0150) or periodic oral exam (procedure code D0120), when billed within a 6 month period. When submitting a claim for procedure code D0140, D0160, D0170, or D0180, the provider must indicate documentation of medical necessity on the claim. These claims are subject to retrospective review. If no comments are indicated on the claim form, the payment may be recouped.

D0120*

A Birth-20. Limited to 1 every 6 months by the same provider. Denied when billed on the same DOS as D0145.

$29.44

D0140*

Used for problem focused examination of a specific tooth or area of the mouth. Limited to one service per day by the same provider or to two services per day by different providers. Denied when billed on the same DOS as D0160 by the same provider. A Birth-20, N

$19.16

D0145*

Limited to one service a day and 10 times a lifetime, with a minimum of 60 days between dates of service. Providers must be certified by DSHS Oral Health Program staff to perform this procedure. Procedure codes D0120, D0150, D0160, D0170, D0180, D8660, D1120, D1203, or D1206 will be denied when billed by any provider on the same DOS. A 6-35 months

$144.97

D0150*

Used for problem focused reevaluation. Limited to 1 every 3 years by the same provider. Denied when billed on the same DOS as D0145. A Birth-20

$36.04

D0160*

Used for problem focused reevaluation. Limited to one service per day by the same provider. Not payable for routine postoperative follow-up. Denied when billed on the same DOS as D0145. A 1-20, N, CCP

$15.25

D0170*

Limited to one service per day by the same provider. When used for emergency claims, refer to General Information. Denied when billed on the same DOS as procedure code D0140 or D0160 for the same provider. Denied when billed on the same DOS as D0145. A Birth-20

$16.88

D0180*

Used for periodontal evaluation. Denied when billed for the same DOS as D0120, D0140, D0145, D0150, D0160 or D0170 by the same provider. A 13-20

$8.02

A=Age range limitations, N=Narrative required, FMX=Full-mouth radiographs (nonpanoramic), MTID=Missing tooth ID(s), PPXR=Preoperative and postoperative radiographs required, PXR=Preoperative radiographs required, PHO=preoperative and postoperative photographs required, PC=Periodontal charting required, PATH=Pathology report required and be retained in the client's record, CCP=Comprehensive Care Program, NC=No charge to Medicaid and may not bill the client, and *= Services payable to an FQHC for a client encounter

The provider must document medical necessity and the specific tooth or area of the mouth on the claim for procedure codes D0140, D0160, and D0170.

Documentation supporting medical necessity for procedure codes D0140, D0160, and D0170 must also be maintained by the provider in the client's medical record and must include the following:

•The client complaint supporting medical necessity for the examination

•The specific area of the mouth that was examined or the tooth involved

•A description of what was done during the visit

•Supporting documentation of medical necessity which may include, but is not limited to, radiographs or photographs

Documentation supporting medical necessity for procedure code D0180 must be maintained by the provider in the client's medical record and must include the following:

•The client complaint supporting medical necessity for the examination

•A description of what was done during the treatment

•Supporting documentation of medical necessity which may include, but is not limited to, radiographs or photographs

Procedure Code
Limitations
Maximum Fee

Radiographs/Diagnostic Imaging (Including Interpretation)

Number of films required is dependent on age of client. A minimum of 8 films is required to be considered a full-mouth series. Adults and children over 12 years of age require 12-20 films, as is appropriate. The Panorex (D0330) with four bitewing radiographs (D0274) may be considered equivalent to the complete or full-mouth series (D0210), and the billed amount for either combination is equivalent to the maximum fee of $72.08.

D0210

Limited to 1 service every 3 years by the same provider. Not allowed as an emergency service. A 2-20

$72.08

D0220

Limited to one service a day by the same provider. A 1-20

$12.82

D0230

The total cost of periapicals and/or other radiographs cannot exceed the payment for a complete intraoral series. A 1-20

$11.74

D0240

Limited to 2 services per day by the same provider. Periapical films taken at an occlusal angle should be billed as periapical radiograph, procedure code D0230. May be billed as an emergency service. A Birth-20

$10.00

D0250

Limited to one service a day by the same provider. A 1-20, N, CCP

$18.75

D0260

A 1-20, N, CCP

$12.50

D0270

Limited to one service a day by the same provider. A 1-20

$5.00

D0272

Limited to one service a day by the same provider. A 1-20

$23.86

D0273

Limited to one service a day by the same provider. A 1-20

$29.60

D0274

Limited to one service a day by the same provider. A 2-20

$35.32

D0277

Limited to one service a day by the same provider. Not to be billed within 36 months of D0210 or D0330. A 2-20

$31.75

D0290

A 1-20, N, CCP

$33.75

D0310

A 1-20, N, CCP

$45.00

D0320

A 1-20, N, CCP

$75.00

D0321

A 1-20, N, CCP

$35.00

D0322

A 1-20, N, CCP

$33.75

D0330*

Limited to one service a day, any provider and to one service every 3 years by the same provider. Not allowed on emergency claims unless third molars or a traumatic condition is involved. 2 years of age or younger, must document the necessity of a panoramic film. The Panorex (D0330) with four bitewing radiographs (D0274) may be considered equivalent to the complete or full-mouth series (D0210), and the billed amount for either combination is equivalent to the maximum fee of $72.08. A 3-20

$65.08

D0340*

Limited to one service a day by the same provider. Not reimbursable separately when a comprehensive orthodontic or crossbite therapy workup is performed. A 1-20, N, CCP

$33.75

D0350*

Limited to one service a day by the same provider. Not reimbursable separately when a comprehensive orthodontic or crossbite therapy workup is performed. A Birth-20

$18.75

D0360*

Prior authorization is required. Limited to a combined maximum of 3 services per year (with procedure codes D0362 and D0363), any provider. Additional services may be considered with documentation of medical necessity. A Birth-20

$288.75

D0362*

Prior authorization is required. Limited to a combined maximum of 3 services per year (with procedure codes D0360 and D0363), any provider. Additional services may be considered with documentation of medical necessity. A Birth-20

$173.25

D0363*

Prior authorization is required. Limited to a combined maximum of 3 services per year (with procedure codes D0360 and D0362), any provider. Additional services may be considered with documentation of medical necessity. A Birth-20

$231.00

Note: Radiograph codes do not include the exam. If an exam is also performed, providers must bill the appropriate ADA procedure code.
A=Age range limitations, N=Narrative required, FMX=Full-mouth radiographs (nonpanoramic), MTID=Missing tooth ID(s), PPXR=Preoperative and postoperative radiographs required, PXR=Preoperative radiographs required, PHO=preoperative and postoperative photographs required, PC=Periodontal charting required, PATH=Pathology report required and be retained in the client's record, CCP=Comprehensive Care Program, NC=No charge to Medicaid and may not bill the client, and *= Services payable to an FQHC for a client encounter

Procedure code D0350 must be used for billing for photographs, and will be accepted only when diagnostic-quality radiographs cannot be taken. Supporting documentation and photographs must be maintained in the client's medical record when medical necessity is not evident on radiographs for dental caries or the following procedure codes. Medical necessity must be documented on the electronic or paper claim.

Procedure Codes

D4210

D4211

D4240

D4241

D4245

D4266

D4267

D4270

D4271

D4273

D4275

D4276

D4355

D4910

Procedure Code
Limitations
Maximum Fee

Tests and Examinations

D0415

A 1-20, N, CCP

$25.00

D0425

Not reimbursable separately. Considered part of another dental procedure.

NC

D0460

Limited to one service a day by the same provider. Not payable for primary teeth. Will deny when billed on the same DOS as any endodontic procedure. A 1-20, N, CCP

$12.50

D0470*

Not reimbursable separately when crown, fixed prosthodontics, diagnostic workup, or crossbite therapy workup is performed. A 1-20, N, CCP

$22.50

Oral Pathology Laboratory

D0472

By pathology laboratories only. (refer to CPT codes)

NC

D0473

By pathology laboratories only. (refer to CPT codes)

NC

D0474

By pathology laboratories only. (refer to CPT codes)

NC

D0480

By pathology laboratories only. (refer to CPT codes)

NC

D0502

A 1-20, N, CCP

$57.50

D0999

A 1-20, N, CCP

Manually priced

A=Age range limitations, N=Narrative required, FMX=Full-mouth radiographs (nonpanoramic), MTID=Missing tooth ID(s), PPXR=Preoperative and postoperative radiographs required, PXR=Preoperative radiographs required, PHO=preoperative and postoperative photographs required, PC=Periodontal charting required, PATH=Pathology report required and be retained in the client's record, CCP=Comprehensive Care Program, NC=No charge to Medicaid and may not bill the client, and *= Services payable to an FQHC for a client encounter

Texas Medicaid & Healthcare Partnership
CPT only copyright 2009 American Medical Association. All rights reserved.
PreviousNextIndex