Before October 16, 2003, Texas Medicaid used 3 local codes for full banding: Z2009 paid $175.00 for Diagnostic work-up approved, Z2011 paid $300.00 for Maxillary bands, and Z2012 paid $300.00 for Mandibular bands. On October 16, 2003, the American Dental Association national procedure code D8080, Comprehensive orthodontic treatment of adolescent dentition, was implemented, combining the 3 local Medicaid codes and paying a maximum fee of $775.00.
Many providers noted the national procedure code did not allow for work-in-progress or “partial” billing (separating out the 3 orthodontic components). As a result, providers have billed in various ways, which has affected their Medicaid payments.
Effective August 13, 2004, for proper reimbursement, the local code must be submitted along with the national procedure code D8080. Local codes (Z2009, Z2011 or Z2012) are placed in the remark/ comment field, depending on the billing method (paper or electronic). Each local code pays the correct reimbursement rate, totaling the maximum payment of $775.00. D8080 must be billed on 3 separate details, with the appropriate remarks code, even if billing for the workup and full banding. Billing on one detail, for a total of $775.00 will no longer be accepted.
Example One
A client is approved for full banding, but after the initial work-up, the client discontinues treatment. This provider would bill the national code D8080 and place the local code Z2009, Diagnostic work-up approved, in the remarks/comment field. The claim would pay $175.00.
Example Two
A client is approved for full banding. The provider continues treatment and places the maxillary bands. The provider would bill the national procedure code D8080 and place the local code Z2009, Diagnostic work-up approved, and Z2011, Maxillary bands, in the remarks/comment field. The claim would pay $475.00.
Important: All electronic claims for D8080 must have the appropriate remarks code associated with the procedure code.
Providers should adhere to the following steps for electronic claim submission (other than TDHconnect) so that TMHP can accurately apply the correct remarks code to the appropriate claim detail.
A DPC Remarks Code must be submitted, only once, and in the first three bytes of the NTE02 at the 2400 loop.
Example One
For a claim with one detail, when the detail is submitted with procedure code D8080 and the detail is submitted with procedure code Z2009, enter the information as follows: DPCZ2009. The total billed will be $175.00.
Example Two
For a claim with two details, where details 1 and 2 are submitted with procedure code D8080, and the detail submitted with procedure code Z2009 and Z2011, enter the information as follows: DPCZ2009Z2011. The total billed will be $475.00.
Example Three
For a claim with three details, where all three details are submitted separately, procedure code D8080, in bytes 4–8 submit the DPC remarks code based on the order of the claim detail: DPCZ2009Z2011Z2012. The total billed will be $775.00.
These methods will ensure accurate and appropriate payment for services rendered and addresses the need for partial billing.
TDHCONNECT BILLING PROCEDURES:
Follow the same guidelines for TDHconnect, with the exception of placing the remarks code into the Remarks Code field, next to the procedure code field, under the Details tab. Do not add DPC if using TDHconnect Software to file claims.
Example One
For a claim with one detail, when the detail is submitted with procedure code D8080 and the detail is submitted with procedure code Z2009, enter the information as follows: In the Procedure Code ID field, enter D8080. Place Z2009 into the Remarks Code field . The total billed will be $175.00.
Example Two
For a claim with two details, where details 1 and 2 are submitted with procedure code D8080, and the detail submitted with remarks codes Z2009 and Z2011, enter the information as follows: For first detail, enter D8080 into the Procedure Code ID field. Place Z2009 into the Remarks Code field. The billed amount will be $175.00. In the second detail, enter D8080 into the Procedure Code ID field. Place Z2011 into the Remarks Code field. The billed amount will be $300.00. The total billed will be $475.00.
Example Three
For a claim with three details, where all three details are submitted with procedure code D8080, and the detail submitted with remarks codes Z2009, Z2011, and Z2012 enter the information as follows: For first detail, enter D8080 into the Procedure Code ID field. Place Z2009 into the Remarks Code field. The billed amount will be $175.00. In the second detail, enter D8080 into the Procedure Code ID field. Place Z2011 into the Remarks Code field. The billed amount will be $300.00. In the third detail, enter D8080 into the Procedure Code ID field. Place Z2012 into the Remarks Code field. The billed amount will be $300.00 The total billed will be $775.00.
Claims received without the local codes are denied.
Some tips for submitting orthodontic requests to TMHP:
-
Use black ink (blue, red, or other colors do not scan).
-
Write legibly. All paper received is scanned into the system and then reviewed. If the request received cannot be read, TMHP sends a letter to the requesting provider. Since the received paper is not readable, TMHP will not be able to inform the provider who filed the claim.
-
Ensure all submitted items, models, radiographs, and paper includes complete client and provider information.
-
Include the name and PCN (Program Case Number) of the client as well as the provider name and TPI (Texas Provider Identifier) on all submitted items.