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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 : 4.2.26 Handicapping Labio-lingual Deviation (HLD) Index : 4.2.26.1 HLD Score Sheet

4.2.26.1
HLD Score Sheet
This sheet and a Boley Gauge are required to score.
Procedure:
PLEASE PRINT CLEARLY:
Address: (Street/City/County/State/ZIP Code)


Severe Traumatic Deviations
Trauma/Accident related only
Overjet in mm. Minus 2 mm.
Example: 8 mm. – 2 mm. = 6 points
Overbite in mm. Minus 3 mm.
Example: 5 mm. – 3 mm. = 2 points
Mandibular Protrusion in mm.
See definitions/instructions to score (previous page)
Open Bite in mm.
See definitions/instructions to score (previous page)
Ectopic Eruption (Anteriors Only)
Reminder: Points cannot be awarded on the same arch
for Ectopic Eruption and Crowding
Anterior Crowding
10 point maximum total for both arches combined

 

Texas Medicaid & Healthcare Partnership
CPT only copyright 2011 American Medical Association. All rights reserved.