Dental

14.1​Enrollment

To enroll in the CSHCN Services Program, dental providers must be actively enrolled in Texas Medicaid, maintain an active license status with the Texas State Board of Dental Examiners (TSBDE) (see Title 22 Texas Administrative Code (TAC), §§110.1–110.18), have a valid Provider Agreement with the CSHCN Services Program, have completed the CSHCN Services Program enrollment process, and comply with all applicable state laws and requirements. Out-of-state dental providers must meet all these conditions, and be located in the United States, within 50 miles of the Texas state border.

To be eligible to receive reimbursement for dental anesthesia providers must have the following information on file with TMHP:

•​Current anesthesia permit level issued by the TSBDE (applies to all dental providers)

•​Proof of an anesthesiology residency recognized by the American Dental Board of Anesthesiology (required to be reimbursed at the enhanced rate for procedure codes D9222 and D9223), if applicable

​Important:CSHCN Services Program providers are responsible for knowing, understanding, and complying with the laws, administrative rules, and policies of the CSHCN Services Program and Texas Medicaid.

By enrolling in the CSHCN Services Program, providers are charged not only with knowledge of the adopted CSHCN Services Program agency rules published in 26 TAC, but also with knowledge of the adopted Medicaid agency rules published in 1 TAC §§351.1–351.883 and specifically including the fraud and abuse provisions contained in 1 TAC §§371.1–371.1719.

CSHCN Services Program providers also are required to comply with all applicable laws, administrative rules, and policies that apply to their professions or to their facilities. Specifically, it is a violation of program rules when a provider fails to provide health-care services or items to recipients in accordance with accepted medical community standards and standards that govern occupations, as explained in 1 TAC §371.1659 for Medicaid providers, which also applies to CSHCN Services Program providers as set forth in 26 TAC §351.6(b)(1). Accordingly, CSHCN Services Program providers can be subject to sanctions for failure to deliver, at all times, health-care items and services to recipients in full accordance with all applicable licensure and certification requirements. These include, without limitation, requirements related to documentation and record maintenance, such that a CSHCN Services Program provider can be subject to sanctions for failure to create and maintain all records required by his or her profession, as well as those required by the CSHCN Services Program and Texas Medicaid.

​Refer to: Section 2.1, “Provider Enrollment” in Chapter 2, “Provider Enrollment and Responsibilities” for more detailed information about CSHCN Services Program provider enrollment procedures.

14.2​Benefits, Limitations, and Authorization Requirements

Diagnostic, therapeutic, and preventive dental services are a benefit of the CSHCN Services Program. Orthodontic services, medically necessary dental rehabilitation and restoration services, care of dental emergencies, and medically necessary services provided by doctors of dental surgery (DDS) or doctors of dental medicine (DMD) including, but not limited to, cleft-craniofacial surgery are also a benefit of the CSHCN Services Program.

14.2.1​Prior Authorization Requirements

Prior authorization is required for all orthodontia services and selected dental services.

All requests for prior authorization must be submitted using the CSHCN Services Program Prior Authorization Request for Dental or Orthodontia Services form. The TMHP-CSHCN Services Program may require the submission of X-rays, models, etc., for specific prior-authorized services. All prior authorization requests must include specific rationale for the requested service, including documentation of medical necessity and appropriateness of the recommended treatment. Additional documentation, including current periapical radiographs, must be maintained in the client’s medical or dental record and submitted to the CSHCN Services Program on request.

Authorization and prior authorization request forms submitted to TMHP must be signed and dated by the dental provider treating the client. If indicated on the form, an authorized representative’s signature is acceptable. All signatures and dates must be current. Stamped signatures are not permitted. Alterations to dates and signatures, such as cross-outs or white-outs, are not allowed. Submitted forms without an original hand-written signature and date will be rejected. Providers must keep the original, signed forms in the client’s medical record as documentation.

​Important:Refer to each individual section under Benefits and Limitations for specific information about prior authorization requirements.

​Refer to: Section 4.4, “Prior Authorizations” in Chapter 4, “Prior Authorizations and Authorizations” for detailed information about prior authorization requirements.

​Important:Photocopy this form and retain the original for future use.

​Note:Fax transmittal confirmations are not accepted as proof of timely prior authorization submission.

14.2.2​Substitute Dentist

The following are conditions for reimbursement of services rendered by a substitute dentist:

•​Dentists who take a leave of absence for no more than 90 days may bill for the services of a substitute dentist who renders services on an occasional basis when the primary dentist is unavailable to provide services. Services must be rendered at the practice location of the dentist who has taken the leave of absence. A locum tenens arrangement is not allowed for dentists.

•​This arrangement will be limited to no more than 90 consecutive days. Under this temporary basis, the primary dentist (who is the billing agent dentist) may not submit a claim for services furnished by a substitute dentist to address long-term vacancies in a dental practice. The billing agent dentist may submit claims for the services of a substitute dentist for longer than 90 consecutive days if the dentist has been called or ordered to active duty as a member of a reserve component of the Armed Forces. CSHCN accept claims from the billing agent dentist for services provided by the substitute dentist for the duration of the billing agent dentist’s active duty as a member of a reserve component of the Armed Forces.

•​Providers billing for services provided by a substitute dentist must bill with modifier U5 in Block 19 of the American Dental Association (ADA) claim form.

•​The billing agent dentist may recover no more than the actual administrative cost of submitting the claim on behalf of the substitute dentist. This cost is not reimbursable by CSHCN.

•​The billing agent dentist must bill substitute dentist services on a different claim form from his or her own services. The billing agent dentist services cannot be billed on the same claim form as substitute dentist services.

•​The substitute dentist must be licensed to practice in the state of Texas, must be enrolled in Texas Medicaid before enrolling in the CSHCN Services Program and must not be on the Texas Medicaid provider exclusion list.

•​The dentist who is temporarily absent from the practice must be indicated on the claim as the billing agent dentist, and his or her name, address, and National Provider Identifier (NPI) must appear in Blocks 53, 54, and 56 of the ADA claim form.

•​The substitute dentist’s NPI number must be documented in Block 35 of the ADA claim form. Electronic submissions do not require a provider signature.

Dentists must familiarize themselves with these requirements and document accordingly. Those services not supported by the required documentation, as detailed above, will be subject to recoupment.

​Note:Dental services must be filed on the ADA claim form.

14.2.3​Diagnostic Services

The CSHCN Services Program may reimburse the following diagnostic dental services for CSHCN Services Program eligible clients:

•​Clinical oral evaluations

•​Radiographs or diagnostic imaging

•​Tests or examinations, including oral pathology procedures

Based on the American Academy of Pediatric Dentistry’s (AAPD) definition of a dental home, the CSHCN Services Program defines a dental home as the dental provider who supports an ongoing relationship with the client that is inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, compassionate, culturally competent, and family-centered way. Establishment of a client’s dental home begins no later than 12 months of age and includes referral to dental specialists when appropriate.

In providing a dental home for a client, the dentist enhances the ability to assist children and their parents in the quest for optimum oral health care. A First Dental Home (FDH) visit can be initiated as early as 6 months of age and is billed using procedure code D0145. The FDH visit includes, but is not limited to:

•​Oral examination.

•​Oral hygiene instruction.

•​Dental prophylaxis, if appropriate.

•​Topical fluoride application using fluoride varnish, if appropriate.

•​Caries risk assessment.

•​Dental anticipatory guidance.

Diagnostic services should be performed for all clients, preferably starting within the first 6 months of the eruption of the first primary tooth, but no later than 1 year of age. Dental home providers should record the oral and physical health history, perform a caries assessment, develop an appropriate preventive oral health regimen, and communicate with and counsel the client’s parent, legal guardian, or primary caregiver.

Caries susceptibility tests (procedure code D0425) are used to analyze the acidic level of the oral cavity using acid or alkali sensitive materials to ascertain the client’s likelihood of developing caries. Caries susceptibility tests are considered part of all other dental procedures and are not separately reimbursed.

Requesting providers must retain in the client’s medical record all documentation to support the diagnosis and treatment of trauma.

14.2.3.1​Prior Authorization Requirements

Prior authorization is required for cone-beam imaging (procedure code D0367) and for diagnostic services not adequately described by more specific procedure codes where an unspecified procedure code (D0999) is necessary.

To obtain prior authorization, a CSHCN Services Program Prior Authorization Request for Dental or Orthodontia Services form must be submitted along with documentation supporting medical necessity and appropriateness. Documentation required includes, but is not limited to:

•​Presenting condition(s).

•​Medical necessity.

•​The status of the client’s treatment.

Prior authorization is not required for any other diagnostic service.

​Refer to: Section 4.4, “Prior Authorizations” in Chapter 4, “Prior Authorizations and Authorizations” for detailed information about prior authorization requirements.

Section 14.2.3.3, “Cone-Beam Imaging” in this chapter.

14.2.3.2​Clinical Oral Evaluations

Documentation supporting medical necessity for procedure codes D0140, D0160, D0170, and D0180 must be maintained by the provider in the client’s medical record and must include:

•​The client complaint supporting medical necessity for the examination.

•​The area of the mouth that was examined or the tooth involved.

•​A description of what was done during the treatment.

•​Supporting documentation of medical necessity, including, but not limited to, radiographs or photographs.

The following clinical oral evaluation procedure codes may be considered for reimbursement:

A caries risk assessment procedure code (D0601, D0602, or D0603) will be required on the same claim, for the same date of service, by the same provider when dental examination procedure code D0120, D0145, or D0150 is submitted for reimbursement. The client’s dental condition(s) that justifies the risk assessment classification submitted with the claim must be clearly documented and maintained by the provider in the client’s medical record.

Professionally developed caries risk assessment tools are available at:

•​American Dental Association (ADA)

•​American Academy of Pediatric Dentistry (AAPD)

•​Department of State Health Services (DSHS), Oral Health Program

14.2.3.3​Cone-Beam Imaging

Cone-beam imaging is used to determine the best course of treatment for cleft palate repair, skeletal anomalies, post-trauma, implanted or fixed prosthodontics, and orthodontic or orthognathic procedures. Cone-beam imaging is limited to initial treatment planning, surgery, and post-surgical follow-up.

Procedure code D0367 must be prior authorized by the TMHP Dental Director.

Procedure code D0367 is limited to a combined maximum of three services per calendar year. Additional services may be considered by the TMHP Dental Director with documentation of medical necessity.

14.2.3.4​First Dental Home

Based on the American Academy of Pediatric Dentistry’s definition, the CSHCN Services Program defines a dental home as the dental provider who supports an ongoing relationship with the client that includes all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way.

In providing a dental home for a client, the dental provider enhances the ability to assist clients and their parents in obtaining optimum oral health care. The first dental home visit can be initiated as early as 6 months of age and must include, but is not limited to, the following:

•​Comprehensive oral examination

•​Oral hygiene instruction with primary caregiver

•​Dental prophylaxis, if appropriate

•​Topical fluoride varnish application when teeth are present

•​Caries risk assessment

•​Dental anticipatory guidance

The dental home provider must keep supporting documentation for procedure code D0145 in the client’s medical record. The supporting documentation must include, but is not limited to, the following:

•​Oral and physical health history review

•​Dental history review

•​Primary caregiver’s oral health

•​Oral evaluation

•​An appropriate preventive oral health regimen

•​Caries risk assessment

•​Dental prophylaxis, which may include a toothbrush prophylaxis

•​Oral hygiene instruction with parent or caregiver

•​Anticipatory guidance communicated to the client’s parent, legal guardian, or primary caregiver, to include the following:

•​Oral health and home care

•​Oral health of primary caregiver or other family members

•​Development of mouth and teeth

•​Oral habits

•​Diet, nutrition, and food choices

•​Fluoride needs

•​Injury prevention

•​Medications and oral health

•​Fluoride varnish application

•​Any referrals, including dental specialist’s name

Procedure codes D0120, D0150, D0160, D0170, D0180, D1120, D1206, D1208, and D8660 will be denied when billed on the same date of service, for any provider as D0145.

A First Dental Home examination is limited to ten services per client lifetime with at least 60 days between visits by any provider.

Reimbursement for procedure code D0145 is limited to dentists certified by the Texas Department of State Health Services (DSHS). Providers can complete a free continuing education course online or attend classroom training to be certified to provide First Dental Home services. For information about training, refer to the Department of State Health Services (DSHS) Oral Health Program web page at hhs.texas.gov/doing-business-hhs/provider-portals/health-services-providers/texas-health-steps/dental-providers/first-dental-home.

14.2.3.5​Radiographs or Diagnostic Imaging

The number of radiograph films required for a complete intraoral series is dependent on the age of the client. An intraoral series requires at least eight films. Adults and children older than 12 years of age require 12 to 20 films to be considered an intraoral series. A panoramic radiographic image (procedure code D0330) plus a minimum of four bitewing radiographic images (procedure code D0274) may be considered equivalent to a comprehensive intraoral series including radiographic images (procedure code D0210).

Supporting documentation must be kept in the client’s dental record when medical necessity is not evident on radiographs.

The following radiographs or diagnostic imaging procedure codes may be considered for reimbursement:

14.2.3.6​Tests and Oral Pathology Procedures

The following procedure codes may be considered for reimbursement and are limited to clients
who are 1 year of age or older:

Procedure code D0460:

•​Includes multiple teeth and contralateral comparisons based on medical necessity.

•​Is considered part of any endodontic procedure and is not separately reimbursed when billed on the same date of service as any endodontic procedure.

•​Is not payable when billed for primary teeth.

•​Is limited to one service per day by the same provider.

​Refer to: Section 14.2.6, “Therapeutic Services” in this chapter for additional information about endodontic procedures.

When billing for diagnostic procedures not adequately described by other procedure codes, providers should use procedure code D0999.

Procedure code D0470 is limited to once per lifetime, any provider.

Only one emergency or trauma claim per client, per day may be submitted. Separate services may be submitted for the same client on the same date of service, one for emergency or trauma and one for nonemergency or routine care.

When billing electronically for emergency or trauma-related dental services, use the ET modifier to indicate emergency.

14.2.4​Orthodontia Services

Orthodontia services are benefits of the CSHCN Services Program for clients with prior authorization and an appropriate diagnosis code that indicates cleft lip, cleft palate, congenital anomalies of skull and face bones, dentofacial functional abnormalaties, or major anomalies of jaw size.

Orthodontia for cosmetic purposes only is not a benefit of the CSHCN Services Program. All removable or fixed orthodontic appliances must be billed with procedure codes D8210 or D8220.

14.2.4.1​Prior Authorization Requirements

Prior authorization is required for all orthodontic services except for the initial orthodontic visit. Prior authorization is only approved for a complete orthodontic treatment plan, and all active orthodontic treatments must be completed within 36 months. Prior authorization is not transferable to another dentist. The new provider must request prior authorization to complete the orthodontic treatment initiated by the previous provider.

Extensions on allowed time frames may be considered no sooner than 60 days before the authorization expires. Extra monthly adjustments (procedure code D8670) will not be prior authorized, but the time frame may be considered for extension not to exceed 36 months of actual treatment.

​Refer to: Section 4.4, “Prior Authorizations” in Chapter 4, “Prior Authorizations and Authorizations” for detailed information about prior authorization requirements.

14.2.4.2​Required Documentation

To obtain prior authorization, the provider must submit the CSHCN Services Program Prior Authorization Request for Dental or Orthodontia Services form.

The following documentation must accompany the form, and must include the date of service the documentation was obtained:

•​A complete orthodontia treatment plan including all the procedures required to complete full treatment such as:

•​Extractions

•​Orthognathic surgery

•​Upper and lower appliances

•​Monthly adjustments

•​Appliance removal (if needed)

•​Special appliances

•​All diagnostic models

•​A cephalometric radiograph with tracing

•​Facial photographs

•​A full series or radiographs or a panoramic radiograph

​Note:Diagnostic models, radiographs, and any other paper diagnostic tools submitted to TMHP will be returned to the submitting provider. Requests submitted with damaged diagnostic models will be returned to the provider as an incomplete request.

A prior authorization request for orthodontia services must include one of the following indications:

•​Cleft lip

•​Cleft palate

•​Congenital anomalies of skull and face bones

•​Dentofacial functional abnormalities

•​Major anomalies of jaw size

A prior authorization request for comprehensive orthodontic treatment or crossbite therapy submitted without the CSHCN Services Program Prior Authorization Request for Dental or Orthodontia Services form, diagnostic model, radiographs (X-rays), and any other necessary supporting documentation will not be considered and will be returned to the provider as incomplete.

The following information must be provided in the case of a transfer of care from one provider to another:

•​A request for prior authorization as outlined above

•​Explanation of why the client left the previous provider

•​Explanation of the client’s treatment status

14.2.4.3​Submitting Local Codes for Orthodontic Procedures

To ensure appropriate claims processing, the local code reflecting the specific service is required on the claim.

For electronic submissions other than TexMedConnect submissions, providers must follow the steps below to ensure the correct local code is accurately applied to the appropriate claim detail:

1)​Submit the DPC prefix in the first three bytes of NTE02 at the 2400 loop. Submit the DPC prefix only once.

2)​Submit the remark code (local code) in bytes 4–8, based on the order of the claim detail. Do not enter any spaces or punctuation between remark codes, unless to designate that the detail is not billed with D8210 or D8220.

Example:​For a claim with three details, where details 1 and 3 are submitted with procedure code W-D8210 and detail 2 is not, enter the following information in the NTE02 at the 2400 loop:

DPC1014D 1046D
(The space shows that detail 2 needs no local code.)

Example:​If all three details require a local code, enter DPC and the appropriate local codes in sequence without any spaces between the codes:

DPC1024D1055D1056D
(The absence of spaces indicates that local codes are needed for all three details.)

To submit using TexMedConnect, enter the local code into the Remarks Code field, located under the Details header. The Remarks Code field is the field following the Procedure Code field. TexMedConnect submitters are not required to enter the DPC prefix, because it is automatically placed in the appropriate field on the TexMedConnect electronic claim.

For paper claim submissions, providers must enter the local code in the Remarks section of the claim form.

Failure to follow the above steps does not cause the claim to deny; however, manual intervention is required to process the claim and a delay of payment may be the result.

Orthodontic procedure codes that were local codes used for prior authorization and reimbursement have been converted to Current Dental Terminology (CDT) (national) procedure codes.

The following procedures are not included in comprehensive treatment:

Monthly adjustments (procedure code D8670) for comprehensive orthodontics are limited to one service per calendar month.

Only one retainer per arch per lifetime (procedure code D8680) is allowed. The delivery of a retainer includes any visits for retainer adjustments. Retainer adjustments are not reimbursed separately.

Procedure code D8080 is a comprehensive code and includes a diagnostic workup as well as all upper and lower orthodontic appliances (braces) necessary to treat the client.

When a diagnostic workup is not approved, individual components may be considered for separate reimbursement. Use the following procedure codes:

Diagnostic model (procedure code D0470) are included in procedure codes (D8010 or D8020).

The orthodontic diagnostic work-up procedures are considered inclusive to procedure codes D8010 or D8020 and are not reimbursed separately. Panoramic radiographic images (procedure code D0330), cephalometric radiographic images (procedure code D0340), oral/facial photographic images obtained intraorally or extraorally (procedure code D0350) and diagnostic models (procedure code D0470) will be denied when billed with any one of the following procedure codes: D8010 or D8020.

Procedure code D8680 includes all retainers necessary to treat the client. Use the following remarks codes according to the services provided:

Procedure code D8010 includes a crossbite workup and removable appliance. Use the following remarks codes according to the services provided:

Procedure code D8020 includes a crossbite workup and the fixed appliance. Use the following remarks codes according to the services provided:

The orthodontic diagnostic work up procedures are considered inclusive procedures. Procedure codes D0330, D0340, D0350, and D0470 are denied when billed with a diagnostic work up procedure.

The following tables display the special fixed and removable orthodontic appliances. Under the current provisions of the Health Insurance Portability and Accountability Act (HIPAA), all fixed appliances are designated as procedure code D8220, and all removable appliances are designated as procedure code D8210. These are entered as a line item on the paper American Dental Association (ADA) Dental Claim Form with the appropriate fee. However, the remarks codes (former local procedure codes), as appropriate and listed below, also need to be entered on the authorization request form and in the Remarks field of the dental claim form (paper and electronic) to ensure correct authorization, accurate records, and reimbursement. Failure to bill the correct procedure codes may result in claim processing delays.

​Note:Prior authorization must be requested using both the CDT procedure code and the remarks codes for orthodontia services.

Use the following remarks codes in the Remarks field for fixed appliances (procedure code D8220):

Use the following remarks codes in the Remarks field for removable appliances (procedure code D8210):

The following procedure codes are used to bill orthodontic services:

The procedure codes in the table above are not reimbursed to orthodontists or oral maxillofacial surgeons. These providers may be reimbursed by the CSHCN Services Program as a dentist or dentistry group provider type by using the appropriate NPI when billing claims.

14.2.5​Preventive Services

The following dental preventive services are benefits of the CSHCN Services Program:

•​Oral hygiene instruction

•​Dental prophylaxis and topical fluoride treatment

•​Dental sealants

•​Space maintainers, including recementation and removal

14.2.5.1​Authorization Requirements

Authorization or prior authorization is not required for preventive dental services.

14.2.5.2​Oral Hygiene Instruction

OHI (procedure code D1330) may be considered for reimbursement for clients who are 1 year of age or older in an office setting when the services are above and beyond the routine brushing and flossing instructions included in the prophylaxis procedure codes and when additional time and expertise is directed toward the client’s care. Procedure code D1330 is limited to once per rolling year by any provider and is denied when billed on the same day as procedure codes D1110, D1120, D1206, or D1208 by any provider.

Procedure code D1330 is not reimbursed to orthodontists or oral maxillofacial surgeons. These providers may be reimbursed by the CSHCN Services Program as a dentist or dentistry group provider type by using the appropriate NPI when billing claims.

14.2.5.3​Dental Prophylaxis and Topical Fluoride Treatment

When performing fluoride treatments, procedure code D1120 and D1208 or procedure code D1110 and D1208 must be billed on the same date of service.

Topical application of fluoride (procedure code D1206 or D1208) is limited to once every six months, by any provider.

Procedure codes D1110 and D1120 include oral health instructions, and are limited to one prophylaxis per 6 calendar months, by any provider. Procedure codes D1110 and D1120 will be denied when submitted on an emergency claim.

The following procedure codes may be considered for reimbursement but are not payable on the same date of service as any D4000 series (periodontal) procedure codes:

The procedure codes in the table above are not reimbursed to orthodontists or oral maxillofacial surgeons. These providers may be reimbursed by the CSHCN Services Program as a dentist or dentistry group provider type by using the appropriate NPI when billing claims.

14.2.5.4​Dental Sealants

Dental sealants (procedure codes D1351 and D1352) are a benefit for clients who are 1 through 20 years of age when applied to primary teeth (Tooth Identification [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).

Dental sealants may be applied by a dentist or dental hygienist.

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.

Sealants may be applied to the 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. Each tooth must be billed separately using procedure code D1351. Reimbursement is on a per tooth basis, regardless of the number of surfaces sealed. Tooth numbers and surfaces must be indicated on the claim form.

Dental sealants and replacement sealants are limited to one every 3 years, per tooth, for the same provider. Procedure code D1351 is not payable on the same date of service as any of D4000 series (periodontal) procedure codes. During claims processing or retrospective review, if the claim, narrative, documentation, or charting by a provider includes language, terms, or acronyms indicating a preventative resin was applied, the procedure will be reimbursed as a dental sealant, not as a restorative procedure.

Procedure code D1351 is not reimbursed to orthodontists or oral maxillofacial surgeons. These providers may be reimbursed by the CSHCN Services Program as a dentist or dentistry group provider type by using the appropriate NPI when billing claims.

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 for posterior permanent teeth only (TID 2-5, 12-15, 18-21, or 28-31) to clients who are 5 years of age or older.

Procedure code D1352 will be denied if a moderate or high caries risk assessment (procedure code D0602 or D0603) has not been submitted, by any provider, within 180 days prior to procedure code D1352.

Procedure codes D1351 and D1352 will be denied if billed as an emergency claim.

14.2.5.5​Caries Arresting Medicament

Application of caries arresting medicament (procedure code D1354) is a benefit for clients who are birth through 6 years of age.

Procedure code D1354 is limited to once per lifetime per TID (A-T and 3, 14, 19, and 30), any provider.

Procedure code D1354 will be denied if billed on the same date of service for the same TID as procedure code D1351 or D1352, any provider.

Procedure code D1354 will be denied when billed within six months of procedure code D9222 or 00170 with modifier U3 by any provider.

​Note:Silver diamine fluoride is the only material providers may use for procedure code D1354.

14.2.5.6​Space Maintainers

One space maintainer per tooth ID may be reimbursed per lifetime, per client. Replacement space maintainers may be considered on appeal with documentation supporting medical or dental necessity.

Space maintainers may be reimbursed with procedure codes D1510, D1516, D1517, D1520, D1526, D1527, and D1575.

Procedure codes D1510 and D1520 are limited to once per lifetime, per quadrant, by any provider.

Procedure codes D1516, D1517, D1526, and D1527 are limited to once per lifetime, per tooth ID, any provider.

Procedure codes D1551, D1552, and D1553 may be reimbursed for clients who are 1 through 12 years of age. Procedure codes D1551 and D1552 are limited to once per lifetime, same provider.

Procedure codes D1553 and D1556 are limited to once per quadrant, per lifetime, any provider.

Procedure code D1551 will be denied if D1516 has been reimbursed within the previous rolling year, same provider.

Procedure code D1552 will be denied if billed within one rolling year of procedure code D1517, same provider.

Procedure codes D1556, D1557, and D1558 may be reimbursed for clients who are 1 through 20 years of age. Removal of a space maintainer (procedure code D1556, D1557, or D1558) is not payable to the provider or dental group practice that originally placed the device. The provider may be reimbursed if the space maintainer was placed by a different provider.

Procedure codes D1510, D1516, D1517, D1520, D1526, and D1527 may be reimbursed for clients who are 1 through 12 years of age. These procedure codes are not reimbursed to orthodontists or oral maxillofacial surgeons. These providers may be reimbursed by the CSHCN Services Program as a dentist or dentistry group provider type by using the appropriate NPI when billing claims.

Space maintainers are designed to prevent tooth movement and are a benefit in the following situations:

•​After premature loss of a deciduous (primary) tooth, first or second molars (tooth identification) (TID): A, B, I, and J for clients who are 1 through 12 years of age.

•​After premature loss of deciduous (primary) tooth, first or second molars (tooth identification) (TID): K, L, S, and T for clients who are 1 through 12 years of age.

•​After loss of a permanent first molar (TID: 3 and 14) for clients who are 3 through 12 years of age.

•​After loss of a permanent first molar (TID: 19 and 30) for clients who are 3 through 12 years of age.

•​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 billed with (procedure code D1575).

​Note:Premature loss is defined as loss of the tooth prior to the expected or normal life of the tooth. For a deciduous/primary molar, this is before eruption of the comparable bicuspid permanent tooth.

Space maintainers submitted with procedure code D1575 are limited to one per tooth ID, per client. Procedure code D1575 is limited to once per lifetime, per quadrant, any provider.

14.2.5.7​Noncovered Counseling Services

14.2.5.7.1​Dental Nutrition Counseling

Procedure code D1310 is not a benefit of the CSHCN Services Program as a separate procedure. Dental nutrition counseling is included as part of all preventive, therapeutic, orthodontic, and diagnostic dental procedures. A client requiring more involved nutrition counseling may be referred to their primary care physician. The provider can refer the client to a CSHCN Services Program-enrolled licensed dietitian for further nutrition counseling.

14.2.5.7.2​Tobacco Counseling

Procedure code D1320 is not a benefit of the CSHCN Services Program as a separate procedure. Tobacco counseling is considered part of any preventive, therapeutic, orthodontic, and diagnostic dental procedures.

14.2.6​Therapeutic Services

The following therapeutic dental services are benefits of the CSHCN Services Program:

•​Restorations

•​Endodontics

•​Periodontics

•​Prosthodontics, both fixed and removable

•​Maxillofacial prosthetics

•​Implants

•​Oral and maxillofacial surgery

•​Adjunctive general services, including, but not limited to:

•​Dental anesthesia

•​Dental hospital call

•​Desensitizing medicaments

•​Dental behavior management

•​Internal bleaching of discolored tooth

•​Occlusal adjustments

14.2.6.1​Prior Authorization Requirements

Prior authorization requirements for specific procedures are contained within each section below. Prior authorization for therapeutic services is valid up to 90 days (this does not apply to orthodontic services).

To obtain prior authorization, the following must be submitted:

•​The CSHCN Services Program Prior Authorization Request for Dental or Orthodontia Services form

•​Provider documentation supporting the medical necessity and appropriateness of the recommended treatment

Each distinct dental procedure code to be performed that requires prior authorization must be listed on the CSHCN Services Program Prior Authorization Request for Dental or Orthodontia Services Form. Repetitive dental procedure codes must be listed to indicate the total quantity to be performed.

Additional documentation, including current periapical radiographs, must be maintained in the client’s medical record and submitted to the CSHCN Services Program on request.

​Refer to: Section 4.4, “Prior Authorizations” in Chapter 4, “Prior Authorizations and Authorizations” for detailed information about prior authorization requirements.

14.2.6.2​Anesthesia Requirements for Clients who are Six Years of Age or Younger

For clients who are six years of age or younger, the following will apply:

•​All Level 4 sedation/general anesthesia services provided by a dentist (procedure codes D9222 and D9223), and any anesthesia services provided by an anesthesiologist (M.D./D.O.) or certified registered nurse anesthetist (CRNA) (procedure code 00170 with modifier U3) provided in conjunction with dental therapeutic services must be prior authorized.

•​The dentist performing the therapeutic dental procedure is responsible for obtaining prior authorization and is also responsible for providing the anesthesia prior authorization information to the anesthesiology provider.

•​The current process of scoring 22 points on the Criteria for Dental Therapy Under General Anesthesia form does not guarantee authorization or reimbursement for clients who are six years of age and younger.

Procedure code 00170 with modifier U3, and procedure codes D9222 and D9223 is limited to once per six calendar months by any provider.

Requests for prior authorization must include, but is not limited to, the following client-specific documents and information:

•​A completed CSHCN Services Program Criteria for Dental Therapy Under General Anesthesia form

•​A completed CSHCN Services Program Prior Authorization Request for Dental of Orthodontia Services form

•​The location of where the procedure(s) will be performed (office, inpatient hospital, or outpatient hospital)

•​Name of the group providing the Level 4 anesthesia services

•​A narrative unique to the client, detailing the reasons for the proposed level of sedation (indicate procedure code D9222, D9223, or 00170 with modifier U3). The narrative must include a history of prior treatment, information about failed attempts at other levels of sedation, behavior in the dental chair, proposed restorative treatment (tooth ID and surfaces), urgent need to provide comprehensive dental treatment based on extent of diagnosed dental caries, and any relevant medical condition(s).

•​Diagnostic quality radiographs or photographs

•​When appropriate radiographs or photographs cannot be taken prior to general anesthesia. The narrative must support the reasons for an inability to perform diagnostic services. For special cases that receive authorization, diagnostic quality radiographs or photographs will be required for payment and will be reviewed by the TMHP dental director.

​Note:In cases of an emergency medical condition, accident, or trauma, prior authorization is not necessary. However, a narrative and appropriate pre- and post-treatment radiographs or photographs must be submitted with the claim, which will be reviewed by the TMHP dental director.

14.2.6.3​Interrupted Treatment Plan

Prior authorization for an incomplete treatment plan is not transferable to the new provider. The new provider must obtain prior authorization to complete the treatment plan initiated by the original provider.

14.2.6.4​Restorations

Restorations do not require prior authorization except for onlays and crowns. Procedure code D2999 requires prior authorization.

Consideration of restoration reimbursement is contingent on compliance with the following limitations:

•​Restorations on primary teeth and permanent posterior teeth may be reimbursed on the basis of the surface or surfaces restored and are paid as a total maximum fee per tooth.

•​More than one restoration on a single surface is considered a single restoration. A multiple surface restoration cannot be billed as two or more separate one-surface restorations.

•​The restorations must show definite crossing of the plane of each surface listed for primary and permanent tooth restoration completed to be considered for reimbursement as a multiple surface restoration.

•​All reimbursement for tooth restorations include local anesthesia and pulp protection media, where indicated, without additional charges. These services will deny as part of another service if billed separately.

•​The CSHCN Services Program may reimburse restorations and therapeutic care based on medical necessity. Therapeutic procedures are not reimbursed for preventive purposes.

Inlay or onlay restorations and crowns–single restorations only may be reimbursed a maximum fee when performed on permanent teeth. This fee includes the actual inlay or onlay or crown, any provisional crown, and any preparatory work before the seating of the permanent crown.

Reimbursement for crowns and onlay restorations are payable once per client, per tooth every ten years. Additional crowns and onlays may be considered with prior authorization and documentation of medical necessity.

Reimbursement for crowns and onlay restorations require submission of post-operative bitewing radiograph(s) (for posterior teeth) or post-operative periapical radiograph(s) (for anterior teeth) with the claim to verify that the restoration meets the standard of care.

Single restoration only crown procedure codes are limited to CSHCN Services Program clients who are 13 years of age or older.

Procedure code D2799 is denied as part of the global fee for a crown.

Use the following procedure codes for restoration services:

The following dental restoration procedure codes will be limited to once per rolling year, for the same TID, by the same provider:

Procedure codes D2335 and D2390 when provided to primary teeth will be limited to once per lifetime, same TID, any provider, and will be denied if any of the following anterior restorations have been paid within a rolling year, for the same TID, by the same provider as the following procedure codes:

Total reimbursement for direct restorations on primary teeth cannot exceed the total dollar amount allowed for a stainless steel crown, per TID, per date of service. This limitation does not apply to procedure code D2335.

14.2.6.4.1​Direct Restorations and Other Restorative Services

Direct restoration of a primary tooth with the use of a prefabricated crown will be considered as a once in a lifetime restoration, same TID, any provider. Exceptions may be considered when pre-treatment X-ray images, intra-oral photos, and narrative documentation clearly support the medical necessity for the replacement of the prefabricated crown procedure codes D2930, D2932, D2933, and D2934 during pre-payment review.

Procedure code D2930 will be denied if the following procedure codes have been billed within a rolling year, for the same TID, by the same provider:

Procedure codes D2933 and D2934 will be denied if the following procedure codes have been billed within a rolling year, for the same TID, by the same provider:

Procedure codes D2931 and D2932 will be denied if the following procedure codes have been billed within a rolling year, for the same TID, by the same provider:

14.2.6.5​Endodontics

The following procedures are limited to four permanent teeth without prior authorization:

•​Initial endodontic therapy (procedure codes D3310, D3320, and D3330)

•​Retreatment of previous root canal therapy (procedure codes D3346, D3347, and D3348)

Procedure code D3221 is considered part of all endodontic procedures and will not be reimbursed separately.

14.2.6.5.1​Prior Authorization

Prior authorization is required for root canal therapy and retreatment of previous root canal therapy (procedure codes D3346, D3347, and D3348) in excess of four root canals. To obtain prior authorization, the CSHCN Services Program Prior Authorization Request for Dental or Orthodontia Services form must be submitted with documentation of medical necessity.

Documentation supporting medical necessity must be maintained in the client’s dental record and include the following:

•​The medical necessity before treatment, during treatment, and post treatment

•​Periapical radiographs

•​The final size of the file to which the canal was enlarged and the type of filling material used

•​Any reason that the root canal may appear radiographically unacceptable must be documented in the client’s dental record

Prior authorization is required for procedure code D3460. Documentation of medical necessity must include the following:

•​The client is 16 years of age or older.

•​Regular treatment failed.

•​The client’s anatomy is such that no other fixed or removable prosthodontic alternatives are available, including, but not limited to anodontia, a result of trauma, or birth defect.

Prior authorization is required for an unspecified endodontic procedure, procedure code D3999.

​Refer to: Section 14.2.6.1, “Prior Authorization Requirements” in this chapter for more information about prior authorization requirements.

Section 4.4, “Prior Authorizations” in Chapter 4, “Prior Authorizations and Authorizations” for detailed information about prior authorization requirements.

14.2.6.5.2​Pulp Caps and Pulpotomy

Direct pulp caps (procedure code D3110) and indirect pulp caps (procedure code D3120) are a benefit for permanent teeth only (TID 1-32).

Direct pulp caps (procedure code D3110) may be reimbursed when billed with the following procedure codes for the same tooth ID, on the same date of service, by the same provider:

 

Indirect pulp caps (procedure code D3120) may be reimbursed when billed with procedure code D2940 for the same tooth ID, on the same date of service by the same provider.

Procedure code D3221 is considered part of all endodontic procedures and will not be reimbursed separately.

14.2.6.5.3​Root Canals

Root canals may only be reimbursed when performed on permanent teeth.

Reimbursement for endodontic therapy (procedure codes D3310, D3320, and D3330), or retreatment of a previous root canal (procedure codes D3346, D3347, and D3348) includes all appointments, radiographs, and procedures necessary to complete the treatment, including, but not limited to:

•​Pulpotomy

•​Radiographs performed pre-, intra-, and postoperatively

Re-treatment claims for an incomplete pulpotomy performed by a dentist not associated with the original treating dentist or dental group will be considered for reimbursement upon appeal.

Documentation of medical necessity and the incomplete initial pulpotomy must be submitted with the appeal. The appeal must also include a written narrative and pre- and post-treatment X-rays, which will be reviewed by a Texas licensed dentist.

​Note:The identified, original treating dentist or dental group will not be considered for reimbursement.

The following services are not considered part of the endodontic therapy procedures or the retreatment procedures of a previous root canal and may be reimbursed separately:

•​Diagnostic evaluation

•​Radiographs performed at the initial, periodic, or emergency service visits

Root canal therapy not carried to completion with a final filling should not be billed using a root canal therapy procedure code. It must be billed using procedure code D3999. Providers must file the claim with a narrative description of the procedures that were completed.

The date of service for a root canal is the date when the service was initiated.

Procedure codes D3220, D3351, D3352, and D3353 performed on a tooth within the 6 months preceding a root canal is considered part of the root canal. The total amount reimbursed will not exceed the total dollar amount allowed for procedure codes D3310, D3320, and D3330, or D3346, D3347, and D3348.

Apicoectomy (procedure codes D3410, D3421, D3425, and D3426) billed after root canal therapy or retreatment of a previous root canal may be reimbursed separately.

Refer to the following table for additional limitations for endodontic services:

14.2.6.6​Periodontics

Medical necessity for third-molar sites includes, but is not limited to:

•​Medical or dental history documenting need due to inadequate healing of bone following third-molar extraction, including date of third-molar extraction.

•​Secondary procedure several months postextraction.

•​Position of the third molar preoperatively.

•​Postextraction probing depths to document continuing bony defect.

•​Postextraction radiographs documenting continuing bony defect.

•​Bone graft and barrier material used.

Medical necessity for other than third-molar sites, includes, but is not limited to:

•​Medical or dental history documenting comorbid condition (e.g., juvenile diabetes, cleft palate, avulsed tooth or teeth, traumatic oral injury).

•​Intra- or extra-oral radiographs of treatment sites.

•​If medical necessity is not radiographically evident, intraoral photographs would be appropriate to request; otherwise, intraoral photographs would be optional unless requested preoperatively by the Health and Human Services Commission (HHSC) or its agent.

•​Periodontal probing depths.

•​Number of intact walls associated with an angular bony defect.

•​Bone graft and barrier material used.

The preventive dental procedure codes D1110, D1120, D1206, D1208, D1351, and D1352 will be denied when billed on the same date of service as any D4000 series periodontal procedure code.

Periodontal scaling and root planing (procedure codes D4341 and D4342) will be denied when submitted for the same date of service as other D4000 series codes, except D4341 and D4342, any provider.

Full mouth debridement (procedure code D4355) will be denied when submitted for the same date of service as the following procedure codes by any provider:

Periodontal medicaments (procedure code D4381) must be applied to all affected teeth at the same visit to be effective, and are limited to one service per client, same TID, per rolling year for clients who are 13 years of age or older.

Periodontal maintenance (procedure code D4910) may be reimbursed only if one of the following occurs:

•​A periodontal surgery or nonsurgical periodontal service (procedure code (D4240, D4241, D4260, or D4261) is billed for the same client by any provider.

•​There is documented evidence of periodontal therapy while the client was not CSHCN Services Program eligible in the client’s dental record within 90 days before the periodontal maintenance.

Periodontal maintenance may be reimbursed no more than 3 times within this 90-day period for the same client, by any provider.

The periodontic procedure codes in the following table that are limited to clients who are 13 years of age or older may also be considered for younger clients based on the medical condition with supporting documentation of medical necessity.

​Refer to: Section 14.2.6.1, “Prior Authorization Requirements” in this chapter.

14.2.6.7​* Prosthodontics (Removable) and Maxillofacial Prosthetics

Local anesthesia is denied as part of removable prosthodontics procedures.

Denture reline procedures are allowed if the reline makes the denture serviceable. Denture reline and rebase procedures are denied if billed within 1 rolling year of a complete or partial denture.

•​Maxillary reline and rebase procedure codes D5710, D5720, D5730, D5740, D5750, and D5760 are denied as part of complete or partial maxillary denture procedures D5110, D5130, D5211, and D5213.

•​Mandibular reline and rebase procedure codes D5711, D5721, D5731, D5741, D5751, and D5761 are denied as part of complete or partial mandibular denture procedures D5120, D5140, D5212, and D5214.

Repairs to partial maxillary dentures (procedure code D5670) are denied as part of maxillary procedure codes D5211, D5213, and D5640.

Repairs to partial mandibular dentures (procedure code D5671) are denied as part of mandibular procedure codes D5212, D5214, and D5640.

The cost of repairs cannot exceed replacement costs.

Procedure codes D5867 and D5875 are denied as part of any repair or modification of any removable prosthetic.

Use the following procedure codes for prosthodontic (removable) services:

​Refer to: Section 14.2.6.1, “Prior Authorization Requirements” in this chapter.

14.2.6.7.1​Maxillofacial Prosthetics

Use the following procedure codes for maxillofacial prosthetic services:

  

 

​Refer to: Section 14.2.6.1, “Prior Authorization Requirements” in this chapter.

14.2.6.7.2​Fixed Prosthodontics

Prior authorization is required for fixed prosthodontics. Fixed prosthodontics are limited to CSHCN Services Program clients who are 16 years of age or older, as the client must be old enough to have mature teeth and minimal jaw growth remaining.

Required documentation for prior authorization includes, but is not limited to:

•​The CSHCN Services Program Prior Authorization Request for Dental or Orthodontia Services form.

•​Documentation of medical necessity for the requested procedure includes, but is not limited to:

•​Documentation supporting that the mouth is free of disease; no untreated periodontal, endodontic disease, or rampant caries.

•​Documentation supporting only one virgin abutment tooth; at least one tooth must require a crown, except when a Maryland bridge is placed.

•​Tooth Identification (TID) System noting only permanent teeth.

•​Documentation supporting that a removable partial is not a viable option to fill the space between the teeth.

•​Appropriate pretreatment radiographs of each involved tooth, such as periapical views must be maintained in the client’s medical record and submitted to the CSHCN Services Program on request. Panoramic films are inadequate to detect caries or tooth structure necessary to evaluate the request.

Prior authorization will not be given when:

•​Films show two good abutment teeth, except when a Maryland bridge will be replaced.

•​There is untreated periodontal or the presence of endodontic disease, or rampant caries which would contraindicate the treatment.

​Refer to: Section 14.2.6.1, “Prior Authorization Requirements” in this chapter.

The following fixed prosthetics (pontics, retainers, and abutments), may be reimbursed with a maximum fee and include any preparatory work before placement of the fixed prosthetic.

  

    

Each abutment and each pontic constitutes a unit in a fixed partial-denture bridge (bridgework).

The following procedure codes are considered part of any other service and are not reimbursed separately:

Use the following procedure codes for fixed prosthodontics services. These codes require prior authorization:

14.2.6.8​* Oral and Maxillofacial Surgery

Prior authorization is required for most oral and maxillofacial surgery, including, but not limited to, invasive procedures for clients with cleft lip, cleft palate, or craniofacial anomalies, which must be performed by a cleft and craniofacial team or a coordinated multidisciplinary team.

All oral surgery procedures include local anesthesia and visits for routine postoperative care.

Use the following table for oral and maxillofacial surgery procedure codes and prior authorization requirements.

 

​Refer to: Section 14.2.6.1, “Prior Authorization Requirements” in this chapter.

14.2.6.9​Adjunctive General Services

Refer to individual procedure codes in the following table for prior authorization requirements:

​Note:For those procedures requiring prior authorization, the prior authorization is valid up to 90 days from the date it is issued.

​Refer to: Section 14.2.6.1, “Prior Authorization Requirements” in this chapter for more information about prior authorization requirements.

Section 4.4, “Prior Authorizations” in Chapter 4, “Prior Authorizations and Authorizations” for detailed information about prior authorization requirements.

14.2.6.9.1​Emergency Dental Treatment Services

Procedure code D9110 is an emergency service only. The type of treatment rendered and tooth identification must be indicated. It must be for a service other than a prescription or topical medication. The reason for the emergency and a narrative of the procedure actually performed must be documented and the appropriate block for emergency must be checked on the claim form.

Procedure code D9110 is a benefit for the following:

•​Sedative or periodontal dressing

•​Starting root canal procedure; (i.e.:, open and drain tooth or re-medication of previously opened tooth)

•​Smoothing fractured tooth that is cutting lips or cheek

•​Debridement or curettage of wound

•​Excision of operculum over an erupting tooth

•​Limited gingivectomy

•​Suture removal by dentist other than the dentist who placed suture(s)

•​Placement of a temporary crown by other than the patient’s regular dentist and one who is not in the process, has not previously, or does not in the future intend to perform an acrylic, polycarbonate, stainless steel or cast crown on this same tooth

•​Tissue conditioning of a full or partial denture

•​Removal of spontaneously or post-surgically sequested bone spicule

•​Spot or limited scaling and root planing

•​Procedures necessary to treat a dry socket

•​Procedures necessary to control bleeding

•​Non-surgical reduction of TMJ dislocation

•​Procedures necessary to relieve pain associated with pericoronitis, particularly third molars

Procedure code D9110 is not a benefit for the following:

•​Prescription written

•​Medication given or administered

•​Application of topical medication to teeth or gums

•​Occlusal adjustments

•​Oral hygiene instructions

14.2.6.10​Dental Anesthesia

All dental providers must comply with the American Academy of Pediatric Dentistry (AAPD) guidelines and TSBDE rules and regulations, including the standards for documentation and record maintenance for dental anesthesia.

Providers must have a level 4 permit and an anesthesiology residency recognized by the American Dental Board of Anesthesiology to receive an enhanced rate for procedure codes D9222 and D9223.

All levels of sedation must have clinical documentation and a narrative in the client’s dental record to support medical necessity of the service. The client’s dental record must be available for review by representatives of HHSC or it’s designee.

14.2.6.10.1​Anesthesia Permit Levels

The following table shows the levels of anesthesia permits that are issued by the TSBDE:

Providers will be reimbursed only for those procedure codes that are covered by their anesthesia permit level. The following procedure codes may be used to bill dental anesthesia and indicates the minimum anesthesia permit level to be reimbursed for these procedure codes:

Dental anesthesia is not age-restricted.

Local anesthesia in conjunction with operative or surgical services (procedure code D9215) is all inclusive with any other dental service and is not reimbursed separately.

Procedure codes D9239 is limited to 15 minutes (1 unit) per day. Procedure code D9243 is limited to 1 hour and 15 minutes per day (5 units).

Reimbursement of procedure code D9248 is limited to one service per client per day. Procedure code D9248 is limited to two times per year, per client.

If more than two nonintravenous (IV) conscious sedation services are required by any provider in a 12 month period, prior authorization is required.

Any dentist providing nonintravenous (IV) conscious sedation must comply with all TSBDE Rules and American Academy of Pediatric Dentistry (AAPD) Guidelines, including maintaining a current permit to provide non-IV conscious sedation. Claims must include a provider statement indicating that the procedure was provided in full compliance with these guidelines. Documentation supporting medical necessity and appropriateness for the use of non-IV conscious sedation must be maintained in the client’s records and is subject to retrospective review.

Supporting documentation includes, but is not limited to the following:

•​Narrative addressing the reason non-IV conscious sedation was necessary

•​Medications used to provide the non-IV conscious sedation

•​The duration of the non-IV conscious sedation, including the start and end times

•​Monitored statistics, such as vital signs and oxygen saturation levels

•​Any resuscitative measures that may have been necessary

The following procedure codes are denied when billed on the same day as procedure code D9248:

​Refer to: Section 14.2.7.3, “Dental General Anesthesia Provided in the Inpatient or Outpatient Setting (Medically Necessary Dental Rehabilitation or Restoration Services)” in this chapter.

14.2.6.10.2​Method for Counting Minutes for Timed Procedure Codes

All claims for reimbursement of procedure codes paid in 15-minute increments are based on the actual amount of billable time associated with the service. For those services for which the unit of service is 15 minutes (1 unit = 15 minutes), partial units should be rounded up or down to the nearest quarter hour.

Time intervals for 1 through 12 units are as follows:

All levels of sedation must have clinical documentation and a narrative in the client’s dental record to support the necessity of the service. Documentation must include the sedation record that indicates sedation start and end times in accordance with the American Academy of Pediatric Dentistry (AAPD) guidelines. The client’s dental record must be available for review by representatives of HHSC or its designee.

14.2.6.11​Dental Behavior Management

Procedure code D9920 is considered for prior authorization in addition to therapeutic procedures when provided in the office and when the client has a diagnosis of an intellectual disability described as mild, moderate, severe, profound, or unspecified.

Documentation supporting the medical necessity and appropriateness of dental behavior management must be retained in the client’s chart and is subject to retrospective review.

Supporting documentation includes, but is not limited to, the following:

•​A current physician statement addressing the intellectual disability, signed and dated within 1 year before the dental behavior management

•​The client’s diagnosis of intellectual disability

•​A description of the service performed, including the specific problem and the behavior management technique applied

•​Personnel and supplies required to provide the behavioral management

•​The duration of the behavior management, including the start and end times

Dental behavior management is not reimbursed with an evaluation, prophylactic treatment, or radiographic procedure.

Except for those procedures requiring prior authorization, admission to an outpatient or freestanding ambulatory surgical center (ASC) for the purpose of performing dentistry services must be authorized.

​Refer to: Section 24.5.1, “Benefits, Limitations, and Authorization Requirements” in Chapter 24, “Hospital” for more information about prior authorization in an ASC.

14.2.6.12​Internal Bleaching of Discolored Tooth

Internal bleaching of a discolored tooth is an accepted endodontic treatment for clients who are 13 years of age or older. It is intended to remove and change the organic material in the enamel of an infected or traumatized tooth. It is considered medically necessary when chemical change of the contents in the interior of the tooth is judged necessary to complete an endodontic treatment to the tooth for therapeutic, not cosmetic purposes. Prior authorization is not required. Procedure code D9974 may be considered for reimbursement when the claim is filed with documentation supporting medical necessity. Claims that are filed without documentation supporting medical necessity are denied as incomplete.

14.2.6.13​Noncovered Services

The following therapeutic services are not benefits of the CSHCN Services Program.

 

14.2.7​Dental Treatment in Hospitals and ASCs

Dental rehabilitation and restoration services requiring general anesthesia may be performed in the inpatient or outpatient setting.

14.2.7.1​Dental Hospital Calls

Dental hospital calls may be reimbursed for clients of any age that require medically necessary general anesthesia or dental treatment in the inpatient or outpatient hospital setting. Providers may bill procedure code D9420 in addition to the dental services performed in the inpatient or outpatient setting. Documentation supporting the medical necessity of the dental hospital call must be retained in the client’s dental record and is subject to retrospective review. Procedure code D9420 is limited to twice per rolling year, per client, any provider. Additional services may be considered with prior authorization and documentation of medical necessity.

​Refer to: Chapter 24, “Hospital” for more information about requirements for inpatient and outpatient services.

14.2.7.2​Authorization and Prior Authorization Requirements

All inpatient hospital admissions for dental services require prior authorization. Except for those specific procedures that require prior authorization, admission to freestanding ASCs or outpatient hospital ambulatory surgical centers (HASCs) for the purpose of performing dentistry services require authorization.

The CSHCN Services Program Criteria for Dental Therapy Under General Anesthesia must be submitted to the TMHP-CSHCN Services Program with supporting documentation of medical necessity.

​Refer to: Chapter 4, “Prior Authorizations and Authorizations” for additional information.

Chapter 24, “Hospital.”

​Refer to: CSHCN Services Program Prior Authorization Request for Inpatient Hospital Admission—For Use by Facilities Only form 

​Refer to: CSHCN Services Program Prior Authorization Request for Inpatient Surgery—For Surgeons Only form.

14.2.7.3​Dental General Anesthesia Provided in the Inpatient or Outpatient Setting (Medically Necessary Dental Rehabilitation or Restoration Services)

Dental rehabilitation or restoration services requiring general anesthesia may be performed in the inpatient or outpatient setting.

CSHCN Services Program dental services should be billed using the following Current Procedural Terminology (CPT) procedure codes and modifier where appropriate:

•​Anesthesia services for general dental anesthesia, procedure code 00170 with modifier U3

•​ASC or HASC dental rehabilitation or restoration, procedure code 41899 with modifier U3

•​Physical examinations before dental restorations under anesthesia, procedure codes 99202, 99222, and 99282

•​Restorations under anesthesia, procedure codes 99222 and 99282

Supporting documentation must be retained in the client’s chart and must reflect compliance with the CSHCN Services Program Criteria for Dental Therapy Under General Anesthesia and the CSHCN Services Program Policy About the Criteria for Dental Therapy Under General Anesthesia, Attachment 1. Dental general anesthesia may be reimbursed once every 6 months per client any provider.

All supporting documentation must be maintained in the client’s medical record. The client’s record must be available for review by representatives of the CSHCN Services Program, the Department of State Health Services (DSHS), the CSHCN Services Program claims contractor, and HHSC. The dental provider is required to maintain the following documentation in the client’s dental record:

•​The medical evaluation justifying the need for anesthesia

•​Description of relevant behavior and reference scale

•​Other relevant narrative justifying the need for general anesthesia

•​Client’s demographics, including date of birth

•​Relevant dental and medical history

•​Dental radiographs, intraora or perioral photography, or diagram of dental pathology

•​Proposed dental plan of care

•​Consent signed by parent or guardian giving permission for the proposed dental treatment and acknowledging that the reason for the use of IV sedation or general anesthesia for dental care has been explained

•​Completed CSHCN Services Program Criteria for Dental Therapy Under General Anesthesia form 

•​The parent or guardian dated signature on the Criteria for Dental Therapy Under General Anesthesia form attesting that the parent or guardian understands and agrees with the dentist’s assessment of their child’s behavior

•​Dentist’s attestation statement and signature, which is put on the bottom of the CSHCN Services Program Criteria for Dental Therapy Under General Anesthesia form or included in the client’s dental record as a separate form

Hospital and outpatient facility admissions are subject to medical necessity review.

14.2.8​Doctor of Dentistry Services as a Limited Physician

The CSHCN Services Program covers services provided by a DDS or DMD if the services are a benefit and furnished within the dentist’s scope of practice as defined by Texas state law. To participate in the CSHCN Services Program as a dentist practicing as a limited physician, a dentist (DDS or DMD) must be enrolled separately as a dentist practicing as a limited physician.

The CSHCN Services Program recognizes the standards of care needed to appropriately address the repair of cleft and craniofacial anomalies as outlined in the guidelines prepared by the American Cleft Palate - Craniofacial Association (acpacares.org).

A comprehensive, multidisciplinary approach is medically necessary to meet all of the needs of clients with complex medical conditions who require treatment by a broad range of medical specialists. Standard of care for the comprehensive repair or reconstruction of craniofacial anomalies for CSHCN Services Program clients requires a team approach either by a C/C team or by an equivalent coordinated multidisciplinary team. The following exceptions may be considered to this requirement:

•​A C/C or equivalent multidisciplinary team is not available in the area and the client is unable to travel. (Medical record documentation must explain the reasons the client is unable to travel.)

•​A C/C or equivalent multidisciplinary team is not available in the area, or the team approach cannot be coordinated over multiple locations. (Medical record documentation must describe attempts to coordinate a team approach.)

•​A C/C or equivalent multidisciplinary team is available but the client or the client’s parent/ guardian refuses to receive care from the team. (Medical record documentation must explain the reason for the refusal of the care offered by the team.)

​Refer to: Section 31.2.39.11, “Cleft/Craniofacial Procedures” in Chapter 31, “Physician” for more detailed information.

If a client has third-party insurance coverage available that requires reconstructive facial surgery involving the bony skeleton of the face (including midface osteotomies and cleft lip and palate repairs performed by a physician), the CSHCN Services Program cannot consider a claim for payment unless all third-party payer requirements are met.

14.2.8.1​Authorization Requirements

The following procedure codes require prior authorization and may be considered with medical review of documentation of medical necessity. These procedures may be considered cosmetic and are not a benefit except when the procedure is performed as a result of trauma or injury to reconstruct tissues or body structures, or to repair damaged tissues.

Documentation of medical necessity indication that the procedure was performed due to trauma or injury must be submitted with the authorization request.

Unless otherwise noted in the following tables, all other procedure codes in this section do not require authorization or prior authorization.

14.2.8.2​Surgery

The following surgery CPT procedure codes are payable to a dentist enrolled in the CSHCN Services Program as a dentist physician:

14.2.8.3​Cleft/Craniofacial Surgery by a Dentist Physician

The following additional codes may be reimbursed to a provider enrolled as a cleft/craniofacial surgeon. Prior authorization is required.

Septoplasty (procedure code 30520) for nonrelated repair or reconstruction of cleft lip, cleft palate, or craniofacial anomalies may be prior authorized with documentation to support medical necessity.

14.2.8.4​Evaluation and Management or Consultation

The following evaluation and management or consultation service procedure codes are payable to a dentist physician:

Evaluation and management codes for home services are not reimbursed to dentists or dentistry groups.

14.2.8.5​Radiology and Laboratory Procedures

The following diagnostic radiology and laboratory procedure codes are payable to a dentist physician:

​Refer to: The CMS website at www.cms.gov/CLIA/10 Categorization of Tests.asp for information about procedure codes and modifier QW requirements. The CSHCN Services Program follows the Medicare categorization of tests for CLIA certificate-holders.

14.2.8.6​Other Procedures Payable to a Dentist Physician

The following additional CPT procedure codes are payable to a dentist enrolled in the CSHCN Services Program as a dentist physician:

Providers must use procedure code T1013 with modifier U1 for the first hour of service, and modifier UA for each additional 15 minutes of service.

Procedure code T1013 billed with modifier U1 is limited to once per day, per provider; procedure code T1013 billed with modifier UA is limited to a quantity of 28 per day.

Procedure codes 90284, J1459, J1561, J1568, J1569, and J1572 will be denied if billed with the same date of service by any provider as the following procedure codes (unless otherwise indicated):

14.2.8.7​Anesthesia by Dentist Physician

In addition to the procedure codes discussed under “Benefits and Limitations” in this chapter, the following anesthesia CPT procedure codes are payable to a dentist physician:

14.3​Claims Information

Dental services must be submitted to TMHP in an approved electronic format or on a paper ADA Dental Claim Form. Providers can obtain copies of this form by contacting the ADA at 1-800-947-4746 or ordering online from the ADA website at www.ada.org. TMHP does not supply the forms. Any paper dental claim submitted using any other version of the dental claim form is not processed and is returned to the submitter.

When completing a paper ADA Dental Claim Form, all required information must be included on the claim, as information is not keyed from attachments. Superbills, or itemized statements, are not accepted as claim supplements.

Providers billing electronically must submit dental claims in American National Standards Institute (ANSI) ASC X12 837D format. Specifications are available to providers developing in-house systems, software developers, and vendors. Because each software package is different, field locations may vary. Providers should contact the software developer or vendor for information about their software. Providers or software vendors may direct questions about development requirements to the TMHP EDI Help Desk at 1-888-863-3638.

Claims must contain the billing provider’s full name, address, and NPI. The billing provider’s full name and address must be entered in Block 48 of the paper ADA Dental Claim Form, and the ten-digit NPI must be entered in Block 49. A claim without a provider name, address, and NPI cannot be processed.

The Healthcare Common Procedure Coding System (HCPCS)/CPT codes included in policy are subject to National Correct Coding Initiative (NCCI) relationships. Exceptions to NCCI code relationships that may be noted in CSHCN Services Program medical policy are no longer valid. Providers should refer to the Centers for Medicare & Medicaid Services (CMS) NCCI web page at www.cms.gov/medicare/coding/ncci-coding-edits or correct coding guidelines and specific applicable code combinations. In instances when CSHCN Services Program medical policy quantity limitations are more restrictive than NCCI Medically Unlikely Edits (MUE) guidance, medical policy prevails.

​Refer to: Chapter 41, “TMHP Electronic Data Interchange (EDI)” for information on electronic claims submissions.

Chapter 5, “Claims Filing, Third-Party Resources, and Reimbursement” for general information about claims filing.

Section 5.7.2.13, “Instructions for Completing the Paper ADA Dental Claim Form” in Chapter 5, “Claims Filing, Third-Party Resources, and Reimbursement” for instructions on completing paper claims. Blocks that are not referenced are not required for processing and may be left blank.

14.3.1​Dental Emergency Claims

The Emergency Indicator field has been removed from the HIPAA-approved 837D electronic transaction. Dental providers submitting electronic claims in the 837D format must use modifier ET to report emergency services. Modifier ET must be placed in the SVC01 section of the 837D format.

Additionally, the Comments field should be used to document the specific nature of the emergency. The Comments field in the HIPAA-approved 837D electronic transaction is 80 bytes long.

To indicate a dental emergency on a paper claim submission (ADA Dental Claim Form), check Block 45, Treatment Resulting From (check the applicable box), and check the Other Accident box for emergency claim reimbursement. If the Other Accident box is checked, information about the emergency must be provided in Block 35, Remarks.

Only one emergency or trauma claim per client, per day may be submitted. Separate services (one for emergency or trauma and one for nonemergency or routine) may be submitted for the same client on the same day, any provider, for separate services and procedure codes.

14.3.2​Tooth Identification (TID) and Surface Identification (SID) Systems

Claims are denied if the procedure code is not compatible with TID or SID. Use the alpha characters to describe tooth surfaces or any combination of surfaces. Anterior teeth have facial and incisal surfaces only. Posterior teeth have buccal and occlusal surfaces only.

14.3.3​Supernumerary Tooth Identification

Each identified permanent tooth and each identified primary tooth has its own identifiable supernumerary number. This developed system can be found in the CDT published by the ADA.

The TID for each identified supernumerary tooth is used for paper and electronic claims and can only be billed with the following codes:

•​For primary teeth only: D7111

•​For both primary and permanent teeth the following codes are billable: D7140, D7210, D7220, D7230, D7240, D7241, D7250, D7285, D7286, and D7510

  

    

   

14.4​Reimbursement

Dental services may be reimbursed the lower of the billed amount or the amount allowed by Texas Medicaid.

For fee information, providers can refer to the Online Fee Lookup (OFL) on the TMHP website at www.tmhp.com.

The CSHCN Services Program implemented rate reductions for certain services. The OFL includes a column titled “Adjusted Fee” to display the individual fees with all percentage reductions applied. Additional information about rate changes is available on the TMHP website at www.tmhp.com/resources/rate-and-code-updates/rate-changes.

​Note:Certain rate reductions including, but not limited to, reductions by place of service, client type program, or provider specialty may not be reflected in the Adjusted Fee column.

14.5​TMHP-CSHCN Services Program Contact Center

The TMHP-CSHCN Services Program Contact Center at 1-800-568-2413 is available Monday through Friday from 7 a.m. to 7 p.m., Central Time, and is the main point of contact for the CSHCN Services Program provider community.