Effective for dates of service on or after September 1, 2023, benefits for dental preventive services will change for the Children with Special Health Care Needs (CSHCN) Services Program.
Caries Arresting Medicament
Application of caries arresting medicament (procedure code D1354) will become a benefit for CSHCN for clients who are birth through 6 years of age.
Procedure code D1354 will be limited to once per lifetime per tooth identification (TID) (A-T and 3, 14, 19, and 30) by dentist, federally qualified health center (FQHC), and dentistry group providers 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 billing D1354 by any provider.
Procedure code D9223 will be denied unless it is billed with procedure code D9222 on the same date of service by any provider.
Note: Silver diamine fluoride is the only material that providers may use for procedure code D1354.
The following procedure codes may be reimbursed to a FQHC for a client visit:
Procedure code D1208 will no longer be reimbursed for services rendered in the inpatient or outpatient hospital settings.
Dental Counseling and Instruction
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 once per rolling year by any provider for services rendered in the office setting.
Space maintainers are designed to prevent tooth movement and are a benefit of the CSHCN Services Program in the following situations:
- After the loss of a permanent first molar (TID 3 and 14) for clients who are 3 through 12 years of age (procedure codes D1520 and D1526)
- After the loss of a permanent first molar (TID 19 and 30) for clients who are 3 through 12 years of age (procedure codes D1520 and D1527)
- After the premature loss of a deciduous or 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, same quadrant, by any provider.
- Procedure code D1551 will be denied if procedure code D1516 was reimbursed within the previous rolling year, by the same provider.
- The age range for procedure codes D1510, D1516, D1517, D1520, D1526, D1527, D1551, D1552, and D1553 will be updated to clients who are 1 year through 12 years of age.
Topical application of fluoride (procedure code D1206 or D1208) will be limited to once every six months by any provider.
The following changes will be implemented for dental sealants:
- Dental sealants are a benefit for clients who are 1 through 20 years of age when applied to primary teeth (TID A, B, I, J, K, L, S, and T) or permanent teeth (TID 1, 2, 3, 4, 5, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 28, 29, 30, 31, and 32).
- Procedure codes D1351 and D1352 are limited to once per lifetime, per TID, by any provider. Exceptions may be considered when pretreatment documentation clearly supports medical necessity.
- Dental sealants can be applied to occlusal, buccal, and lingual pits and fissures of teeth. The tooth must be at risk for dental decay and be free of proximal caries and restorations on the surface to be sealed.
- Procedure code D1351 will be denied if it is billed on the same date of service for the same permanent TID as procedure code D1352.
- Procedure code D1352 may be reimbursed only for posterior permanent teeth (TID 2-5, 12-15, 18-21, or 28-31).
- 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 will be denied if billed as an emergency claim.
For more information, call the TMHP-CSHCN Services Program Contact Center at 800-568-2413.