Table of Contents Previous Next Index

2012 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 4. Texas Health Steps (THSteps) Dental : 4.2 Services, Benefits, Limitations, and Prior Authorization : 4.2.14 Restorative Services

4.2.14
 
Reimburse primary TIDs #A-T at $61.98; reimburse permanent TIDs #1–5, 12–21, and 28–32 at $65.72. A Birth–20, PXR
Reimburse primary TIDs #A-T at $82.90; reimburse permanent TIDs #1–5, 12–21, and 28–32 at $87.46. A Birth–20, PXR
Reimburse primary TIDs #A-T at $90.01; reimburse permanent TIDs #1–5, 12–21, and 28–32 at $111.42. A 1–20, PXR
Reimburse primary TIDs #A-T at $52.69; reimburse permanent TIDs #1–5, 12–21, and 28–32 at $60.04. A 1–20, PXR
All fees for resin restorations on primary teeth are limited to $156.06, which is the fee for a stainless steel crown (exceptions: D2335 and D2933). All fees for resin restorations on permanent teeth are limited to a total of $170.38 for posterior teeth and $170.38 for anterior teeth. Resin restoration includes composites or glass ionomer.
Reimburse primary anterior TIDs #C-H, M-R at $68.75; reimburse permanent anterior TIDs #6-11, 22–27 at $150.00. A Birth-20, PXR
Reimburse primary posterior TIDs #A, B, I, J, K, L, S, T at $76.98; reimburse permanent posterior TIDs #1–5, 12–21, 28–32 at $84.08. A Birth-20, PXR
Reimburse primary posterior TIDs #A, B, I, J, K, L, S, T at $98.98; reimburse permanent posterior TIDs #1–5, 12–21, 28–32 at $110.20. A Birth-20, PXR
Reimburse primary posterior TIDs #A, B, I, J, K, L, S, T at $87.11; reimburse permanent posterior TIDs #1–5, 12–21, 28–32 at $101.18. A 1–20, PXR
Reimburse primary posterior TIDs #A, B, I, J, K, L, S, T at $64.62; reimburse permanent posterior TIDs #1–5, 12–21, 28–32 at $75.06. A 1-20, PXR
A 13–20, N, PPXR, CCP
A 13–20, N, PPXR, CCP
A 13–20, N, PPXR, CCP
For procedure codes D2510 through D2664, inlay/onlay (permanent teeth only), porcelain is allowed on all teeth. Prior authorization is required for any combination of inlays/onlays or permanent crowns that exceed the limit of four inlays/onlays or permanent crowns per lifetime, any provider.
A 13–20, N, PPXR, CCP
A 13–20, N, PPXR, CCP
A 13–20, N, PPXR, CCP
Same as D2520. A 13–20, N, PPXR, CCP
All materials accepted. A 13–20, N, PPXR, CCP
All materials accepted. A 13–20, N, PPXR, CCP
All materials accepted. A 13–20, N, PPXR, CCP
All materials accepted. A 13–20, N, PPXR, CCP
All materials accepted. A 13–20, N, PPXR, CCP
All materials accepted. A 13–20, N, PPXR, CCP
All materials accepted. A 13–20, N, PPXR, CCP
All materials accepted. A 13–20, N, PPXR, CCP
All materials accepted. A 13–20, N, PPXR, CCP
All materials accepted. A 13–20, N, PPXR, CCP
All materials accepted. A 13–20, N, PPXR, CCP
All materials accepted. A 13–20, N, PPXR, CCP
All materials accepted. A 13–20, N, PPXR, CCP
All materials accepted. A 13–20, N, PPXR, CCP
Prior authorization is required for any combination of inlays/onlays or permanent crowns that exceed the limit of four inlays/onlays or permanent crowns per lifetime, any provider.
All materials accepted. A 13–20, N, PPXR, CCP
All materials accepted. A 13–20, N, PPXR, CCP
All materials accepted. A 13–20, N, PPXR, CCP
All materials accepted. A 13–20, N, PPXR, CCP
All materials accepted. A 13–20, N, PPXR, CCP
All materials accepted. A 13–20, N, PPXR, CCP
All materials accepted. A 13–20, N, PPXR
All materials accepted. A 13–20, N, PPXR, CCP
A 13-20, N, PPXR, CCP
A 13-20, N, PPXR, CCP
A 13-20, N, PPXR, CCP
A 13–20, N, PPXR, CCP
A 13–20, PXR
A 1–20, PXR
A Birth–20, PXR
A 1–20, PXR
A 1–20, PXR (primary tooth)
Provider payments received in excess of $45.00 for restorative work performed within six months of a crown procedure on the same tooth will be deducted from the subsequent crown procedure reimbursement. Not allowed on primary teeth.
A 4–20, N, CCP, PXR
Not payable with D2952 or D3950 on the same TID by the same provider. Not allowed on primary teeth.
A 13–20, N, CCP, PXR
For removal of posts (for example, fractured posts) not to be used in conjunction with endodontic retreatment (D3346, D3347, D3348). Not allowed on primary teeth.
A 4–20, CCP, PXR
A 13–20, N, PPXR, CCP
A 13–20, N, PPXR, CCP
A 13–20, N, PPXR, CCP
May be reimbursed up to four services per lifetime for each tooth. Payable to any THSteps dental provider who performed the original cementation of the crown. A 13-20
A 1–20, PXR (permanent teeth only)
A 1–20, N, CCP, PXR
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 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
CPT only copyright 2011 American Medical Association. All rights reserved.