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2012 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 4. Texas Health Steps (THSteps) Dental : 4.2 Services, Benefits, Limitations, and Prior Authorization : 4.2.12 Preventive Services

4.2.12
 
Dental Prophylaxis
Limited to one prophylaxis per client, same provider, per six-month period (includes oral health instructions). If submitted on emergency claim, procedure code will be denied. Denied when submitted for the same DOS as any D4000 series periodontal procedure code. A 13–20
Limited to one prophylaxis per client, same provider, per six-month period (includes oral health instructions). If submitted on emergency claim, procedure code will be denied. Denied when submitted for the same DOS as any D4000 series periodontal procedure code, or with procedure code D0145. A 6 months – 12 years
Includes oral health instructions. Denied when submitted for the same DOS as any D4000 series periodontal procedure code or with procedure code D0145. A 6 months - 12 years, N, CCP
Includes oral health instructions. Denied when submitted for the same DOS as any D4000 series periodontal procedure code. A 13-20, N, CCP
Includes oral health instructions. Denied when submitted for the same DOS as any D4000 series periodontal procedure code or with procedure code D0145. A 6 months-20 years, N, CCP
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.
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 for the same DOS as dental prophylaxis (D1110, D1120) 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
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 for the same DOS as any D4000 series periodontal procedure code. Sealants and replacement sealants are limited to one every 3 years per tooth by the same provider or provider group. Dental sealants performed more frequently than once every three years by a different provider are also a benefit if the different provider is not associated with the provider or provider group that initially placed the sealant on the tooth. A 0–20
Space Maintenance (Passive Appliances)
Space maintainers are a benefit of Texas Medicaid after premature loss of primary or secondary molars (TID A, B, I, J, K, L, S, and T for clients who are 1 through 12 years of age, and after loss of permanent molars (TID 3, 14, 19, and 30) for clients who are 3 through 20 years of age. Limited to 1 space maintainer per TID per client.
When procedure code D1510 or D1515 have been previously reimbursed, the recementation of space maintainers (procedure code D1550) may be considered for reimbursement to either the same or different THSteps dental provider. 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.
A 1–20 (TIDs #A, B, I, J, K, L, S, T), MTID
A 1–20 (TIDs #3, 14, 19, 30), MTID
A 1–20 (TIDs #A, B, I, J, K, L, S, T), MTID
A 1–20 (TIDs #3, 14, 19, 30), MTID
A 1–20 (TIDs #A, B, I, J, K, L, S, T), MTID
A 1–20 (TIDs #3, 14, 19, 30), MTID
A 1–20 (TIDs #A, B, I, J, K, L, S, T), MTID
A 1–20 (TIDs #3, 14, 19, 30), MTID
A 1–20 (TIDs #A, B, I, J, K, L, S, T), MTID
A 1–20 (TIDs #3, 14, 19, 30), MTID
A 1–20 (TIDs #A, B, I, J, K, L, S, T), MTID
A 1–20 (TIDs #3, 14, 19, 30), MTID
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

Texas Medicaid & Healthcare Partnership
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