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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) : 4.2.27.8 Orthodontic Procedure Codes and Fee Schedule

4.2.27.8
When submitting claims for orthodontic procedures, use the following procedure codes:
 
D0330*, D0340*, D0350*, and D0470*
A 1-20
Replaces Z2016. Not payable to the dentist who placed the appliance. Includes removal of arch bar and premature removal of braces. A 1-20
Refer to subsection 4.2.28, “Special Orthodontic Appliances” in this handbook for associated remarks field code.
Refer to subsection 4.2.28, “Special Orthodontic Appliances” in this handbook for associated remarks field code.
Replaces Z2008. Denied when submitted for the same DOS as D0145 by any provider. Denied when submitted for the same DOS as D0120 or D0150 by the same provider.
Replaces Z2014 and Z2015; one retainer per arch per lifetime; may be replaced once because of loss or breakage (prior authorization is required).
Although procedure code D8692 is not a benefit of Texas Medicaid, providers can use procedure code D8680 to submit a claim for retainer(s). Providers must include local code Z2014 or Z2015 on the claim form to indicate upper or lower, as appropriate.
* = Services payable to an FQHC for a client encounter.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.