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 : 4.2.15 Endodontics Services

4.2.15
Therapeutic pulpotomy (procedure code D3220) and apexification and recalcification procedures (procedure codes D3351, D3352, and D3353) are considered part of the root canal (procedure codes D3310, D3320, and D3330) or retreatment of a previous root canal (procedure codes D3346, D3347, and D3348). When therapeutic pulpotomy or apexification and recalcification procedures are submitted with root canal codes, the reimbursement rate is adjusted to ensure that the total amount reimbursed does not exceed the total dollar amount allowed for the root canal procedure.
Reimbursement for a root canal includes all appointments necessary to complete the treatment. Pulpotomy and radiographs performed pre, intra, and postoperatively are included in the root canal reimbursement.
Root canal therapy that has only been initiated, or taken to some degree of completion, but not carried to completion with a final filling, may not be submitted as a root canal therapy code. It must be submitted using code D3999 with a narrative description of what procedures were completed in the root canal therapy.
Documentation supporting medical necessity must be kept in the client’s record and include the following: the medical necessity as documented through periapical radiographs of tooth treated showing pre-treatment, during treatment, and post-treatment status; the final size of the file to which the canal was enlarged; and the type of filling material used. Any reason that the root canal may appear radiographically unacceptable must be documented in the client's record.
If the client is pregnant and does not want radiographs, use alternative treatment (temporary) until after delivery.
Procedure codes D3110 and D3120 will not be reimbursed when submitted with the following procedure codes for the same tooth, for the same DOS, by the same provider: D2952, D2953, D2954, D2955, D2957, D2980, D2999, D3220, D3230, D3240, D3310, D3320, or D3330.
A 1–20, N, PXR, CCP
A 1–20, N, PXR, CCP
Denied when performed within six months of D3230, D3240, D3310, D3320, or D3330 for the same primary TID, same provider. Denied when performed within six months of D3310, D3320, or D3330 on the same permanent TID, same provider. A Birth-20, PXR
Anterior primary incisors and cuspids.
TIDs #C-H; M-R. A 1–20, PXR
Posterior first and second molars.
TIDs #A, B, I, J, K, L, S, T. A 1–20, PXR
Endodontic Therapy (including Treatment Plan, Clinical Procedures, and Follow-up Care)
A 6–20, PPXR
A 6–20, PPXR
A 6–20, PPXR
A 6–20, PPXR
A 6–20, PPXR
A 6–20, PPXR
A 6–20, N, PXR, CCP
A 6–20, N, PXR, CCP
A 6–20, PPXR, CCP
A 6–20, N, PPXR, CCP
A 6–20, N, PPXR, CCP
A 6–20, N, PPXR, CCP
A 6–20, N, PPXR, CCP
A 6–20, N, PPXR, CCP
A 6–20, N, PXR, CCP
Prior authorization required. Submit request with periapical radiographs, for each tooth involved. A 16-20, N, PPXR, CCP
A 6–20, N, PXR, CCP
A 1–20, N, CCP
A 6–20, N, PXR, CCP
A 6–20, N, PXR, CCP
A 1–20, N, PXR, CCP
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.