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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 : 4.2.22 Oral and Maxillofacial Surgery Services

4.2.22
All oral surgery procedures include local anesthesia, suturing, if needed, and visits for routine postoperative care.
 
A 1–20, PXR
A 1–20, PXR
A 1–20, PXR
Involves tissue incision and removal of bone to remove a permanent or primary tooth root left in the bone from a previous extraction, caries, or trauma. Usually some degree of soft or hard tissue healing has occurred. A 1–20, N, PXR
Requires prior authorization. A 1–20, N, PXR; TIDs #1–16 only.
A 1–20, N, PXR, CCP
Requires prior authorization. A 1–20, N, PXR, CCP
A 1–20, N, PXR
A 1–20
A 1–20, PXR, PATH, CCP
A 1–20, PXR, PATH, CCP
A 1–20, N, PXR, CCP
A 4–20, N, PXR, CCP
A 1–20, N, PXR, CCP
A 1–20, N, PXR, CCP
A 1–20, N, PXR, CCP
A 1–20, N, PXR, CCP
A 1–20, PXR, PATH
A 1–20, PXR, PATH
The incidental removal of cysts/lesions attached to the root(s) of a simple extraction is considered part of the extraction or surgical fee. A 1–20, N, PXR, PATH, CCP
The incidental removal of cysts/lesions attached to the root(s) of an extracted tooth is considered part of the extraction or surgical fee. A 1–20, N, PXR, PATH, CCP
The incidental removal of cysts/lesions attached to the root(s) of an extracted tooth is considered part of the extraction or surgical fee. A 1–20, N, PXR, PATH, CCP
The incidental removal of cysts/lesions attached to the root(s) of an extracted tooth is considered part of the extraction or surgical fee. A 1–20, N, PXR, PATH, CCP
The incidental removal of cysts/lesions attached to the root(s) of an extracted tooth is considered part of the extraction or surgical fee. A 1–20, N, PXR, PATH, CCP
The incidental removal of cysts/lesions attached to the root(s) of an extracted tooth is considered part of the extraction or surgical fee. A 1–20, N, PXR, PATH, CCP
The incidental removal of cysts/lesions attached to the root(s) of a simple extraction is considered part of the extraction or surgical fee. A Birth–20, N, PXR, PATH, CCP
The incidental removal of cysts/lesions attached to the root(s) of a simple extraction is considered part of the extraction or surgical fee. A Birth–20, N, PXR, PATH, CCP
The incidental removal of cysts/lesions attached to the root(s) of a simple extraction is considered part of the extraction or surgical fee. A 1–20, N, PXR, PATH, CCP
TID required. A 1–20, PXR
A 1–20, N, PXR, CCP
A 1–20, N, PXR
A 1–20, N, PXR
A 1–20, N, PXR
A 1–20, N, PXR, CCP
A 1–20, N, PXR, CCP
A 1–20, N, PXR
A 1–20, N, PXR, CCP
A 1–20, N, PXR, CCP
A 1–20, N, PXR, CCP
A 1–20, N, PXR, CCP
A 1–20, N, PXR, CCP
A 1–20, N, PXR, CCP
A 1–20, N, PXR, CCP
A 1–20, N, PXR, CCP
A 1–20, N, PXR, CCP
A 1–20, N, PXR, CCP
Per arch, appliance removal (not by the dentist who placed the appliance). Includes removal of arch bar. Prior authorization is required. A 1–20, N, PXR, CCP
A 1–20, 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
CPT only copyright 2014 American Medical Association. All rights reserved.