This article has been updated. To view the updated information, see “Correction to ‘Texas Health Steps Dental Preventive Benefits to Change September 1, 2023.’”
Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.
Effective for dates of service on or after September 1, 2023, dental preventive services benefits will change for Texas Health Steps.
Caries Arresting Medicament
Application of caries arresting medicament (procedure code D1354) will become a benefit for Texas Health Steps for clients who are birth through six years of age.
Procedure code D1354 will be limited to once per lifetime per TID (A-T and 3, 14, 19, and 30) by any provider for services rendered in the office setting.
Procedure code D1354 will be denied if billed on the same date of service for the same TID as procedure code D1351 or D1352 by any provider.
Procedure codes D9222 and 00170 with modifier U3 will be denied if billed within six months of D1354 by any provider.
Note: Silver diamine fluoride is the only material providers may use for procedure code D1354.
Dental Education and Counseling
Tobacco counseling (procedure code D1320) is considered a part of all dental procedures and may not be billed separately. Oral hygiene instruction procedure code D1330 is limited to services rendered in the office setting.
Reimbursement
Reimbursement for dental services exceeding the benefit limitations may be considered when medically necessary. Providers must submit documentation supporting medical necessity when submitting the claim. The documentation must be kept in the client’s medical record.
Preventive Procedure Codes
The following changes will be implemented for preventive procedure codes:
- Topical application fluoride (procedure codes D1206 or D1208) is limited to once every six months, by any provider.
- Procedure codes D1110, D1120, D1206, and D1208 will be denied when billed as an emergency claim.
- Procedure codes D1110 and D1120 will no longer be reimbursed to orthodontist and oral maxillofacial surgeon providers.
- Procedure code D1208 will no longer be reimbursed to orthodontist, oral maxillofacial surgeon, and Texas Health Steps Dental Group providers for services rendered in the office setting and to all provider types for services rendered in the inpatient and outpatient hospital setting.
Dental Sealants
The following changes will be implemented for dental sealants:
- The age range for procedure code D1351 will be updated to clients who are 1 year through 20 years of age.
- Procedure codes D1351 and D1352 are limited to once per lifetime, per TID, by any provider.
- Reimbursement for procedure codes D1351 and D1352 will be on a per-tooth basis, regardless of the number of surfaces sealed. TID and surface identification (SID) must be indicated on the claim form.
- Procedure code D1351 will be denied if billed on the same date of service for the same permanent TID as procedure code D1352, by any provider.
- Procedure codes D1351 and D1352 will be denied if billed as an emergency claim.
- Procedure code D1351 will no longer be reimbursed to orthodontists and oral maxillofacial surgeon.
Space Maintainers
Space maintainers are designed to prevent tooth movement and are a benefit of Texas Medicaid in the following situations:
- After premature loss of a deciduous/primary first and/or second molar (TID A, B, I, and J) for clients who are 1 through 12 years of age (procedure codes D1510 and D1516)
- After premature loss of a deciduous/primary first and/or second molar (TID K, L, S, and T) for clients who are 1 through 12 years of age (procedure codes D1510 and D1517)
- After premature loss of a deciduous/primary second molar (TID A, J, K, and T) for clients who are 3 through 7 years of age (procedure code D1575)
The following changes will be implemented for space maintainers:
- Procedure codes D1510, D1520, D1553, D1556 and D1575 are limited to once per lifetime, per quadrant, by any provider.
- Procedure codes D1516, D1517, D1526, and D1527 are limited to once per lifetime, same procedure code, by any provider.
- Procedure code D1553 will be denied if procedure code D1510 was reimbursed within the previous rolling year, same quadrant, by the same provider.
- Procedure code D1551 will be denied if procedure code D1516 was reimbursed within the previous rolling year, by the same provider.
- Procedure code D1552 will be denied if procedure code D1517 was reimbursed within the previous rolling year, by the same provider.
- Procedure codes D1551 and D1552 are limited to once per lifetime, by the same provider.
For more information, call the TMHP Contact Center at 800-925-9126.