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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 : 4.2.24 Dental Anesthesia

Dental providers must have the following information on file with TMHP to be eligible for reimbursement for dental anesthesia:
A portability permit from the TSBDE (required to be reimbursed for anesthesia provided in a location other than the provider’s office or satellite office). If the provider does not have a permit, the services will be denied.
Providers must have a level 4 permit, a TSBDE portability permit, and an anesthesiology residency recognized by the American Dental Board of Anesthesiology to bill the enhanced rate for procedure code D9223.
All dental providers must comply with the American Academy of Pediatric Dentistry (AAPD) guidelines and TSBDE rules and regulations, including the standards for documentation and record maintenance for dental anesthesia.
Anesthesia Permit Levels
The following table shows the levels of anesthesia permits that are issued by the TSBDE:
Nitrous oxide/oxygen inhalation conscious sedation
Automatically qualifies for Level 1, Level 2, Level 3, and Level 4 permit privileges
Providers will be reimbursed only for those procedure codes that are covered by their anesthesia permit level. The following table indicates the anesthesia procedure codes and the minimum anesthesia permit level to be reimbursed for the procedure codes:
Local anesthesia in conjunction with operative or surgical services (procedure code D9215) is all inclusive with any other dental service and is not reimbursed separately.

Texas Medicaid & Healthcare Partnership
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