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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 : 4.2.18 Periodontal Services

4.2.18
Procedure codes D4210 and D4211, when submitted for clients who are 12 years of age and younger, will be initially denied, but may be appealed with documentation of medical necessity. Preoperative and postoperative photographs are required for the following procedure codes: D4210, D4211, D4270, D4273, D4275, D4276, D4277, D4278, D4283, D4285, D4355, and D4910.
Procedure codes D4283 and D4285 are limited to three teeth per site, same day same provider. Procedure code D4283 must be billed along with procedure code D4273 and procedure code D4285 must be billed along with procedure code D4275.
Preoperative and postoperative photographs are required when medical necessity is not evident on radiographs for the following procedure codes: D4240, D4241, D4245, D4266, and D4267. Documentation is required when medical necessity is not evident on radiographs for the following procedure codes: D4210, D4211, D4240, D4241, D4245, D4266, D4267, D4270, D4273, D4275, D4276, D4277, D4278, D4283, D4285, D4355, and D4910.
Procedure code D4278 must be billed on the same date of service as procedure code D4277 or the service will be denied.
Claims for preventive dental procedure codes D1110, D1120, D1206, D1208, and D1351 will be denied when submitted for the same DOS as any D4000 series periodontal procedure codes.
Procedure codes D4266 and D4267 may be appealed with documentation of medical necessity. Medical necessity for third molar sites are:
Medical or dental history documenting need due to inadequate healing of bone following third molar extraction, including the date of third molar extraction.
Medical necessity for other than third molar sites are:
 
A 13–20, N, PPXR, PHO, CCP
A 13–20, N, PHO, CCP
A 13–20, N, FMX, PXR, PHO when medical necessity is not evident on radiographs, PC, CCP
Limited to once per year. A 13–20, N, FMX, PXR, PHO when medical necessity is not evident on radiographs, PC
A six- to eight-week healing period following crown lengthening before final tooth preparation, impression making, and fabrication of a final restoration is required for claims submission of this code. A 13–20, N, PPXR, CCP
A 13–20, N, FMX, PXR, PC, CCP
Limited to once per year. A 13–20, N, FMX, PXR, PC
A 13–20, N, PXR, PHO when medical necessity is not evident on radiographs, CCP
A 13–20, N, PXR, PHO when medical necessity is not evident on radiographs, CCP
A 13–20, N, PXR, PHO, CCP
This procedure is performed to create or augment gingiva, to obtain root coverage or to eliminate frenum pull, or to extend the vestibular fornix. A 13–20, N, PXR, PHO, CCP
This procedure is performed in an edentulous area adjacent to a periodontally involved tooth. Gingival incisions are used to allow removal of a tissue wedge to gain access and correct the underlying osseous defect and to permit close flap adaptation.
A 13–20, N, PXR, CCP
Limited to once per day. A 13–20, PXR, PHO
A 1–20, PXR
A 1–20, PXR
D4341 is denied if provided within 21 days of D4355. Denied when submitted for the same DOS as other D4000 series codes or with D1110, D1120, D1206, D1208, D1351, D1510, D1515, D1520, or D1525.
A 13–20, FMX, PC, PXR, CCP
Denied when submitted for the same DOS as other D4000 series codes or with D1110, D1120, D1206, D1208, D1351, D1510, D1515, D1520, or D1525.
A 13–20, PC, FMX
D4355 is not payable if provided within 21 days of D4341. Denied when submitted for the same DOS as other D4000 series codes or with D1110, D1120, D1206, D1208, D1351, D1510, D1515, D1520, or D1525.
A 13–20, N, PXR, PHO, CCP
This procedure does not replace conventional or surgical therapy required for debridement, respective procedures, or regenerative therapy. The use of controlled-release chemotherapeutic agents is an adjunctive therapy or for cases in which systemic disease or other factors preclude conventional or surgical therapy.
A 13–20, N, PXR, CCP
Payable only following active periodontal therapy by any provider as evidenced either by a submitted claim for procedure code D4240, D4241, D4260, or D4261 or by evidence through client records of periodontal therapy while not Medicaid-eligible. Not payable within 90 days after D4355, not payable for the same DOS as any other evaluation procedure. Limited to once per 12 calendar months by the same provider.
A 13–20, N, PXR, PHO, CCP
A 13–20, N, PXR, CCP
A 13–20, N, PXR, CCP
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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