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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 : 4.2.21 Adjunctive General Services

Emergency service only. The type of treatment rendered and TID must be indicated. It must be a service other than a prescription or topical medication. The reason for emergency and a narrative of the procedure actually performed must be documented and the appropriate block for emergency must be checked. Refer to subsection 4.2.27, “Emergency or Trauma Related Services for All THSteps Clients and Clients Who Are 5 Months of Age and Younger” in this handbook
Refer to:
Subsection, “Criteria for Dental Therapy Under General Anesthesia” in this handbook for general anesthesia criteria and additional information
Claim form narrative must describe the situation if used as a diagnostic tool. Denied if submitted with D9248. A 1–20, N, CCP
Claim form narrative must explain how the doctor initiated a procedure, but could not complete it, and needs to claim the rendered anesthesia. Denied if submitted with D9248. A 1–20, N, CCP
May be submitted with D9221. May be submitted twice within a 12–month period. Denied if submitted with D9248. Dental anesthesiologists are reimbursed at a rate of $202.55. A 1–20
May be considered for reimbursement for conscious sedation services. Denied if submitted with D9248. A 1–20
Must be submitted with D9241. May be considered for reimbursement for additional conscious sedation services. Denied if submitted with D9248. A 1–20
May be submitted twice within a 12-month period. Must comply with all TSBDE rules and AAPD guidelines, including maintaining a current permit to provide non-intravenous (IV) conscious sedation. A 1–20
An oral evaluation by a specialist of any type who is also providing restorative or surgical services must be submitted as D0160. A 1–20, N, CCP
One charge per hospital or ASC case; one case per client in a 12-month period. Documentation supporting the reason that dental services could not be performed in the office setting must be retained in the client's record and may be subject to retrospective review and recoupment. A 1–20, N
During regularly scheduled hours, no other services performed. Visits for routine postoperative care are included in all therapeutic and oral surgery fees. A 1–20, N
Procedure code D9630 is not payable for take home fluorides or drugs. Prescriptions should be given to clients to be filled by the pharmacy for these medications as the pharmacy is reimbursed by the Medicaid Vendor Drug Program. Procedure code D9630 is payable for medications (antibiotics, analgesics, etc.) administered to a client in the provider's office. Documentation of dosage and route of administration must be provided in the Remarks section of the claim.
Refer to:
(Vol. 1, General Information).
Includes, but is not limited to, oral antibiotics, oral analgesic, and oral sedatives administered in the office. May not be submitted with codes D9220, D9221, D9230, D9241, D9248, D9610, and D9920. A 1–20, N
Per whole mouth application, does not include fluoride. Not to be used for bases, liners, or adhesives under or with restorations. Limited to once per year. A 18–20, N, CCP
The provider must indicate the client’s medical diagnosis of intellectual disability using one of the following diagnosis codes or indicate that the client is ICF-MR eligible in the Remarks field of the claim form:
Documentation supporting the medical necessity and appropriateness of dental behavior management must be retained in the client's chart and available to state agencies upon request, and is subject to retrospective review. Documentation of medical necessity must include:
A current physician statement addressing the intellectual disability. The statement must be signed and dated within one year prior to the dental behavior management.
A description of the service performed (including the specific problem and the behavior management technique applied).
Dental behavior management is not reimbursed with an evaluation, prophylactic treatment, or radiographic procedure. Denied if submitted with D9248. A 1–20
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
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