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December 2016 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 4 Texas Health Steps (THSteps) Dental : 4.2 Services, Benefits, Limitations, and Prior Authorization : 4.2.16 Restorative Services

4.2.16
A Birth–20, PXR
A Birth–20, PXR
A 1–20, PXR
A 1–20, PXR
A Birth–20, PXR
A Birth–20, PXR
A Birth–20, PXR
A 1–20, PXR
For procedure codes D2510 through D2664, inlay/onlay (permanent teeth only), porcelain is allowed on all teeth. Prior authorization is required for all inlays/onlays or permanent crowns. Procedure codes D2543, D2544, D2650 through DD2652 and D2662 through D2664 are payable once per client, per tooth every ten years.
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
Reimbursement for crowns and onlay restorations require submission of post-operative bitewing radiograph(s) (for posterior teeth); post-operative periapical radiograph(s) (for anterior teeth) will need to be submitted with the claim to verify that the restoration meets the standard of care.
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
Limited to TID #4–13 and 20–29 only.
All materials accepted. A 13–20, N, PPXR, CCP
Limited to TID #4–13 and 20–29 only.
All materials accepted. A 13–20, N, PPXR, CCP
Limited to TID #4–13 and 20–29 only.
All materials accepted. A 13–20, N, PPXR, CCP
Limited to TID #4–13 and 20–29 only.
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
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
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 2014 American Medical Association. All rights reserved.