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13.3.3.3 Reimbursement
Oral Hygiene Instruction
Procedure code D1330 may be considered for reimbursement when the services are above and beyond the routine brushing and flossing instructions included in the prophylaxis procedure codes and when additional time and expertise is directed toward the client's care. Procedure code D1330 is limited to once per year by any provider and is denied when billed on the same day as procedure codes D1110, D1120, and D1206 by the same provider.
Dental Prophylaxis and Topical Fluoride Treatment
When performing fluoride treatments, procedure codes D1203 and D1204 must be billed on the same date of service as procedure codes D1110 and D1120.
The following procedure codes may be considered for reimbursement but are not payable on the same date of service as any D4000 series (periodontal) procedure codes:
Dental Sealants
Dental sealants may be considered for reimbursement for clients under 21 years of age. Sealants may be applied to the occlusal, buccal, and lingual pits and fissures of any tooth. The tooth must be at risk for dental decay and be free of proximal caries and restorations on the surface to be sealed. Each tooth must be billed separately using procedure code D1351. Reimbursement is on a per tooth basis, regardless of the number of surfaces sealed. Tooth numbers and surfaces must be indicated on the claim form. Replacement sealants are not reimbursed. Claims and documentation submitted that include language, terms, or acronyms that indicate a preventive resin was applied, may be reimbursed as a sealant (procedure code D1351), and not as a restorative procedure.
If, upon claims processing or retrospective review, the finding of the claim, narrative, documentation, or charting, by a provider, of terms or acronyms indicating preventive resin or combination of similar words, the procedure is reimbursed as a dental sealant only and not for any of the restorative procedures. Procedure code D1351 is not payable on the same date of service as any of D4000 series (periodontal) procedure codes.
Space Maintainers
Space maintainers are designed to prevent tooth movement and may be reimbursed by the CSHCN Services Program in the following situations:
• After premature loss of deciduous/primary tooth first and/or second molars, TID: A, B, I, J, K, L, S, and T for clients 1 through 12 years of age.
•After loss of a permanent first molars (TID 3, 14, 19 and 30) for clients 3 through 20 years of age.
Note: Premature loss is defined as loss of the tooth before the expected or normal life of the tooth. For a deciduous/primary molar, this is before eruption of the comparable permanent tooth.
One space maintainer per tooth ID may be reimbursed per lifetime, per client. Replacement space maintainers may be considered on appeal with documentation supporting medical/dental necessity.
Space maintainers may be reimbursed with procedure codes D1510, D1515, D1520, and D1525.
When procedure codes D1510 or D1515 have been previously reimbursed, the recementation of space maintainers may be considered for reimbursement to either the same or a different CSHCN Services Program dental provider when billed with procedure code D1550.
Procedure code D1555 may be considered for reimbursement for the removal of a space maintainer. This procedure code is denied to the provider that originally placed the appliance but may be reimbursed to the following:
•To a provider that did not originally place the appliance.
•To the dental group that originally placed the appliance on the client.
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