Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.
Effective for dates of service on or after November 1, 2019, dental exception-to-periodicity modifiers will be clarified for Texas Health Steps Diagnostic and Therapeutic Dental services.
Texas Health Steps Dental Checkups
- Texas Health Steps dental checkups include an oral evaluation, prophylaxis, topical fluoride, and appropriate radiographs.
- The Texas Health Steps dental periodicity schedule for preventative and diagnostic procedures does not apply to clients living in an intermediate care facility for individuals with intellectual or developmental disabilities (ICF-IID) who are 21 years of age and older.
Exception to Periodicity Oral Evaluation, Dental Checkup, and Emergency or Trauma Related Services
Oral evaluations and dental checkups allow for the early diagnosis and treatment of dental problems. They might be needed at more frequent intervals than noted in the periodicity schedule.
If needed, a dental checkup or oral evaluation can still be reimbursed when the service falls outside the periodicity schedule. The rules for such exceptions are outlined below.
Exception-to-Periodicity Oral Evaluation
A Texas Health Steps exception-to-periodicity oral evaluation is limited to dental procedure code D0120.
An exception-to-periodicity oral evaluation is allowed when the service is:
- Medically necessary and based on risk factors and health needs for clients birth through 6 months of age.
- Mandated service required to meet federal or state exam requirements for Head Start, daycare, foster care or preadoption.
Providers must include all appropriate procedure codes on the dental claim submission form. Additionally, dental providers must include modifier SC or 32 to identify the reason for the exception.
Exception-to-Periodicity Dental Checkup
A Texas Health Steps exception-to-periodicity dental checkup is allowed when:
- The client will not be available for the next periodically due dental checkup. This includes clients whose parents are migrant or seasonal workers.
- Providers must include all appropriate procedure codes on the dental claim submission form. Additionally, dental providers must include modifier SC to identify the reason for the exception.
Exception-to-Periodicity Emergency or Trauma Related Oral Evaluation
A Texas Health Steps exception-to-periodicity emergency or trauma related oral evaluation is limited to dental procedure code D0140.
Procedure code D0140 is limited to once per day for the same provider and twice per day for any provider.
A Texas Health Steps exception-to-periodicity emergency or trauma related dental service will be allowed when the service is:
- Required for immediate treatment and any follow-up treatment.
- Required for therapeutic services needed to complete a case for clients, 5 months of age and younger, when initiated as emergency services, trauma, or early childhood caries.
When submitting a claim for emergency or trauma related dental services, the provider must include:
- “Trauma” or “Emergency” in Block 30 “Description” field.
- The original date of treatment or incident in Block 35, “Remark” field.
- Completion of Block 45, “Treatment Resulting from” field, if applicable.
Providers must include all appropriate procedure codes on the dental claim submission form. Additionally, dental providers must include modifier ET to identify the reason for the exception.
Documentation
The client’s dental medical record must include documentation for the exception-to-periodicity Texas Health Steps oral evaluation, dental checkup or exception-to-periodicity emergency or trauma related service for medical necessity.
Dental services are subject to retrospective review and recoupment if documentation does not support the services submitted for payment.
Reimbursement
The following procedure codes with modifiers to identify the reason for the exception must be included on the ADA dental claim submission form. Procedure codes must be included in Block 29. Modifiers must be included in Block 19:
|
Procedure Code |
Modifier to Identify Exemption |
Modifier Description |
|---|---|---|
|
D0120 |
32 |
Mandated Service |
|
D0120 |
SC |
Medically Necessary Service |
|
D0140, D9110 |
ET |
Emergency – Trauma Related Services |
Procedure code D0140 is limited to once per day for the same provider and twice per day for any provider.
Providers may refer to the Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, Appendix G., “American Academy of Pediatric Dentistry Periodicity Guidelines,” for periodicity and radiograph standards.
Adjunctive General Services
When submitting a claim for an unclassified treatment procedure code D9110 the provider must include:
- “Trauma” or “Emergency” in Block 30 “Description” field
- The original date of treatment or incident in Block 35, “Remark” field
- Completion of Block 45, “Treatment Resulting from” field, if applicable
Providers must include all appropriate procedure codes on the dental claim submission form. Additionally, dental providers must include modifier ET to identify the reason for the exception.
The client’s dental medical record must include documentation for the exception-to-periodicity Texas Health Steps oral evaluation, dental checkup or exception-to-periodicity emergency or trauma related service for medical necessity.
For more information, call the TMHP Contact Center at 800-925-9126.