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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 : 4.2.23 Adjunctive General Services

Refer to:
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 4.2.30, “Emergency or Trauma Related Services for All THSteps Clients and Clients Who Are 5 Months of Age and Younger” in this handbook
Refer to:
Criteria for Dental Therapy Under General Anesthesia on the TMHP website at for general anesthesia criteria and additional information.
Limited to three hours per day. Prior authorization is required. Denied if submitted with D9248. Dental anesthesiologists are reimbursed at an enhanced rate if the provider has a level 4 permit, TSBDE portability permit, and proof of an anesthesiology residency recognized by the American Dental Board of Anesthesiology on file with TMHP. Providers who do not have the TSBDE portability permit and proof of anesthesiology residency on file with TMHP will still be eligible for reimbursement. A 1–20
May be considered for reimbursement for conscious sedation services. Limited to one and one-half hours per day. 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 Ambulatory Surgery Center (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.
Includes, but is not limited to, oral antibiotics, oral analgesic, and oral sedatives administered in the office. May not be submitted with codes 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 described as mild, moderate, severe, profound, or unspecified by using the most appropriate diagnosis code in the diagnosis code field of the claim form, or the provider must indicate that the client is ICF-IID 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 detailing the client’s the intellectual disability. The statement must be signed and dated within one year prior to the dental behavior management.
Dental behavior management is not reimbursed with an evaluation, prophylactic treatment, or radiographic procedure. Denied if submitted with D9248. A 1–20
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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