|
19.19 Special Orthodontic Appliances
As with all orthodontic services, all removable or fixed special orthodontic applicances must be prior authorized. The prior authorization request must include both the national code and remarks code. However, prior authorization requests may omit the DPC prefix to the eight-digit remarks code.
All removable or fixed special orthodontic appliances must be billed with national procedure code D8210 or D8220. Dental models must be submitted when requesting prior authorization of a thumb-sucking or tongue thrust appliance. To ensure appropriate claims processing, the DPC remarks code (local procedure code) reflecting the specific service is also required. The appropriate remarks codes must be entered on the authorization request form. Failure to follow the following steps will cause the claims to deny. Failure to enter the DPC remarks code and the appropriate procedure code will not result in claim denial; however, manual intervention is required to process the claim, which may result in a delay of payment.
For paper claim submissions, providers must enter the local procedure code in Block 35 (Remarks) of the 2006 ADA claim form.
For electronic submissions, providers enter the DPC remarks code in the Comments field to ensure correct authorization, accurate records, and reimbursement.
For electronic submissions other than TexMedConnect or TDHconnect software submissions, providers must follow the steps below to ensure TMHP accurately applies the correct local procedure code to the appropriate claim detail:
1) |
The DPC prefix must be submitted, only once, in the first three bytes of the NTE02 at the 2400 loop. |
2) |
In bytes 4-8, providers must submit the remark code (local procedure code) based on the order of the claim detail. Do not enter any spaces or punctuation between remark codes, unless to designate the detail is not billed with D8210 or D8220. |
Example: For a claim with three details, where details one and three are submitted with procedure code D8210 and detail two is not, enter the following information in the NTE02 at the 2400 loop: DPC1014D 1046D. (The space shows that detail two needs no local code.) If all details require a local code, enter DPC, no spaces, and the appropriate local codes.
To submit using TexMedConnect or TDHconnect software, providers must enter the local code into the Remarks Code field, located under the details header. The Remarks Code field is the field directly after the Procedure Code field. TexMedConnect and TDHconnect software submitters are not required to manually enter the DPC prefix as it is placed in the appropriate field on the TexMedConnect or TDHconnect electronic claim.
The following table identifies the appropriate DPC remarks codes to use when requesting authorization or billing for procedure code D8210 or D8220:
|
Procedure Code
|
Remarks Code
|
Remarks Code Description
|
Maximum Fee
|
|
Special Orthodontic Appliances
|
|
D8220*
|
DPC1000D
|
Appliance with horizontal projections
|
$250
|
|
D8220*
|
DPC1001D
|
Appliance with recurved springs
|
$250
|
|
D8220*
|
DPC1002D
|
Arch wires for crossbite correction (for total treatment)
|
$595
|
|
D8220*
|
DPC1003D
|
Banded maxillary expansion appliance
|
$375
|
|
D8210*
|
DPC1004D
|
Bite plate/bite plane
|
$100
|
|
D8210*
|
DPC1005D
|
Bionator
|
$100
|
|
D8210*
|
DPC1006D
|
Bite block
|
$250
|
|
D8210*
|
DPC1007D
|
Bite-plate with push springs
|
$250
|
|
D8220*
|
DPC1008D
|
Bonded expansion device
|
$225
|
|
D8210*
|
DPC1010D
|
Chateau appliance (face mask, palatal exp and hawley)
|
$300
|
|
D8210*
|
DPC1011D
|
Coffin spring appliance
|
$275
|
|
D8220*
|
DPC1012D
|
Crib
|
$100
|
|
D8210*
|
DPC1013D
|
Dental obturator, definitive (obturator)
|
$250
|
|
D8210*
|
DPC1014D
|
Dental obturator, surgical (obturator, surgical stayplate, immediate temporary obturator)
|
$250
|
|
D8220*
|
DPC1015D
|
Distalizing appliance with springs
|
$250
|
|
D8220*
|
DPC1016D
|
Expansion device
|
$375
|
|
D8210*
|
DPC1017D
|
Face mask (protraction mask)
|
$350
|
|
D8220*
|
DPC1018D
|
Fixed expansion appliance
|
$375
|
|
D8220*
|
DPC1019D
|
Fixed lingual arch
|
$225
|
|
D8220*
|
DPC1020D
|
Fixed mandibular holding arch
|
$100
|
|
D8220*
|
DPC1021D
|
Fixed rapid palatal expander
|
$375
|
|
D8210*
|
DPC1022D
|
Frankel appliance
|
$100
|
|
D8210*
|
DPC1023D
|
Functional appliance for reduction of anterior openbite and crossbite
|
$375
|
|
D8210*
|
DPC1024D
|
Headgear (face bow)
|
$150
|
|
D8220*
|
DPC1025D
|
Herbst appliance (fixed or removable)
|
$250
|
|
D8220*
|
DPC1026D
|
Inter-occlusal cast cap surgical splints
|
$375
|
|
D8210*
|
DPC1027D
|
Intrusion arch
|
$100
|
|
D8220*
|
DPC1028D
|
Jasper jumpers
|
$100
|
|
D8220*
|
DPC1029D
|
Lingual appliance with hooks
|
$100
|
|
D8220*
|
DPC1030D
|
Mandibular anterior bridge
|
$175
|
|
D8220*
|
DPC1031D
|
Mandibular bihelix (similar to a quad helix for mandibular expansion to attempt nonextraction treatment)
|
$100
|
|
D8210*
|
DPC1032D
|
Mandibular lip bumper
|
$100
|
|
D8220*
|
DPC1036D
|
Mandibular lingual 6x6 arch wire
|
$100
|
|
D8210*
|
DPC1037D
|
Mandibular removable expander with bite plane (crozat)
|
$275
|
|
D8210*
|
DPC1038D
|
Mandibular ricketts rest position splint
|
$375
|
|
D8210*
|
DPC1039D
|
Mandibular splint
|
$225
|
|
D8210*
|
DPC1040D
|
Maxillary anterior bridge
|
$175
|
|
D8210*
|
DPC1041D
|
Maxillary bite-opening appliance with anterior springs
|
$100
|
|
D8220*
|
DPC1042D
|
Maxillary lingual arch with spurs
|
$100
|
|
D8220*
|
DPC1043D
|
Maxillary and mandibular distalizing appliance
|
$100
|
|
D8220*
|
DPC1044D
|
Maxillary quad helix with finger springs
|
$325
|
|
D8220*
|
DPC1045D
|
Maxillary and mandibular retainer with pontics
|
$175
|
|
D8210*
|
DPC1046D
|
Maxillary Schwarz
|
$250
|
|
D8210*
|
DPC1047D
|
Maxillary splint
|
$225
|
|
D8210*
|
DPC1048D
|
Mobile intraoral Arch-Mia (similar to a Bihelix for nonextraction treatment)
|
$100
|
|
D8220*
|
DPC1049D
|
Modified quad helix appliance
|
$275
|
|
D8220*
|
DPC1050D
|
Modified quad helix appliance (with appliance)
|
$275
|
|
D8220*
|
DPC1051D
|
Nance appliance
|
$100
|
|
D8220*
|
DPC1052D
|
Nasal stent
|
$250
|
|
D8210*
|
DPC1053D
|
Occlusal orthotic device
|
$175
|
|
D8210*
|
DPC1054D
|
Orthopedic appliance
|
$250
|
|
D8210*
|
DPC1055D
|
Other mandibular utilities
|
$100
|
|
D8210*
|
DPC1056D
|
Other maxillary utilities
|
$100
|
|
D8220*
|
DPC1057D
|
Palatal bar
|
$225
|
|
D8210*
|
DPC1058D
|
Post-surgical retainer
|
$125
|
|
D8220*
|
DPC1059D
|
Quad helix appliance held with transpalatal arch horizontal projections
|
$275
|
|
D8220*
|
DPC1060D
|
Quad helix maintainer
|
$275
|
|
D8220*
|
DPC1061D
|
Rapid palatal expander (RPE), such as quad Helix, Haas, or Menne
|
$350
|
|
D8210*
|
DPC1062D
|
Removable bite plate
|
$100
|
|
D8210*
|
DPC1063D
|
Removable mandibular retainer
|
$100
|
|
D8210*
|
DPC1064D
|
Removable maxillary retainer
|
$100
|
|
D8210*
|
DPC1065D
|
Removable prosthesis
|
$175
|
|
D8210*
|
DPC1066D
|
Sagittal appliance 2 way
|
$250
|
|
D8210*
|
DPC1067D
|
Sagittal appliance 3 way
|
$350
|
|
D8220*
|
DPC1068D
|
Stapled palatal expansion appliance
|
$375
|
|
D8210*
|
DPC1069D
|
Surgical arch wires
|
$250
|
|
D8210*
|
DPC1070D
|
Surgical splints (surgical stent/wafer)
|
$250
|
|
D8210*
|
DPC1071D
|
Surgical stabilizing appliance
|
$250
|
|
D8220*
|
DPC1072D
|
Thumbsucking appliance, requires submission of models
|
$175
|
|
D8210*
|
DPC1073D
|
Tongue thrust appliance, requires submission of models
|
$100
|
|
D8210*
|
DPC1074D
|
Tooth positioner (full maxillary and mandibular)
|
$325
|
|
D8210*
|
DPC1075D
|
Tooth positioner with arch
|
$100
|
|
D8220*
|
DPC1076D
|
Transpalatal arch
|
$100
|
|
D8220*
|
DPC1077D
|
Two bands with transpalatal arch and horizontal projections forward
|
$175
|
|
D8220*
|
DPC1078D
|
W-appliance
|
$275
|
|
|
|
