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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 : 4.2.27 Orthodontic Services (THSteps) : Minor Treatment to Control Harmful Habits
Special orthodontic appliances are a benefit for minor treatment to control harmful habits.
Orthodontic appliances for minor treatment to control harmful habits must be submitted with procedure codes D8210, D8220, and D8670.
Monthly adjustments (procedure code D8670) for minor treatment to control harmful habits are limited up to 10 visits.
Claims for panoramic films (procedure code D0330), cephalometric films (procedure code D0340), oral/facial photographic images obtained intraorally or extraorally (procedure code D0350) and diagnostic models (procedure code D0470) will be denied when they are submitted with procedure code D8210 or D8220.
Each orthodontic appliance (procedure code D8210 and D8220) are limited to once per arch, per lifetime.

Texas Medicaid & Healthcare Partnership
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