TMPPM 2010 >5.3.12 Preventive Services


Procedure Code	Limitations	Maximum Fee
Dental Prophylaxis
If performing fluoride treatments, procedure codes D1203 and D1204 must be submitted on the same DOS as the cleaning (D1110 and D1120).
D1110*	Limited to one prophylaxis per client per 6-month period (includes oral health instructions). If billed on emergency claim, procedure code will be denied. Denied when billed on the same DOS as any D4000 series periodontal procedure code. A 13-20	$56.00
D1120*	Limited to one prophylaxis per client per 6-month period (includes oral health instructions). If billed on emergency claim, procedure code will be denied. Denied when billed on the same DOS as any D4000 series periodontal procedure code, or with procedure code D0145. A 6 months - 12 years	$37.50
Topical Fluoride Treatment (Office Procedure)
D1203*	Includes oral health instructions. Denied when billed on the same DOS as any D4000 series periodontal procedure code or with procedure code D0145. A 6 months - 12 years, N, CCP	$15.00
D1204*	Includes oral health instructions. Denied when billed on the same DOS as any D4000 series periodontal procedure code. A 13-20, N, CCP	$15.00
D1206	Includes oral health instructions. Denied when billed on the same DOS as any D4000 series periodontal procedure code or with procedure code D0145. A 6 months-20 years, N, CCP	$15.00
Other Preventive Services
D1310	Denied as part of all preventative, therapeutic and diagnostic dental procedures. A client requiring more involved nutrition counseling may be referred to a THSteps primary care physician.	NC
D1320	A client requiring tobacco counseling may be referred to a THSteps primary care provider.	NC
D1330	Requires documentation of the type of instructions, number of appointments, and content of instructions. 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. 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. Limited to once per client, per year by any provider. A 1-20, N, CCP	$12.50
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. 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. Denied when billed on the same DOS as any D4000 series periodontal procedure code. Sealants and replacement sealants are limited to one every 3 years per tooth by any provider. A 1-20	$28.82
Space Maintenance (Passive Appliances)
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 (TIDs #A, B, I, J, K, L, S, and T) or the loss of a permanent first molar (TIDs #3, 14, 19, and 30). 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. Replacement space maintainers may be considered upon appeal with documentation supporting medical necessity. Removal of a fixed space maintainer is not payable to the provider or dental group practice that originally placed the device.
D1510*	A 1-20 (TIDs #A, B, I, J, K, L, S, T), MTID A 1-20 (TIDs #3, 14, 19, 30), MTID	$160.00
D1515*	A 1-20 (TIDs #A, B, I, J, K, L, S, T), MTID A 1-20 (TIDs #3, 14, 19, 30), MTID	$237.50
D1520*	A 1-20 (TIDs #A, B, I, J, K, L, S, T), MTID A 1-20 (TIDs #3, 14, 19, 30), MTID	$75.00
D1525*	A 1-20 (TIDs #A, B, I, J, K, L, S, T), MTID A 1-20 (TIDs #3, 14, 19, 30), MTID	$106.25
D1550	A 1-20 (TIDs #A, B, I, J, K, L, S, T), MTID A 1-20 (TIDs #3, 14, 19, 30), MTID	$18.75
D1555*	A 1-20(TIDs #A, B, I, J, K, L, S, T), MTID A 1-20 (TIDs #3, 14, 19, 30), MTID	$50.00
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 must 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

5.3.13 Therapeutic Services

Medicaid reimbursement is contingent on compliance with the following limitations:

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Total restorative fee per tooth on primary teeth cannot exceed $156.06, which is the fee for a stainless steel crown (exceptions: D2335 and D2933).

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All fees for tooth restorations include local anesthesia and pulp protective media, where indicated, without additional charges. These services are considered part of the restoration.

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More than one restoration on a single surface is considered a single restoration.

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Multiple surface restorations must show definite crossing of the plane of each surface listed for each primary and permanent tooth completed.

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A multiple surface restoration cannot be billed as two or more separate one-surface restorations.

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Restorations and therapeutic care are provided as a Medicaid service based on medical necessity and reimbursed only for therapeutic reasons and not preventive purposes (refer to CDT).

All dental restorations and prosthetic appliances that require lab fabrication may be submitted for reimbursement using the date the final impression was made as the DOS. If the client did not return for final seating of the restoration or appliance, a narrative must be included on the claim form and in the client's chart in lieu of a postoperative radiograph. The 95-day filing deadline is in effect from the date of the final impression. If the client returns to the office after the claim has been filed, the dentist is obligated to attempt to seat the restoration or appliance at no cost to the client or Texas Medicaid. For records retention requirements, refer to Subsection 5.4, "Documentation Requirements" in this handbook.

Direct pulp caps may be reimbursed separately from any final tooth restoration performed on the same tooth (as noted by the TID) on the same DOS by the same provider.