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Chapter
7
Dental
7.1 Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-2
7.2 Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-2
7.3 Benefits and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-2
7.3.1 Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-2
7.3.2 Dental Orthodontics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-3
7.3.3 Coverage/Policy Clarifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-7
7.3.4 Dental Sealants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-10
7.4 Summary of Authorization Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-10
7.4.1 Prior Authorization Required. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-10
7.4.1.1 Diagnostic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-10
7.4.1.2 Restorative Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-10
7.4.1.3 Endodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-10
7.4.1.4 Periodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-11
7.4.1.5 Prosthodontic (Removable) Procedures . . . . . . . . . . . . . . . . . . . . . . . . . 7-11
7.4.1.6 Maxillofacial Prosthodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . 7-11
7.4.1.7 Implant Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-12
7.4.1.8 Prosthodontic (Fixed) Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-12
7.4.1.9 Oral and Maxillofacial Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-13
7.4.1.10 Orthodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-13
7.4.1.11 Adjunctive General Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-13
7.4.2 Prior Authorization Not Required. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-14
7.4.2.1 Diagnostic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-14
7.4.2.2 Preventive Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-14
7.4.2.3 Restorative Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-15
7.4.2.4 Endodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-16
7.4.2.5 Periodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-16
7.4.2.6 Prosthodontic (Removable) Procedures . . . . . . . . . . . . . . . . . . . . . . . . . 7-16
7.4.2.7 Oral and Maxillofacial Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-17
7.4.2.8 Orthodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-17
7.4.2.9 Adjunctive General Services Procedures . . . . . . . . . . . . . . . . . . . . . . . . 7-17
7.5 Dental Treatment in Hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-17
7.5.1 Dental Hospital Call . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-17
7.5.2 Dental Surgeries Performed in ASC/HASC . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-17
7.6 Doctor of Dentistry Services as a Limited Physician . . . . . . . . . . . . . . . . . . . . . . . . . 7-18
7.6.1 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-18
7.6.2 Cleft/Craniofacial Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-19
7.6.3 Evaluation and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-19
7.6.4 X-ray (CPT) Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-19
7.6.5 Anesthesia by Dentist Physician. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-19
7.7 Claims Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-19
7.7.1 Dental Claim Electronic Billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-20
7.7.2 Dental Claim Paper Billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-20
7.7.3 Dental Emergency Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-20
7.7.4 Dental Claim Form Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-20
7
Chapter 7
7.1 Enrollment
To enroll in the CSHCN Program, dental providers must be actively enrolled in the Texas Medicaid
Program, have a valid Provider Agreement with CSHCN, have completed the CSHCN enrollment process,
and comply with all applicable state laws and requirements.
7.2 Reimbursement
Reimbursement for dental services is the lower of the billed amount or the amount allowed by the Texas
Medicaid Program. All participating CSHCN dental providers are required to submit the American Dental
Association (ADA) Dental Claim Form for paper claim submissions to the CSHCN Program. Obtain these
forms by contacting the ADA at 1-800-947-4746.
Refer to: The "2002 ADA Claim Form Example" on page C-18.
7.3 Benefits and Limitations
CSHCN provides coverage for dental services to program eligible clients. Coverage of dental services
is limited to what is necessary to prevent, treat, or correct dental and oral complications. Additional
specific information regarding benefits and limitations for orthodontia, dental orthodontics, dental
policy clarifications, and dental sealants follows.
Specific procedure or diagnosis codes related to program benefits and coverage may be listed in this
chapter. These listings are intended to provide helpful information, but should not be considered
all-inclusive. From time to time, codes are added, deleted, or revised. Coverage and coding information
is updated in the CSHCN Provider Bulletin. Call the TMHP-CSHCN Contact Center at 1-800-568-2413
with questions regarding covered procedure or diagnosis codes.
7.3.1 Anesthesia
Each dentist licensed by the Texas State Board of Dental Examiners (TSBDE) practicing in Texas who
has obtained a permit from the TSBDE to administer anesthesia in accordance with the rules of the
TSBDE, and who is enrolled as a CSHCN provider, may be reimbursed for anesthesia services provided
to CSHCN clients having dental/oral and maxillofacial surgical procedures. These services must be
performed in the dental office (POS 1), free standing or hospital-based surgical center (POS 3), or
hospital (POS 3 or 5) in accordance with all applicable rules for administration and supervision of
anesthesia services.
CDT anesthesia codes D9220, D9221, D9230, D9241, and D9248 are covered benefits. Local code
D924X, Intravenous sedation, is no longer a benefit, use D9241, IV sedation, instead.
Except for D9221, only one anesthesia procedure may be reimbursed per day for the same client.
D9248, Non-IV conscious sedation, is a benefit when provided in the office setting. Any dentist
providing non-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. Documentation supporting medical necessity and appropriateness for the use of non-IV
conscious sedation must be maintained in the client’s record and is subject to retrospective review.
Reimbursement for non-IV conscious sedation is limited to:
• Clients aged 1 through 20 years.
• One non-IV conscious sedation service per client per day.
• Two non-IV conscious sedation services per 12 months per client without prior authorization.
A provider must obtain prior authorization to perform more than two non-IV conscious sedation services
for the same client in a 12-month period.
7–2
Dental
7.3.2 Dental Orthodontics
Orthodontic procedures require prior authorization and may be reimbursed for the following diagnoses:
Diagnosis Code
Description
52400–52409
Major anomalies of jaw size
52410–52419
Anomalies of relationship of jaw to cranial base
5245
Dentofacial functional abnormalities
74900–74925
Cleft palate and cleft lip
7540
Certain congenital musculoskeletal deformities of skull, face, and jaw
75555
Acrocephalosyndactyly
7560
Anomalies of skull and face bones
All removable or fixed orthodontic appliances must be billed with CDT-4 procedure code D8210 for
removable appliance, or D8220 for fixed appliance. To ensure appropriate claims processing, the local
procedure code reflecting the specific service is also required. For paper claim submissions, enter the
local procedure code in the remarks section of the claim form.
For electronic submissions other than TDHconnect 3.0 software submissions, follow the steps below
to ensure TMHP accurately applies the correct local procedure code 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.
7
2) Submit the remark code (local procedure 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
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 TDHconnect 3.0 software, 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.
TDHconnect 3.0 submitters are not required to manually enter the DPC prefix, as it is automatically
placed in the appropriate field on the TDHconnect 3.0 electronic claim.
Failure to follow the above steps does not cause the claim to deny; however, manual intervention is
required to process the claim, and may result in a delay of payment. For answers to questions about
how to implement these processes, contact TMHP-CSHCN at 1-800-568-2413 and select Option 2 to
speak with a TMHP representative.
Local code D924X, Intravenous sedation, is no longer a benefit. Providers should use D9241, Intravenous sedation. All other orthodontic procedure codes that were local procedure codes used for prior
authorization and reimbursement have been converted to CDT-4 (national) procedure codes.
The following procedures are not included in comprehensive treatment:
CDT Code
Description
Remarks Code
Description
D8660
Preorthodontic tx visit
Z2008
Initial orthodontic visit
D8670
Periodic orthodontc tx visit
Z2013
Orthodontic adjustments, per month
*D7997
Appliance removal
Z2016
Premature appliance removal, per arch
*May only be paid to a provider not billing for comprehensive treatment.
7–3
Chapter 7
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. Use the following procedure
codes:
CDT Code
Description
Remarks Code
Description
D8080
Compre dental tx adolescent
Z2009
or
Z2011
or
Z2012
Diagnostic workup, approved
or
Orthodontic appliance, upper (braces)
or
Orthodontic appliance, lower (braces)
When a diagnostic workup is not approved, individual components may be considered for separate
reimbursement. Use the following procedure codes:
CDT Code
Description
Remarks Code
Description
D0330
Dental panoramic film
Z2010
Diagnostic workup, not approved
D0340
Dental cephalometric film
Z2010
Diagnostic workup, not approved
D0350
Oral/facial images
Z2010
Diagnostic workup, not approved
D0470
Diagnostic casts
Z2010
Diagnostic workup, not approved
Local code 1009D, Brackets, was replaced with CDT code D8690, Orthodontic treatment.
Procedure code D8680 includes all retainers necessary to treat the client. Use the following remarks
codes according to the service(s) provided:
CDT Code
Description
Remarks Code
Description
D8680
Orthodontic retention
1033D
Mandibular, fixed, 2x4 retainer
D8680
Orthodontic retention
1034D
Mandibular, fixed, 3x3 retainer
D8680
Orthodontic retention
1035D
Mandibular, fixed, 4x4 retainer
D8680
Orthodontic retention
Z2014
Orthodontic retainer, upper
D8680
Orthodontic retention
Z2015
Orthodontic retainer, lower
Procedure code D8050 includes a crossbite workup and removable appliance:
CDT Code
Description
Remarks Code
Description
D8050
Intercep dental tx primary
8110D
Crossbite therapy, removable
appliance
D8050
Intercep dental tx primary
Z2018
Crossbite, workup
Procedure code D8060 includes a crossbite workup and the fixed appliance:
CDT Code
Description
Remarks Code
Description
D8060
Intercep dental tx transitn
8120D
Crossbite therapy, fixed appliance
D8060
Intercep dental tx transitn
Z2018
Crossbite, workup
The following tables display the special fixed and removable orthodontic appliances. Under the current
provisions of 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
2002 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 code(s) may result in
claim processing delays.
Note: Prior authorization must be requested using both the CDT procedure code(s) and the remarks
code(s).
7–4
Dental
Use the following local codes in the Remarks field for fixed designs (CDT code D8220):
Local Code for the
Remarks Field
Fixed Designs Description
1000D
Appliance for horizontal projections
1001D
Appliance for recurved springs
1002D
Arch wires for crossbite correction, for total treatment
1003D
Banded maxillary expansion appliance
1008D
Bonded expansion device
1012D
Crib
1015D
Distalizing appliance with springs
1016D
Expansion device
1018D
Fixed expansion device
1019D
Fixed lingual arch
1020D
Fixed mandibular holding arch
1021D
Fixed rapid palatal expander
1025D
Herbst appliance, fixed or removable
1026D
Interocclusal cast cap surgical splints
1028D
Jasper jumpers
1029D
Lingual appliance with hooks
1030D
Mandibular anterior bridge
1031D
Mandibular bihelix, similar to a quad helix for mandibular expansion to attempt
nonextraction treatment
1036D
Mandibular lingual, 6x6, arch wire
1042D
Maxillary lingual arch with spurs
1043D
Maxillary and mandibular distalizing appliance
1044D
Maxillary quad helix with finger springs
1045D
Maxillary and mandibular retainer with pontics
1049D
Modified quad helix appliance
1050D
Modified quad helix appliance, with appliance
1051D
Nance stent
1052D
Nasal stent
1057D
Palatal bar
1059D
Quad helix appliance held with transpalatal arch horizontal projections
1060D
Quad helix maintainer
1061D
Rapid palatal expander (RPE), i.e., quad helix, haas, or menne
1068D
Stapled palatal expansion appliance
1072D
Thumb sucking appliance, requires submission of models
1076D
Transpalatal arch
1077D
Two bands with transpalatal arch and horizontal projections forward
1078D
W-appliance
7
7–5
Chapter 7
Use the following local codes in the Remarks field for removable designs (CDT code D8210):
7–6
Local Code for the
Remarks Field
Fixed Designs Description
1004D
Bite plate/bite plane
1005D
Bionator
1006D
Bite block
1007D
Bite plate with push springs
1010D
Chateau appliance (face mask, palatal expander, and hawley)
1011D
Coffin spring appliance
1013D
Dental obturator, definitive (obturator)
1014D
Dental obturator, surgical (obturator, surgical stayplate, immediate temporary
obturator)
1017D
Face mask (protraction mask)
1022D
Frankel appliance
1023D
Functional appliance for reduction of anterior open bite and crossbite
1024D
Head gear (face bow)
1027D
Intrusion arch
1032D
Mandibular lip bumper
1037D
Mandibular removable expander with bite plane (crozat)
1038D
Mandibular ricketts rest position splint
1039D
Mandibular splint
1040D
Maxillary anterior bridge
1041D
Maxillary bite-opening appliance with anterior springs
1046D
Maxillary Schwarz
1047D
Maxillary splint
1048D
Mobile intraoral arch (MIA), similar to a bihelix for nonextraction treatment
1053D
Occlusal orthotic device
1054D
Orthopedic appliance
1055D
Other mandibular utilities
1056D
Other maxillary utilities
1062D
Removable bite plane
1063D
Removable mandibular retainer
1064D
Removable maxillary retainer
1065D
Removable prosthesis
1066D
Sagittal appliance, 2-way
1067D
Sagittal appliance, 3-way
1069D
Surgical arch wires
1070D
Surgical splints (surgical stent/wafer)
1071D
Surgical stabilizing appliance
1073D
Tongue thrust appliance, requires submission of models
Dental
Local Code for the
Remarks Field
Fixed Designs Description
1074D
Tooth positioner, full maxillary and mandibular
1075D
Tooth positioner with arch
7.3.3 Coverage/Policy Clarifications
The following information provides procedure and diagnosis code clarification for CSHCN dental and
orthodontia policies. CSHCN policy requires the following:
• Reviewing claims for procedure codes when a dental provider submits an ADA procedure code under
the dental TPI and also bills the equivalent Current Procedural Terminology (CPT) procedure code
using the medical TPI:
Procedure Codes
21025–21026
21127
21485
D5958–D5959
D7550
21029–21032
21188
41800
D6040
D7820
21034
21215
41805–41806
D6050
D7880
21040–21041
21230
41822–41823
D7440–D7441
D7950
21044–21045
21240
41825–41827
D7461
D7955
21082–21083
21242–21246
41830
D7465
D7999
21085
21255
41950
D7480
21110
21270
70332
D7510
21116
21295–21296
D0320
D7530
21123
21480
D5954–D5955
D7540
7
• Reviewing duplicate dental services that are submitted on different claims (same procedure, tooth
ID, surface ID, place of service, date of service, and same provider TPI) for the following procedure
codes:
Procedure Codes
1009D
D0260
D4240
D4341
D7320
D0230
D4210
D4260
D7310
D9221
• Denying follow-up visit procedure codes 99052, 99054, 99211 through 99215, 99281 through
99285, D4341, and D4355 if billed within 90 days of radiation treatment provided by the same
provider.
• Reviewing partials and/or relines within one year of original denture/reline; procedure codes D5211
through D5214, D5281, D5710 through D5711, D5720 through D5721, D5730 through D5731,
D5740 through D5741, D5750 through D5751, and D5760 through D5761.
• Limiting full mouth X-rays with exam and subsequent reline of dentures to once every three years;
procedure codes D0210, D0277, D5710 through D5711, D5720 through D5721, D5730 through
D5731, D5740 through D5741, D5750 through D5751, and D5760 through D5761.
• Reviewing all inpatient claims billed with one of the following oral surgery diagnoses:
Diagnosis Codes
520–52000
5211–52110
5224–52240
5238–52380
5249–52490
5201–52010
5212–52120
5225–52250
5239–52390
525–52500
5202–52020
5213–52130
5226–52260
524–52400
5251–52510
5203–52030
5214–52140
5227–52270
52401–52409
52511–52513
5204–52040
5215–52150
5228–52280
5241–52410
52519
5205–52050
5216–52160
5229–52290
52411–52419
5252–52520
7–7
Chapter 7
Diagnosis Codes
5206–52060
5217–52170
523–52300
5242–52420
5253–52530
5207–52070
5218–52180
5231–52310
5243–52430
5258–52580
5208–52080
5219–52190
5232–52320
5244–52440
5259–52590
5209–52090
522–52200
5233–52330
5245–52450
V5875
521–52100
5221–52210
5234–52340
5246–52460
V722–V7220
52101–52105
5222–52220
5235–52350
52461
52109–52109
5223–52230
5236–52360
5248–52480
• Reviewing for medical necessity visits/consults billed by a dentist for a diagnosis other than a dental
diagnosis as follows:
Diagnosis Codes
0542–05420
216–21600
5225–52250
6828–68290
78199
112–11200
2163–21630
5227–52270
709–70900
802–80310
140–14690
22801
5233–52330
71509–71509
8481–84810
149–14900
230–23000
524–52420
71518
8732–87390
1498–14980
232–23200
5245–52490
71528
8744–87450
1602–16020
2323–23230
52510–52511
71618
9062–90620
170–17010
235–23500
52519
7169–71690
920–92000
173–17300
238–23800
526–52690
7381–73819
935–93500
1733–17330
3501–35010
5272–52790
74441–74442
959–95900
195–19500
351–35100
5281–52870
749–75000
95909
210–21070
470–47000
529–52950
75029
9981–99810
212–21200
473–47300
5298–52980
756–75600
9985–99850
213–21310
478–47810
682–68200
781–78100
• Reviewing procedures billed with a noncovered dental restoration/rehabilitation diagnosis for clients
older than 21 years of age: diagnosis codes 521 through 52105, 52109, and 52512 through
52513.
• Reviewing procedures billed with a noncovered mental retardation diagnosis for clients from age 0
through 20 years: diagnosis codes 317 through 31900.
• Limiting the paid amount for restorations and stainless steel crowns on primary teeth to ensure that
the total amount paid does not exceed the payment allowed on each tooth for tooth IDs A through T
and 99:
Procedure Codes
D2110
D2330–2332
D2385–D2388
D2662–D2664
D2120–2330
D2335–2337
D2542
D2780–D2783
D2130–2131
D2380–D2382
D2650–D2652
D2930
D2932
• Limiting the paid amount for restorations and stainless steel crowns on anterior teeth to ensure that
the total amount paid does not exceed the payment allowed on each tooth for tooth IDs 06 through
11, 22 through 27, and 99:
Procedure Codes
7–8
D2140
D2330–D2332
D2380–D2382
D2650–D2652
D2150
D2335
D2385–D2388
D2662–D2664
D2160–D2161
D2337
D2542
D2931–D2932
Dental
• Limiting the paid amount for restorations and stainless steel crowns on permanent posterior teeth
to ensure that the total amount paid does not exceed the payment allowed on each tooth for tooth
IDs 1 through 5, 12 through 21, 28 through 32, and 99:
Procedure Codes
D2140
D2330–D2332
D2380–D2382
D2650–D2652
D2150
D2335
D2385–D2388
D2662–D2664
D2160–D2161
D2337
D2542
D2931–D2932
• Denying procedures billed more than once per year, per client by any provider: procedure codes
J9219, 88240 through 88241, 88271 through 88275, D1330, and D9951.
• Limiting the paid amount for X-rays per date of service, billed on the same claim by any provider to
ensure that the amount paid for X-rays per case does not exceed the payment for the all inclusive
X-ray procedure: procedure codes D0210, D0220, D0230, D0240, D0270, D0272, D0274, and
D0330.
• Reviewing procedures that are limited to once in a lifetime (dental exams/panorex codes for clients
from age 0 through 20 years): procedure code D0330.
• Limiting posterior crowns to four per lifetime, any type, any provider: procedure codes D2710,
D2722, D2740, D2750, D2752, and D2790 through D2792.
• Limiting anterior crowns to two per lifetime, any type, any provider: procedure code D2751.
• Reviewing sealants billed on a previously restored surface or on a tooth previously crowned or
extracted.
7
• The following CPT procedure codes are benefits of the CSHCN Program for physicians and dentists
when provided in the following payable places of service (POS):
Procedure Code
Description
POS
2–20520
Removal of foreign body
1, 3, 5
4–70380
X-ray exam of salivary gland
1, 5
I–70380
X-ray exam of salivary gland
1, 3, 5
T–70380
X-ray exam of salivary gland
1
5–88305
Tissue exam by pathologist
1, 3, 5, 6
I–88305
Tissue exam by pathologist
3, 5
T–88305
Tissue exam by pathologist
6
5–88331
Path consult intraop, 1 bloc
1, 3, 5, 6
I–88331
Path consult intraop, 1 bloc
3, 5
T–88331
Path consult intraop, 1 bloc
6
5–88332
Path consult intraop, add’l
1, 3, 5, 6
I–88332
Path consult intraop, add’l
3, 5
T–88332
Path consult intraop, add’l
6
• The following CPT procedure codes are payable to dental provider types 27 (Dentist D.D.S. and
D.M.D.) and 96 (Dentistry Group):
Procedure Code
Description
POS
4–76375
3D/holograph reconstr add-on
1, 5
I–76375
3D/holograph reconstr add-on
1, 3, 5
T–76375
3D/holograph reconstr add-on
1
7–9
Chapter 7
7.3.4 Dental Sealants
Dental sealants are a benefit for clients under the age of 21. Dental sealants may be applied to the
occlusal, buccal and lingual pits and fissures of any tooth (CDT code D1351, Dental sealant per tooth).
The tooth must be at risk for dental decay and be free of proximal caries and restorations on the surface
to be sealed.
Dental sealants are a benefit when applied to deciduous (baby or primary) teeth. Replacement sealants
are not reimbursed. Reimbursement is based on Medicaid pricing for procedure D1351. Tooth numbers
and surfaces must be indicated on the claim form.
When two or more sealants are applied within one quadrant and the dentist is reimbursed the maximum
quadrant fee, any other sealants applied within the same quadrant are not reimbursed during the six
months following the application of the original sealants. However, if a dentist seals a newly erupted
permanent molar in that quadrant during this six-month period, it may be paid the full single tooth
amount on appeal.
7.4 Summary of Authorization Requirements
Dental services listed in Section 7.4.1 require prior authorization. All orthodontia must also be prior
authorized as specified in preceding sections of this chapter. CSHCN does not require the submission
of X-rays, models, etc., for prior authorized services. All prior authorization requests must include
specific rationale for the requested service including documentation of medical necessity.
Reimbursement for appliance adjustments is limited to one per month, per client. Newborn appliances
and surgical archwires do not require authorization and may be adjusted more than once per month.
Note: Fax transmittal confirmations are not accepted as proof of timely authorization submission.
Refer to: Appendix C, "Request for Dental Authorization or Orthodontia Prior Authorization," on
page C-27, for an example of this form.
Tip: Photocopy this form and retain the original for future use.
7.4.1 Prior Authorization Required
The following procedure codes must be prior authorized:
7.4.1.1 Diagnostic Procedures
Procedure
Code
Description
D0999
Unspecified diagnostic proce
7.4.1.2 Restorative Procedures
Procedure
Code
Description
D2999
Dental unspec restorative pr
7.4.1.3 Endodontic Procedures
7–10
Procedure
Code
Description
Procedure
Code
Description
D3346
Retreat root canal anterior
D3460
Endodontic endosseous implan
D3347
Retreat root canal bicuspid
D3470
Intentional replantation
D3348
Retreat root canal molar
D3999
Endodontic procedure
Dental
7.4.1.4 Periodontic Procedures
Procedure
Code
Description
Procedure
Code
Description
D4245
Apically positioned flap
D4271
Free soft tissue graft proc
D4249
Crown lengthen hard tissue
D4273
Subepithelial tissue graft
D4266
Guided tiss regen resorble
D4274
Distal/proximal wedge proc
D4267
Guided tiss regen nonresorb
D4276
Con tissue w dble ped graft
D4270
Pedicle soft tissue graft pr
D4999
Unspecified periodontal proc
7.4.1.5 Prosthodontic (Removable) Procedures
Procedure
Code
Description
Procedure
Code
Description
D5110
Dentures complete maxillary
D5721
Dentures rebase part mandbl
D5120
Dentures complete mandible
D5810
Denture interm cmplt maxill
D5130
Dentures immediat maxillary
D5811
Denture interm cmplt mandbl
D5140
Dentures immediat mandible
D5820
Denture interm part maxill
D5211–D5212 Dentures maxill part resin
D5821
Denture interm part mandbl
D5213–D5214 Dentures maxill part metal
D5850
Denture tiss conditn maxill
D5281
Removable partial denture
D5851
Denture tiss condtin mandbl
D5510
Dentur repr broken compl bas
D5860
Overdenture complete
D5520
Replace denture teeth complt
D5861
Overdenture partial
D5710
Dentures rebase cmplt maxil
D5862
Precision attachment
D5711
Dentures rebase cmplt mand
D5899
Removable prosthodontic proc
D5720
Dentures rebase part maxill
7
7.4.1.6 Maxillofacial Prosthodontic Procedures
Procedure
Code
Description
Procedure
Code
Description
D5911
Facial moulage sectional
D5935
Mandibular denture prosth
D5912
Facial moulage complete
D5936
Temp obturator prosthesis
D5913
Nasal prosthesis
D5937
Trismus appliance
D5914
Auricular prosthesis
D5951
Feeding aid
D5915
Orbital prosthesis
D5952
Pediatric speech aid
D5916
Ocular prosthesis
D5953
Adult speech aid
D5919
Facial prosthesis
D5954
Superimposed prosthesis
D5922
Nasal septal prosthesis
D5955
Palatal lift prosthesis
D5923
Ocular prosthesis interim
D5958
Intraoral con def inter plt
D5924
Cranial prosthesis
D5959
Intraoral con def mod palat
D5925
Facial augmentation implant
D5960
Modify speech aid prosthesis
D5926
Replacement nasal prosthesis
D5982
Surgical stent
D5927
Auricular replacement
D5983
Radiation applicator
D5928
Orbital replacement
D5984
Radiation shield
7–11
Chapter 7
Procedure
Code
Description
Procedure
Code
Description
D5929
Facial replacement
D5985
Radiation cone locator
D5931
Surgical obturator
D5986
Fluoride applicator
D5932
Postsurgical obturator
D5987
Commissure splint
D5933
Refitting of obturator
D5988
Surgical splint
D5934
Mandibular flange prosthesis
D5999
Maxillofacial prosthesis
7.4.1.7 Implant Procedures
Procedure
Code
Description
Procedure
Code
Description
D6010
Odontics endosteal implant
D6080
Implant maintenance
D6020
Odontics abutment placement
D6090
Repair implant
D6040
Odontics eposteal implant
D6095
Odontics repr abutment
D6050
Odontics transosteal implnt
D6100
Removal of implant
D6055
Implant connecting bar
D6199
Implant procedure
7.4.1.8 Prosthodontic (Fixed) Procedures
7–12
Procedure
Code
Description
Procedure
Code
Description
D6210
Prosthodont high noble metal
D6781
Crown 3/4 cast based metal
D6211
Bridge base metal cast
D6782
Crown 3/4 cast noble metal
D6212
Bridge noble metal cast
D6783
Crown 3/4 porcelain/ceramic
D6240
Bridge porcelain high noble
D6790
Crown full high noble metal
D6241
Bridge porcelain base metal
D6791
Crown full base metal cast
D6242
Bridge porcelain nobel metal
D6792
Crown full noble metal cast
D6245
Bridge porcelain/ceramic
D6920
Dental connector bar
D6250
Bridge resin w/high noble
D6930
Dental recement bridge
D6251
Bridge resin base metal
D6940
Stress breaker
D6252
Bridge resin w/noble metal
D6950
Precision attachment
D6545
Dental retainr cast metl
D6970
Post & core plus retainer
D6548
Porcelain/ceramic retainer
D6971
Cast post bridge retainer
D6720
Retain crown resin w hi nble
D6972
Prefab post & core plus reta
D6721
Crown resin w/base metal
D6973
Core build up for retainer
D6722
Crown resin w/noble metal
D6975
Coping metal
D6740
Crown porcelain/ceramic
D6976
Each addtnl cast post
D6750
Crown porcelain high noble
D6977
Each addtl prefab post
D6751
Crown porcelain base metal
D6980
Bridge repair
D6752
Crown porcelain noble metal
D6999
Fixed prosthodontic proc
D6780
Crown 3/4 high noble metal
Dental
7.4.1.9 Oral and Maxillofacial Surgery
Procedure
Code
Description
Procedure
Code
Description
D7260
Oral antral fistula closure
D7460
Rem nonodonto cyst to 1.25cm
D7272
Tooth transplantation
D7461
Rem nonodonto cyst > 1.25 cm
D7280
Exposure impact tooth orthod
D7472
Removal of torus palatinus
D7285
Biopsy of oral tissue hard
D7530
Removal fb skin/areolar tiss
D7286
Biopsy of oral tissue soft
D7540
Removal of fb reaction
D7290
Repositioning of teeth
D7550
Removal of sloughed off bone
D7291
Transseptal fiberotomy
D7560
Maxillary sinusotomy
D7310
Alveoplasty w/ extraction
D7820
Closed tmp manipulation
D7320
Alveoplasty w/o extraction
D7880
Occlusal orthotic appliance
D7340
Vestibuloplasty ridge extens
D7899
Tmj unspecified therapy
D7350
Vestibuloplasty exten graft
D7950
Mandible graft
D7410
Rad exc lesion up to 1.25 cm
D7955
Repair maxillofacial defects
D7411
Excision benign lesion>1.25c
D7960
Frenulectomy/frenulotomy
D7412
Excision benign lesion compl
D7970
Excision hyperplastic tissue
D7413
Excision malig lesion<=1.25c
D7971
Excision pericoronal gingiva
D7414
Excision malig lesion>1.25cm
D7972
Surg redct fibrous tuberosit
D7440
Malig tumor exc to 1.25 cm
D7980
Sialolithotomy
D7441
Malig tumor > 1.25 cm
D7983
Closure of salivary fistula
D7450
Rem odontogen cyst to 1.25cm D7997
Appliance removal
D7451
Rem odontogen cyst > 1.25 cm D7999
Oral surgery procedure
7
7.4.1.10 Orthodontic Procedures
Refer to: "Dental Orthodontics" on page 7-3.
7.4.1.11 Adjunctive General Services
Procedure
Code
Description
Procedure
Code
Description
D9220
General anesthesia
D9920
Behavior management
D9221
General anesthesia ea ad 15m D9940
Dental occlusal guard
D9310
Dental consultation
D9950
Occlusion analysis
D9420
Hospital call
D9952
Complete occlusal adjustment
D9610
Dent therapeutic drug inject
D9974
Intrnl bleaching per tooth
D9630
Other drugs/medicaments
D9999
Adjunctive procedure
Note: Invasive procedures for clients with cleft palate/lip and/or craniofacial anomalies must be prior
authorized and performed by approved cleft/craniofacial teams or approved affiliated providers. See
"Specialty Team/Center Approval" on page 3-4, and "Specialty Team/Center" on page 17-4, for
additional information.
7–13
Chapter 7
7.4.2 Prior Authorization Not Required
The following procedure codes do not require authorization or prior authorization and may be used when
submitting claims:
7.4.2.1 Diagnostic Procedures
Procedure
Code
Description
Procedure
Code
Description
D0120
Periodic oral evaluation
D0274
Dental bitewings four films
D0140
Limit oral eval problm focus
D0277
Vert bitewings-sev to eight
D0150
Comprehensve oral evaluation
D0290
Dental film skull/facial bon
D0160
Extensv oral eval prob focus
D0310
Dental saliography
D0170
Re-eval,est pt,problem focus
D0320
Dental tmj arthrogram incl i
D0210
Intraor complete film series
D0321
Dental other tmj films
D0220
Intraoral periapical first f
D0322
Dental tomographic survey
D0230
Intraoral periapical ea add
D0330
Dental panoramic film
D0240
Intraoral occlusal film
D0340
Dental cephalometric film
D0250
Extraoral first film
D0350
Oral/facial images
D0260
Extraoral ea additional film
D0425
Caries susceptibility tests
D0270
Dental bitewing single film
D0460
Pulp vitality tests
D0272
Dental bitewings two films
D0470
Diagnostic casts
7.4.2.2 Preventive Procedures
Sealants may be applied at any age to the occlusal, buccal, and lingual pits and fissures of any tooth
that is at risk for dental decay and is free of proximal caries and restorations on the surface to be
sealed. Indicate the tooth numbers and surfaces on the claim form. To bill for more than one tooth in
a quadrant, bill each tooth separately using code D1351. Replacement sealants are not reimbursed. If
a dentist has applied two or more sealants in a particular quadrant and has been paid the maximum
quadrant fee, any other sealants applied in that quadrant are not paid during the six months following
the application of those sealants. However, recognizing that it is good dental practice to seal teeth as
soon as possible upon eruption, if a dentist seals a newly erupted permanent molar in that quadrant
during this six-month period, it may be paid (on appeal only) the full single-tooth amount. The tooth
number(s) and surfaces must be indicated on the claim form. The following are billable preventive
procedure codes:
7–14
Procedure
Code
Description
Procedure
Code
Description
D1110
Dental prophylaxis adult
D1351
Dental sealant per tooth
D1120
Dental prophylaxis child
D1510
Space maintainer fxd unilat
D1201
Topical fluor w prophy child
D1515
Fixed bilat space maintainer
D1203
Topical fluor w/o prophy chi
D1520
Remove unilat space maintain
D1204
Topical fluor w/o prophy adu
D1525
Remove bilat space maintain
D1205
Topical fluoride w/ prophy a
D1550
Recement space maintainer
D1330
Oral hygiene instruction
Dental
7.4.2.3 Restorative Procedures
Procedure
Code
Description
Procedure
Code
D2140
Amalgam one surface permanen D2710
Crown resin laboratory
D2150
Amalgam two surfaces permane D2720
Crown resin w/ high noble me
D2160
Amalgam three surfaces perma
D2721
Crown resin w/ base metal
D2161
Amalgam 4 or > surfaces perm
D2722
Crown resin w/ noble metal
D2330
Resin one surface-anterior
D2740
Crown porcelain/ceramic subs
D2331
Resin two surfaces-anterior
D2750
Crown porcelain w/ h noble m
D2332
Resin three surfaces-anterio
D2751
Crown porcelain fused base m
D2335
Resin 4/> surf or w incis an
D2752
Crown porcelain w/ noble met
D2390
Ant resin-based cmpst crown
D2780
Crown 3/4 cast hi noble met
D2391
Post 1 srfc resinbased cmpst
D2781
Crown 3/4 cast base metal
D2392
Post 2 srfc resinbased cmpst
D2782
Crown 3/4 cast noble metal
D2393
Post 3 srfc resinbased cmpst
D2783
Crown 3/4 porcelain/ceramic
D2394
Post >=4srfc resinbase cmpst
D2790
Crown full cast high noble m
D2410
Dental gold foil one surface
D2791
Crown full cast base metal
D2420
Dental gold foil two surface
D2792
Crown full cast noble metal
D2430
Dental gold foil three surfa
D2910
Dental recement inlay
D2510
Dental inlay metalic 1 surf
D2920
Dental recement crown
D2520
Dental inlay metallic 2 surf
D2930
Prefab stnlss steel crwn pri
D2530
Dental inlay metl 3/more sur
D2931
Prefab stnlss steel crown pe
D2542
Dental onlay metallic 2 surf
D2932
Prefabricated resin crown
D2543
Dental onlay metallic 3 surf
D2933
Prefab stainless steel crown
D2544
Dental onlay metl 4/more sur
D2940
Dental sedative filling
D2610
Inlay porcelain/ceramic 1 su
D2950
Core build-up incl any pins
D2620
Inlay porcelain/ceramic 2 su
D2951
Tooth pin retention
D2630
Dental onlay porc 3/more sur
D2952
Post and core cast + crown
D2642
Dental onlay porcelin 2 surf
D2953
Each addtnl cast post
D2643
Dental onlay porcelin 3 surf
D2954
Prefab post/core + crown
D2644
Dental onlay porc 4/more sur
D2955
Post removal
D2650
Inlay composite/resin one su
D2957
Each addtnl prefab post
D2651
Inlay composite/resin two su
D2960
Laminate labial veneer
D2652
Dental inlay resin 3/mre sur
D2961
Lab labial veneer resin
D2662
Dental onlay resin 2 surface
D2962
Lab labial veneer porcelain
D2663
Dental onlay resin 3 surface
D2970
Temporary- fractured tooth
D2664
Dental onlay resin 4/mre sur
D2980
Crown repair
Description
7
7–15
Chapter 7
7.4.2.4 Endodontic Procedures
Procedure
Code
Description
Procedure
Code
Description
D3110
Pulp cap direct
D3353
Apexification/recalc final
D3120
Pulp cap indirect
D3410
Apicoect/perirad surg anter
D3220
Therapeutic pulpotomy
D3421
Root surgery bicuspid
D3221
Gross pulpal debridement
D3425
Root surgery molar
D3230
Pulpal therapy anterior prim
D3426
Root surgery ea add root
D3240
Pulpal therapy posterior pri
D3430
Retrograde filling
D3310
Anterior
D3450
Root amputation
D3320
Root canal therapy 2 canals
D3910
Isolation- tooth w rubb dam
D3330
Root canal therapy 3 canals
D3920
Tooth splitting
D3351
Apexification/recalc initial
D3950
Canal prep/fitting of dowel
D3352
Apexification/recalc interim
7.4.2.5 Periodontic Procedures
Procedure
Code
Description
Procedure
Code
Description
D4210
Gingivectomy/plasty per quad
D4320
Provision splnt intracoronal
D4211
Gingivectomy/plasty per toot
D4321
Provisional splint extracoro
D4240
Gingival flap proc w/ planin
D4341
Periodontal scaling & root
D4241
Gngvl flap w rootplan 1-3 th
D4342
Periodontal scaling 1-3teeth
D4260
Osseous surgery per quadrant
D4355
Full mouth debridement
D4261
Osseous surgl-3teethperquad
D4381
Localized chemo delivery
D4265
Bio mtrls to aid soft/os reg
D4910
Periodontal maint procedures
D4273
Subepithelial tissue graft
D4920
Unscheduled dressing change
D4275
Soft tissue allograft
7.4.2.6 Prosthodontic (Removable) Procedures
7–16
Procedure
Code
Description
Procedure
Code
Description
D5410
Dentures adjust cmplt maxil
D5670
Replc tth&acrlc on mtl frmwk
D5411
Dentures adjust cmplt mand
D5671
Replc tth&acrlc mandibular
D5421
Dentures adjust part maxill
D5730
Denture reln cmplt maxil ch
D5422
Dentures adjust part mandbl
D5731
Denture reln cmplt mand chr
D5610
Dentures repair resin base
D5740
Denture reln part maxil chr
D5620
Rep part denture cast frame
D5741
Denture reln part mand chr
D5630
Rep partial denture clasp
D5750
Denture reln cmplt max lab
D5640
Replace part denture teeth
D5751
Denture reln cmplt mand lab
D5650
Add tooth to partial denture
D5760
Denture reln part maxil lab
D5660
Add clasp to partial denture
D5761
Denture reln part mand lab
Dental
7.4.2.7 Oral and Maxillofacial Surgery
Procedure
Code
Description
Procedure
Code
Description
D7111
Coronal remnants deciduous t
D7282
Mobilize erupted/malpos toot
D7140
Extraction erupted tooth/exr
D7510
I&d absc intraoral soft tiss
D7240
Impact tooth remov comp bony
D7520
I&d abscess extraoral
D7241
Impact tooth rem bony w/comp
D7670
Closd rductn splint alveolus
D7250
Tooth root removal
D7910
Dent sutur recent wnd to 5cm
D7261
Primary closure sinus perf
D7911
Dental suture wound to 5 cm
D7270
Tooth reimplantation
D7912
Suture complicate wnd > 5 cm
D7281
Exposure tooth aid eruption
D7972
Surg redct fibrous tuberosit
7.4.2.8 Orthodontic Procedures
All orthodontic procedures require prior authorization.
Refer to: "Dental Orthodontics" on page 7-3.
7
7.4.2.9 Adjunctive General Services Procedures
Procedure
Code
Description
Procedure
Code
Description
D8660
Preorthodontic tx visit
D9230
Analgesia
D9110
Tx dental pain minor proc
D9430
Office visit during hours
D9210
Dent anesthesia w/o surgery
D9440
Office visit after hours
D9211
Regional block anesthesia
D9910
Dent appl desensitizing med
D9212
Trigeminal block anesthesia
D9930
Treatment of complications
D9215
Local anesthesia
D9951
Limited occlusal adjustment
7.5 Dental Treatment in Hospitals
All inpatient hospital admissions require prior authorization.
7.5.1 Dental Hospital Call
A dental hospital call (D9420) may be reimbursed for clients requiring medically necessary anesthesia
and/or dental treatment in the inpatient or outpatient hospital setting.
Documentation supporting the medical necessity of a dental hospital call (D9420) must be retained in
the patient’s record and is subject to retrospective review. This documentation includes any medical,
physical (e.g. traumatic event), mental, or behavioral disability, and a description of the service
performed that required the hospital call. Charts are subject to retrospective review.
Except for those procedures requiring prior authorization, admission to ambulatory surgical centers
(outpatient and freestanding) for the purpose of performing dentistry services must be authorized by
TMHP.
7.5.2 Dental Surgeries Performed in ASC/HASC
Dental surgery services provided by an anesthesiologist and/or an ambulatory surgical center/hospital
ambulatory surgical center (ASC/HASC) must bill using modifier EP. Anesthesiologists should bill
procedure code 00170, Anesth, procedure on mouth, with modifier EP. ASC/HASCs should bill
procedure code 41899, Dental surgery procedure, with modifier EP.
7–17
Chapter 7
7.6 Doctor of Dentistry Services as a Limited Physician
CSHCN covers services provided by a doctor of dentistry (DDS, DMD, or DDM) if the services are
covered and furnished within the dentist’s scope of practice as defined by Texas state law. To participate in the CSHCN Program as a dentist practicing as a limited physician, a dentist (DDS, DMD, or
DDM) must be enrolled separately as a dentist practicing as a limited physician.
For treatment of clients with cleft/craniofacial anomalies, dental providers must conform to the CSHCN
rules for cleft/craniofacial specialty team/center enrollment and be members of or affiliated with a
cleft/craniofacial center team.
Refer to: "Requirements for Cleft/Craniofacial Center Team Approval" on page 3-5, "Cleft/Craniofacial
Surgery" on page 7-19, and "Specialty Team/Center" on page 17-4, for more 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, CSHCN cannot consider a claim for payment unless all third party payer
requirements are met.
7.6.1 Surgery
The following surgery CPT codes are payable to a dentist enrolled in the CSHCN Program as a dentist
physician:
Procedure Codes
10060–10061
21044–21045
21490
42100
10120–10121
21050
29800–29804
42104–42107
10140
21060
30580–30600
42120
10160
21116
40490
42160
10180
21240–21243
40500
42180–42182
11440–11446
21310
40510–40520
42300–42305
12011–12018
21343–21348
40830–40831
42310–42320
12051–12057
21355–21366
40840–40845
42325–42326
13131–13132*
21385–21395
41000–41010
42330–42340
13300
21400–21401
41015–41018
42400–42405
20000–20005
21406–21408
41100–41105
42410–42415
20200–20205
21421–21423
41108
42650
21010
21431–21436
41110–41114
42660
21015
21440
41115–41116
42665
21025–21026
21445
41250–41252
42810
21029–21032
21450–21453
41520
21034
21454–21470
41822–41823
21040–21041
21480–21485
42000
* Procedure codes 13131 and 13132 are payable only for repairs to the forehead, cheeks, chin, mouth, and
neck.
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Dental
7.6.2 Cleft/Craniofacial Surgery
The following surgery codes are payable to a dentist physician only if the dentist physician also is
enrolled as a member of or affiliated with a CSHCN-approved cleft/craniofacial team. These procedures
must be prior authorized:
Procedure Codes
21076–21077
21193–21196
21275
40761
21079–21089
21198–21199
21280–21282
42145
21100
21206
21295–21296
42200–42227
21110
21208–21215
21299
42235
21120–21123
21230–21235
21497
42260
21125–21127
21244–21249
30460–30462
42280–42281
21137–21139
21255–21256
30520
61550–61559
21141–21160
21260–21263
40527
62115–62117
21172–21184
21267–21268
40650–40654
67950
21188
21270
40700–40720
67961–67975
7
7.6.3 Evaluation and Management
The following evaluation and management services (CPT codes) are payable to a dentist physician:
Procedure Codes
99201–99205
99231–99233
99251–99255
99211–99215
99238
99261–99263
99218–99223
99241–99245
99281–99285
7.6.4 X-ray (CPT) Procedures
The following diagnostic X-ray procedures from CPT are payable to a dentist physician:
Procedure Codes
70100–70110
70332
70140–70150
70355
70328–70330
70380
76375
7.6.5 Anesthesia by Dentist Physician
In addition to the CDT codes discussed under Benefits and Limitations in this chapter, the following
anesthesia CPT procedures are payable to a dentist physician:
Procedure Codes
00100–00102
00170–00172
99100
00160–00164
00190–00192
99140
7.7 Claims Information
Providers billing for dental services may bill electronically or use the 2002 ADA Dental Claim Form.
Refer to: The "2002 ADA Claim Form Example" on page C-18.
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Chapter 7
7.7.1 Dental Claim Electronic Billing
Providers billing electronically must submit dental claims in NSF or X.12 837D formats. 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.
7.7.2 Dental Claim Paper Billing
All participating CSHCN dental providers must use the 2002 ADA Dental Claim Form for paper claim
submissions to the CSHCN Program. Obtain these forms by contacting the ADA at 1-800-947-4746. Any
paper dental claim submitted using any other version of the dental claim form may not be processed
and will be returned to the submitter.
Claims must contain the billing provider’s full name, address, and/or nine-character TPI. The billing
provider’s full name and address must be entered in Block 48 of the ADA Dental Claim Form, and the
nine-character TPI must be entered in Block 49. A claim without a provider name, address, or TPI cannot
be processed.
Refer to: The "2002 ADA Claim Form Example" on page C-18.
7.7.3 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 (2002 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.
7.7.4 Dental Claim Form Instructions
The instructions describe the information that must be entered in each of the block numbers of the
2002 ADA Dental Claim Form. Thoroughly complete the dental claim form according to the instructions
to facilitate prompt and accurate reimbursement and reduce followup inquiries. Review the "2002 ADA
Claim Form Example" on page C-18, and the "Instructions for Completing the 2002 ADA Claim Form"
on page C-15.
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