Download Chapter 8: Dental

Chapter
8
8
Dental
8.1 Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.2 Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.2.1 Tooth Identification (TID) and Surface Identification (SID) Systems . . . . . . . . . . .
8.2.2 Supernumerary Tooth Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8-2
8-2
8-2
8-2
8.3 Benefits and Limitations . . . . . . . . .
8.3.1 Anesthesia . . . . . . . . . . . . . .
8.3.2 Dental Orthodontics . . . . . . .
8.3.3 Coverage/Policy Clarifications
8-3
8-3
8-4
8-8
..
..
..
..
.
.
.
.
.
.
.
.
..
..
..
..
.
.
.
.
..
..
..
..
.
.
.
.
.
.
.
.
..
..
..
..
.
.
.
.
.
.
.
.
..
..
..
..
.
.
.
.
..
..
..
..
.
.
.
.
.
.
.
.
..
..
..
..
.
.
.
.
.
.
.
.
..
..
..
..
.
.
.
.
..
..
..
..
.
.
.
.
.
.
.
.
..
..
..
..
.
.
.
.
8.4 Summary of Authorization Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.4.1 Prior Authorization Required. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.4.1.1 Diagnostic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.4.1.2 Restorative Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.4.1.3 Endodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.4.1.4 Periodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.4.1.5 Prosthodontic (Removable) Procedures . . . . . . . . . . . . . . . . . . . . . . . . .
8.4.1.6 Maxillofacial Prosthodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . .
8.4.1.7 Implant Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.4.1.8 Prosthodontic (Fixed) Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.4.1.9 Oral and Maxillofacial Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.4.1.10 Orthodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.4.1.11 Adjunctive General Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.4.2 Prior Authorization Not Required. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.4.2.1 Diagnostic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.4.2.2 Preventive Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.4.2.3 Restorative Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.4.2.4 Endodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.4.2.5 Periodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.4.2.6 Prosthodontic (Removable) Procedures . . . . . . . . . . . . . . . . . . . . . . . . .
8.4.2.7 Oral and Maxillofacial Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.4.2.8 Adjunctive General Services Procedures . . . . . . . . . . . . . . . . . . . . . . . .
8.5 Dental Treatment in Hospitals and/or Ambulatory Surgical Centers . . . . . . . . . . . . . .
8.5.1 Dental Hospital Call . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.5.2 Dental Surgeries Performed in ASCs/HASCs . . . . . . . . . . . . . . . . . . . . . . . . . .
8.6 Doctor of Dentistry Services as a Limited Physician . . . . . . . . . . . . . . . . . . . . . . . . .
8.6.1 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.6.2 Cleft/Craniofacial Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.6.3 Evaluation and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.6.4 X-ray Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.6.5 Anesthesia by Dentist Physician. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.7 Claims Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.7.1 Dental Claim Electronic Billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.7.2 Dental Claim Paper Billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.7.3 Dental Emergency Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.7.4 Dental Claim Form Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CPT only copyright 2005 American Medical Association. All rights reserved.
.
.
.
.
8-20
8-20
8-20
8-21
8-21
8-21
8-21
8-21
8-21
8-22
8-22
8-22
8-22
8-23
8-23
8-23
8-24
8-24
8-25
8-25
8-25
8-25
8-25
8-25
8-25
8-26
8-26
8-28
8-28
8-28
8-29
8-29
8-29
8-29
8-29
8-30
Chapter 8
8.1 Enrollment
To enroll in the CSHCN Services Program, dental providers must be actively enrolled in the Texas
Medicaid Program, 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 be located in the United States, within 50 miles of the Texas
state border.
Refer to: Section 3.1, “Provider Enrollment,” on page 3-2 for more detailed information about CSHCN
Services Program provider enrollment procedures.
8.2 Reimbursement
Reimbursement for dental services is the lower of the billed amount or the amount allowed by the Texas
Medicaid Program. All participating CSHCN Services Program dental providers are required to submit
the American Dental Association (ADA) Dental Claim Form for paper claim submissions to the CSHCN
Services Program. Providers can obtain copies of this form by contacting ADA at 1-800-947-4746.
Refer to: Appendix B, “ADA Dental Claim Form Example,” on page B-19.
8.2.1 Tooth Identification (TID) and Surface Identification (SID) Systems
Claims are denied if the procedure code is not compatible with TID and/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.
3)$
"U CCAL
$I
STAL
&ACI
AL
)N CI
SAL
,I
N GU AL
-E SI
AL
/ CCLU SAL
3)$
$"
$&
$)
$,
$/
),
-"
-)
-,
-/
/"
/,
3)$
$ &)
$ &,
$ &$ ),
$ ,"
$ ,$ /"
$ /,
),&
- "$
- )$
- )&
- ,"
- ,&
- ,)
- /"
- /$
- /,
/",
3)$
$ ,)&
$ /,"
- )$ &
- )$ ,
- )$ ,&
- )&,
- ,"$
- ,$ &
- /$ "
- /$ ,
- /$ ,"
- /,"
8.2.2 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 2006 Current Dental Terminology (CDT)
published by the ADA.
The TID for each identified supernumerary tooth will be 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
Permanent Teeth Upper Arch
Tooth # 1
2
3
4
5
Super # 51 52 53 54 55
8–2
6
56
7
57
8
58
9
59
10
60
11
61
12
62
13
63
14
64
15
65
16
66
CPT only copyright 2005 American Medical Association. All rights reserved.
Dental
Permanent Teeth Lower Arch
Tooth # 32 31 30 29
Super # 82 81 80 79
28
78
27
77
26
76
25
75
24
74
23
73
22
72
Primary Teeth Upper Arch
Tooth # A
B
C
D
Super # AS
BS CS DS
E
ES
F
FS
G
GS
H
HS
I
IS
J
JS
Primary Teeth Lower Arch
Tooth # T
S
R
Q
Super # TS
SS RS QS
P
PS
O
OS
N
NS
M
MS
L
LS
K
KS
21
71
20
70
19
69
18
68
17
67
8.3 Benefits and Limitations
The CSHCN Services Program 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 and authorization/prior
authorization requirements 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 and 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 about covered procedure or diagnosis codes.
8
8.3.1 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 Services Program provider, may be reimbursed for anesthesia
services provided to CSHCN Services Program clients having dental/oral and maxillofacial surgical
procedures. These services must be performed in the dental office (place of service [POS] 1), inpatient
hospital (POS 3), or freestanding or hospital-based surgical center (POS 5) in accordance with all applicable rules for administration and supervision of anesthesia services.
CDT procedure codes for anesthesia services D9220, D9221, D9230, D9241, D9248, and D9610 are
covered benefits.
Except for procedure code D9221, only one anesthesia procedure may be reimbursed per day for the
same client.
Procedure code D9248 is a benefit when provided in the office setting. Any dentist providing non-intravenous (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 1 through 20 years of age
• 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.
Refer to: Section 8.6.5, “Anesthesia by Dentist Physician,” on page 8-29 for more information about
anesthesia CPT procedure codes that are payable to a dentist physician.
CPT only copyright 2005 American Medical Association. All rights reserved.
8–3
Chapter 8
8.3.2 Dental Orthodontics
Orthodontic procedures require prior authorization and may be reimbursed for the following diagnosis
codes:
8–4
Diagnosis Code
Description
52400
Major anomalies of jaw size, unspecified anomaly
52401
Major anomalies of jaw size, maxillary hyperplasia
52402
Major anomalies of jaw size, mandibular hyperplasia
52403
Major anomalies of jaw size, maxillary hypoplasia
52404
Major anomalies of jaw size, mandibular hypoplasia
52405
Major anomalies of jaw size, macrogenia
52406
Major anomalies of jaw size, microgenia
52707
Excessive tuberosity of jaw
52409
Major anomalies of jaw size, other specified anomaly
52410
Anomalies of relationship of jaw to cranial base, unspecified anomaly
52411
Anomalies of relationship of jaw to cranial base, maxillary asymmetry
52412
Anomalies of relationship of jaw to cranial base, other jaw asymmetry
52419
Anomalies of relationship of jaw to cranial base, other specified anomaly
52451
Abnormal jaw closure
52452
Limited mandibular range of motion
52453
Deviation in opening and closing of the mandible
52454
Insufficient anterior guidance
52455
Centric occlusion maximum intercuspation discrepancy
52456
Non-working side interference
52457
Lack of posterior occlusal support
52459
Other dentofacial functional abnormalities
74900
Cleft palate, unspecified
74901
Cleft palate, unilateral, complete
74902
Cleft palate, unilateral, incomplete
74903
Cleft palate, bilateral, complete
74904
Cleft palate, bilateral, incomplete
74910
Cleft lip, unspecified
74911
Cleft lip, unilateral, complete
74912
Cleft lip, unilateral, incomplete
74913
Cleft lip, bilateral, complete
74914
Cleft lip, bilateral, incomplete
74920
Cleft palate with cleft lip, unspecified
74921
Cleft palate with cleft lip, unilateral, complete
74922
Cleft palate with cleft lip, unilateral, incomplete
74923
Cleft palate with cleft lip, bilateral, complete
74924
Cleft palate with cleft lip, bilateral, incomplete
74925
Other combinations of cleft palate with cleft lip
CPT only copyright 2005 American Medical Association. All rights reserved.
Dental
Diagnosis Code
Description
7540
Congenital musculoskeletal deformities of skull, face, and jaw
75555
Acrocephalosyndactyly
7560
Congenital anomalies of skull and face bones
All removable or fixed orthodontic appliances must be billed with CDT procedure codes D8210 or
D8220. To ensure appropriate claims processing, the local code reflecting the specific service is also
required. For paper claim submissions, providers must enter the local code in the Remarks section of
the claim form.
For electronic submissions other than TDHconnect 3.0 software submissions, providers must follow the
steps below to ensure TMHP accurately applies the correct local 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.
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:
8
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 enter the DPC prefix, because 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 a delay of payment may be the result. For answers to questions about
how to implement these processes, providers can contact TMHP-CSHCN at 1-800-568-2413 and select
Option 2 to speak with a TMHP representative.
Local code D924X is no longer a benefit. Use procedure code D9241 instead. All other orthodontic
procedure codes that were local codes used for prior authorization and reimbursement have been
converted to CDT (national) procedure codes.
The following procedures are not included in comprehensive treatment:
CDT Procedure Code
Remarks Code
Description
D8660
Z2008
Initial orthodontic visit
D8670
Z2013
Orthodontic adjustments, per month
D7997*
Z2016
Premature appliance removal, per arch
*May only be paid to a provider not billing for comprehensive treatment.
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 remarks codes Z2009,
Z2011, or Z2012.
CDT Procedure Code
Remarks Code
Description
D8080
Z2009
or
Z2011
or
Z2012
Diagnostic workup, approved
or
Orthodontic appliance, upper (braces)
or
Orthodontic appliance, lower (braces)
CPT only copyright 2005 American Medical Association. All rights reserved.
8–5
Chapter 8
When a diagnostic workup is not approved, individual components may be considered for separate
reimbursement. Use the following procedure codes:
CDT Procedure Code
Remarks Code
Description
Z2010
Diagnostic workup, not approved
D0330
D0340
D0350
D0470
Local code 1009D was replaced with CDT procedure code D8690.
Procedure code D8680 includes all retainers necessary to treat the client. Use the following remarks
codes according to the service(s) provided:
Remarks Code
Description
1033D
Mandibular, fixed, 2x4 retainer
1034D
Mandibular, fixed, 3x3 retainer
1035D
Mandibular, fixed, 4x4 retainer
Z2014
Orthodontic retainer, upper
Z2015
Orthodontic retainer, lower
Procedure code D8050 includes a crossbite workup and removable appliance. Use the following
remarks codes according to the service(s) provided:
Remarks Code
Description
8110D
Crossbite therapy, removable appliance
Z2018
Crossbite, workup
Procedure code D8060 includes a crossbite workup and the fixed appliance. Use the following remarks
codes according to the service(s) provided:
Remarks Code
Description
8120D
Crossbite therapy, fixed appliance
Z2018
Crossbite, workup
The orthodontic diagnostic work up procedures are considered inclusive procedures. Procedure codes
D0330, D0340, D0350, and D0470 will be 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 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 and the remarks
code(s) for orthodontia services.
Use the following remarks codes in the Remarks field for fixed appliances (procedure code D8220):
8–6
Remarks Code
Fixed Appliances 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
CPT only copyright 2005 American Medical Association. All rights reserved.
Dental
Remarks Code
Fixed Appliances Description
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
8
Use the following remarks codes in the Remarks field for removable appliances (procedure code
D8210):
Remarks Code
Removable Appliances 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
CPT only copyright 2005 American Medical Association. All rights reserved.
8–7
Chapter 8
Remarks Code
Removable Appliances Description
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
1074D
Tooth positioner, full maxillary and mandibular
1075D
Tooth positioner with arch
8.3.3 Coverage/Policy Clarifications
The following information provides procedure and diagnosis code clarification for CSHCN Services
Program dental and orthodontia policies. CSHCN Services Program policy requires the following:
• Reviewing claims for procedure codes when a dental provider submits an ADA procedure code under
the dental provider identifier and also bills the equivalent CPT procedure code using the medical
provider identifier:
ADA Procedure Codes
D0320
D5954
D5955
D5958
D5959
D6040
D6050
D7440
D7441
D7461
D7465
D7510
D7530
D7540
D7550
D7820
D7880
D7955
D7999
CPT Procedure Codes
8–8
2/F-21025
2/F-21026
2/F-21029
2/F-21030
2-21031
2-21032
2/8/F-21034
2/F-21040
2/8/F-21044
2/8-21045
2-21082
2-21083
2-21085
2-21110
2-21116
2/8/F-21123
2/8/F-21127
2/8-21188
2/F-21215
2/8/F-21230
CPT only copyright 2005 American Medical Association. All rights reserved.
Dental
CPT Procedure Codes
2/8/F-21240
2/8/F-21242
2/8/F-21243
2/8/F-21244
2/F-21245
2/F-21246
2/8-21255
2/F-21270
2/F-21295
2/F-21296
2/F-21480
2/F-21485
2/F-41800
2/F-41806
2-41822
2-41823
2-41825
2-41826
2/F-41827
2-41830
2-41850
4/I/T-70332
• 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 identifier) for the following
procedure codes:
Procedure Codes
D0230
D0260
D4210
D4240
D4341
D7310
D7320
D9221
D4260
• Denying follow-up visit procedure codes listed below if billed within 90 days of radiation treatment
provided by the same provider:
Procedure Codes
1-99211
1-99212
1-99213
1-99214
1-99215
1-99281
1-99282
1-99283
1-99284
1-99285
D4341
D4355
• Reviewing partials and/or relines within one year of original denture/reline:
8
Procedure Codes
D5211
D5212
D5213
D5214
D5281
D5710
D5711
D5720
D5721
D5730
D5731
D5740
D5741
D5750
D5751
D5760
D5761
• Limiting full mouth X-rays with exam and subsequent reline of dentures to once every three years:
Procedure Codes
D0210
D0277
D5710
D5711
D5720
D5721
D5730
D5731
D5740
D5741
D5750
D5751
D5760
D5761
• Reviewing all inpatient claims billed with one of the following oral surgery diagnosis codes:
Diagnosis Code
Description
5200
Anodontia
5201
Supernumerary teeth
5202
Abnormalities of size and form of teeth
5203
Mottled teeth
5204
Disturbances of tooth formation
5205
Hereditary disturbances in tooth structure, not elsewhere classified
5206
Disturbances in tooth eruption
5207
Teething syndrome
5208
Other specified disorders of tooth development and eruption
5209
Unspecified disorder of tooth development and eruption
52100
Dental caries, unspecified
52101
Dental caries limited to enamel
52102
Dental caries extending into dentine
CPT only copyright 2005 American Medical Association. All rights reserved.
8–9
Chapter 8
8–10
Diagnosis Code
Description
52103
Dental caries extending into pulp
52104
Arrested dental caries
52105
Odontoclasia
52106
Dental caries pit and fissure
52107
Dental caries of smooth surface
52108
Dental caries of root surface
52109
Other dental caries
52110
Excessive attrition, unspecified
52120
Abrasion, unspecified
52130
Erosion, unspecified
52140
Pathological resorption, unspecified
5215
Hypercementosis
5216
Ankylosis of teeth
5217
Intrinsic posteruptive color changes
5218
Other specified diseases of hard tissues of teeth
5219
Unspecified disease of hard tissues of teeth
5220
Pulpitis
5221
Necrosis of the pulp
5222
Pulp degeneration
5223
Abnormal hard tissue formation in pulp
5224
Acute apical periodontitis of pulpal origin
5225
Periapical abscess without sinus
5226
Chronic apical periodontitis
5227
Periapical abscess with sinus
5228
Radicular cyst
5229
Other and unspecified diseases of pulp and periapical tissues
5230
Acute gingivitis
5231
Chronic gingivitis
52320
Gingival recession, unspecified
52321
Gingival recession, minimal
52322
Gingival recession, moderate
52323
Gingival recession, severe
52324
Gingival recession, localized
52325
Gingival recession, generalized
5233
Acute periodontitis
5234
Chronic periodontitis
5235
Periodontosis
5236
Accretions on teeth
5238
Other specified periodontal diseases
5239
Unspecified gingival and periodontal disease
52400
Major anomalies of jaw size, unspecified anomaly
52401
Major anomalies of jaw size, maxillary hyperplasia
52402
Major anomalies of jaw size, mandibular hyperplasia
52403
Major anomalies of jaw size, maxillary hypoplasia
CPT only copyright 2005 American Medical Association. All rights reserved.
Dental
Diagnosis Code
Description
52404
Major anomalies of jaw size, mandibular hypoplasia
52405
Major anomalies of jaw size, macrogenia
52406
Major anomalies of jaw size, microgenia
52407
Excessive tuberosity of jaw
52409
Major anomalies of jaw size, other specified anomaly
52410
Anomalies of relationship of jaw to cranial base, unspecified anomaly
52411
Anomalies of relationship of jaw to cranial base, maxillary asymmetry
52412
Anomalies of relationship of jaw to cranial base, other jaw asymmetry
52419
Anomalies of relationship of jaw to cranial base, other specified anomaly
52420
Unspecified anomaly of dental arch relationship
52430
Unspecified anomaly of tooth position
5244
Malocclusion, unspecified
52450
Dentofacial functional abnormality, unspecified
52460
Temporomandibular joint disorders, unspecified
52461
Temporomandibular joint disorders, adhesions and ankylosis (bony or fibrous)
52481
Anterior soft tissue impingement
52482
Posterior soft tissue impingement
52489
Other specified dentofacial anomalies
5249
Unspecified dentofacial anomalies
5250
Exfoliation of teeth due to systemic causes
52510
Acquired absence of teeth, unspecified
52511
Loss of teeth due to trauma
52512
Loss of teeth due to periodontal disease
52513
Loss of teeth due to caries
52519
Other loss of teeth
52520
Unspecified atrophy of edentulous alveolar ridge
5253
Retained dental root
5258
Other specified disorders of the teeth and supporting structures
5259
Unspecified disorder of the teeth and supporting structures
V5875
Aftercare following surgery of the teeth, oral cavity and digestive system, NEC
V722
Dental examination
8
• Reviewing for medical necessity any visits/consults billed by a dentist for a diagnosis other than the
following dental diagnosis codes:
Diagnosis Code
Description
0542
Herpetic gingivostomatitis
1120
Candidiasis of mouth
1400
Malignant neoplasm of upper lip, vermilion border
1401
Malignant neoplasm of lower lip, vermilion border
1403
Malignant neoplasm of upper lip, inner aspect
1404
Malignant neoplasm of lower lip, inner aspect
1405
Malignant neoplasm of lip, unspecified, inner aspect
1406
Malignant neoplasm of commissure of lip
1408
Malignant neoplasm of other sites of lip
1409
Malignant neoplasm of lip, unspecified, vermilion border
CPT only copyright 2005 American Medical Association. All rights reserved.
8–11
Chapter 8
8–12
Diagnosis Code
Description
1410
Malignant neoplasm of base of tongue
1411
Malignant neoplasm of dorsal surface of tongue
1412
Malignant neoplasm of tip and lateral border of tongue
1413
Malignant neoplasm of ventral surface of tongue
1414
Malignant neoplasm of anterior two-thirds of tongue, part unspecified
1415
Malignant neoplasm of junctional zone of tongue
1416
Malignant neoplasm of lingual tonsil
1418
Malignant neoplasm of other sites of tongue
1419
Malignant neoplasm of tongue, unspecified
1420
Malignant neoplasm of parotid gland
1421
Malignant neoplasm of submandibular gland
1422
Malignant neoplasm of sublingual gland
1428
Malignant neoplasm of other major salivary glands
1429
Malignant neoplasm of salivary gland, unspecified
1430
Malignant neoplasm of upper gum
1431
Malignant neoplasm of lower gum
1438
Malignant neoplasm of other sites of gum
1439
Malignant neoplasm of gum, unspecified
1440
Malignant neoplasm of anterior portion of floor of mouth
1441
Malignant neoplasm of lateral portion of floor of mouth
1448
Malignant neoplasm of other sites of floor of mouth
1449
Malignant neoplasm of floor of mouth, part unspecified
1450
Malignant neoplasm of cheek mucosa
1451
Malignant neoplasm of vestibule of mouth
1452
Malignant neoplasm of hard palate
1453
Malignant neoplasm of soft palate
1454
Malignant neoplasm of uvula
1455
Malignant neoplasm of palate, unspecified
1456
Malignant neoplasm of retromolar area
1458
Malignant neoplasm of other specified parts of mouth
1459
Malignant neoplasm of mouth, unspecified
1460
Malignant neoplasm of tonsil
1461
Malignant neoplasm of tonsillar fossa
1462
Malignant neoplasm of tonsillar pillars (anterior) (posterior)
1463
Malignant neoplasm of vallecula epiglottica
1464
Malignant neoplasm of anterior aspect of epiglottis
1465
Malignant neoplasm of junctional region of oropharynx
1466
Malignant neoplasm of lateral wall of oropharynx
1467
Malignant neoplasm of posterior wall of oropharynx
1468
Malignant neoplasm of other specified sites of oropharynx
1469
Malignant neoplasm of oropharynx, unspecified site
1490
Malignant neoplasm of pharynx, unspecified
1498
Malignant neoplasm of other sites within the lip and oral cavity
1602
Malignant neoplasm of maxillary sinus
CPT only copyright 2005 American Medical Association. All rights reserved.
Dental
Diagnosis Code
Description
1700
Malignant neoplasm of bones of skull and face, except mandible
1701
Malignant neoplasm of mandible
1730
Other malignant neoplasm of skin of lip
1733
Other malignant neoplasm of skin of other and unspecified parts of face
1950
Malignant neoplasm of head, face, and neck
2100
Benign neoplasm of lip
2101
Benign neoplasm of tongue
2102
Benign neoplasm of major salivary glands
2103
Benign neoplasm of floor of mouth
2104
Benign neoplasm of other and unspecified parts of mouth
2105
Benign neoplasm of tonsil
2106
Benign neoplasm of other parts of oropharynx
2107
Benign neoplasm of nasopharynx
2120
Benign neoplasm of nasal cavities, middle ear, and accessory sinuses
2130
Benign neoplasm of bones of skull and face
2131
Benign neoplasm of lower jaw bone
2160
Benign neoplasm of skin of lip
2163
Benign neoplasm of skin of other and unspecified parts of face
22801
Hemangioma of skin and subcutaneous tissue
2300
Carcinoma in situ of lip, oral cavity, and pharynx
2320
Carcinoma in situ of skin of lip
2323
Carcinoma in situ of skin of other and unspecified parts of face
2350
Neoplasm of uncertain behavior of major salivary glands
2380
Neoplasm of uncertain behavior of bone and articular cartilage
3501
Trigeminal neuralgia
3510
Bell’s palsy
470
Deviated nasal septum
4730
Chronic maxillary sinusitis
4781
Other diseases of nasal cavity and sinuses
5225
Periapical abscess without sinus
5227
Periapical abscess with sinus
5233
Acute periodontitis
52400
Major anomalies of jaw size, unspecified anomaly
52401
Major anomalies of jaw size, maxillary hyperplasia
52402
Major anomalies of jaw size, mandibular hyperplasia
52403
Major anomalies of jaw size, maxillary hypoplasia
52404
Major anomalies of jaw size, mandibular hypoplasia
52405
Major anomalies of jaw size, macrogenia
52406
Major anomalies of jaw size, microgenia
52407
Excessive tuberosity of jaw
52409
Major anomalies of jaw size, other specified anomaly
52410
Anomalies of relationship of jaw to cranial base, unspecified anomaly
52411
Anomalies of relationship of jaw to cranial base, maxillary asymmetry
52412
Anomalies of relationship of jaw to cranial base, other jaw asymmetry
CPT only copyright 2005 American Medical Association. All rights reserved.
8
8–13
Chapter 8
8–14
Diagnosis Code
Description
52419
Anomalies of relationship of jaw to cranial base, other specified anomaly
52420
Unspecified anomaly of dental arch relationship
52421
Angle’s Class I
52422
Angle’s Class II
52423
Angle’s Class III
52424
Open anterior occlusal relationship
52425
Open posterior occlusal relationship
52426
Excessive horizontal overlap
52427
Reverse articulation
52428
Anomalies of interarch distance
52429
Other anomalies of dental arch relationship
52450
Dentofacial functional abnormality, unspecified
52451
Abnormal jaw closure
52452
Limited mandibular range of motion
52453
Deviation in opening and closing of the mandible
52454
Insufficient anterior guidance
52455
Centric occlusion maximum intercuspation discrepancy
52456
Non-working side interference
52457
Lack of posterior occlusal support
52459
Other dentofacial functional abnormalities
52460
Temporomandibular joint disorders, unspecified
52461
Temporomandibular joint disorders, adhesions and ankylosis (bony or fibrous)
52462
Temporomandibular joint disorders, arthralgia of temporomandibular joint
52463
Temporomandibular joint disorders, articular disc disorder (reducing or
non-reducing)
52464
Temporomandibular joint disorders, articular disc disorder (reducing or
non-reducing)
52469
Temporomandibular joint disorders, other specified temporomandibular joint
disorders
52470
Dental alveolar anomalies, unspecified alveolar anomaly
52471
Dental alveolar anomalies, alveolar maxillary hyperplasia
52472
Dental alveolar anomalies, alveolar mandibular hyperplasia
52473
Dental alveolar anomalies, alveolar maxillary hypoplasia
52474
Dental alveolar anomalies, alveolar mandibular hypoplasia
52475
Vertical displacement of alveolus and teeth
52476
Occlusal plane deviation
52479
Dental alveolar anomalies, other specified alveolar anomaly
52481
Anterior soft tissue impingement
52482
Posterior soft tissue impingement
52489
Other specified dentofacial anomalies
5249
Unspecified dentofacial anomalies
52510
Acquired absence of teeth, unspecified
52511
Loss of teeth due to trauma
52512
Loss of teeth due to periodontal disease
52513
Loss of teeth due to caries
CPT only copyright 2005 American Medical Association. All rights reserved.
Dental
Diagnosis Code
Description
52519
Other loss of teeth
5260
Developmental odontogenic cysts
5261
Fissural cysts of jaw
5262
Other cysts of jaws
5263
Central giant cell (reparative) granuloma
5264
Inflammatory conditions of jaw
5265
Alveolitis of jaw
52681
Exostosis of jaw
52689
Other specified diseases of the jaws
5269
Unspecified disease of the jaws
5272
Sialoadenitis
5273
Abscess of salivary gland
5274
Fistula of salivary gland
5275
Sialolithiasis
5276
Mucocele of salivary gland
5277
Disturbance of salivary secretion
5278
Other specified diseases of the salivary glands
5279
Unspecified disease of the salivary glands
5281
Cancrum oris
5282
Oral aphthae
5283
Cellulitis and abscess of oral soft tissues
5284
Cysts of oral soft tissue
5285
Diseases of lips
5286
Leukoplakia of oral mucosa, including tongue
5287
Other disturbances of oral epithelium, including tongue
52871
Minimal keratinized residual ridge mucosa
52872
Excessive keratinized residual ridge mucosa
52879
Other disturbances of oral epithelium, including tongue
5290
Glossitis
5291
Geographic tongue
5292
Median rhomboid glossitis
5293
Hypertrophy of tongue papillae
5294
Atrophy of tongue papillae
5295
Plicated tongue
5296
Glossodynia
5298
Other specified conditions of the tongue
6820
Cellulitis and abscess of face
6828
Cellulitis and abscess of other specified sites
6829
Cellulitis and abscess of unspecified sites
70900
Dyschromia, unspecified
71509
Osteoarthrosis, generalized, involving multiple sites
71518
Osteoarthrosis, localized, primary, involving other specified sites
71528
Osteoarthrosis, localized, secondary, involving other specified sites
71618
Traumatic arthropathy involving other specified sites
CPT only copyright 2005 American Medical Association. All rights reserved.
8
8–15
Chapter 8
8–16
Diagnosis Code
Description
71690
Unspecified arthropathy, site unspecified
73810
Other acquired deformity of head, unspecified deformity
73811
Other acquired deformity of head, zygomatic hyperplasia
73812
Other acquired deformity of head, zygomatic hypoplasia
73819
Other acquired deformity of head, other specified deformity
74441
Branchial cleft sinus or fistula
74442
Branchial cleft cyst
74900
Cleft palate, unspecified
74901
Cleft palate, unilateral, complete
74902
Cleft palate, unilateral, incomplete
74903
Cleft palate, bilateral, complete
74904
Cleft palate, bilateral, incomplete
74910
Cleft lip, unspecified
74911
Cleft lip, unilateral, complete
74912
Cleft lip, unilateral, incomplete
74913
Cleft lip, bilateral, complete
74914
Cleft lip, bilateral, incomplete
74920
Cleft palate with cleft lip, unspecified
74921
Cleft palate with cleft lip, unilateral, complete
74922
Cleft palate with cleft lip, unilateral, incomplete
74923
Cleft palate with cleft lip, bilateral, complete
74924
Cleft palate with cleft lip, bilateral, incomplete
74925
Other combinations of cleft palate with cleft lip
7500
Tongue tie
75029
Other specified congenital anomalies of pharynx
7560
Congenital anomalies of skull and face bones
7810
Abnormal involuntary movements
78199
Other symptoms involving nervous and musculoskeletal systems
8020
Closed fracture of nasal bones
8021
Open fracture of nasal bones
80220
Closed fracture of unspecified site of mandible
80221
Closed fracture of condylar process of mandible
80222
Closed fracture of subcondylar process of mandible
80223
Closed fracture of coronoid process of mandible
80224
Closed fracture of unspecified part of ramus of mandible
80225
Closed fracture of angle of jaw
80226
Closed fracture of symphysis of body of mandible
80227
Closed fracture of alveolar border of body of mandible
80228
Closed fracture of other and unspecified part of body of mandible
80229
Closed fracture of multiple sites of mandible
80230
Open fracture of unspecified site of mandible
80231
Open fracture of condylar process of mandible
80232
Open fracture of subcondylar process of mandible
80233
Open fracture of coronoid process of mandible
CPT only copyright 2005 American Medical Association. All rights reserved.
Dental
Diagnosis Code
Description
80234
Open fracture of unspecified part of ramus of mandible
80235
Open fracture of angle of jaw
80236
Open fracture of symphysis of body of mandible
80237
Open fracture of alveolar border of body of mandible
80238
Open fracture of body of mandible, other and unspecified
80239
Open fracture of multiple sites of mandible
8024
Closed fracture of malar and maxillary bones
8025
Open fracture of malar and maxillary bones
8026
Closed fracture of orbital floor (blow-out)
8027
Open fracture of orbital floor (blow-out)
8028
Closed fracture of other facial bones
8029
Open fracture of other facial bones
80300
Other closed skull fracture without mention of intracranial injury, with unspecified state of consciousness
80301
Other closed skull fracture without mention of intracranial injury, with no loss
of consciousness
80302
Other closed skull fracture without mention of intracranial injury, with brief (less
than one hour) loss of consciousness
80303
Other closed skull fracture without mention of intracranial injury, with moderate
(1–24 hours) loss of consciousness
80304
Other closed skull fracture without mention of intracranial injury, with prolonged
(more than 24 hours) loss of consciousness and return to pre-existing
conscious level
80305
Other closed skull fracture without mention of intracranial injury, with prolonged
(more than 24 hours) loss of consciousness, without return to pre-existing
conscious level
80306
Other closed skull fracture without mention of intracranial injury, with loss of
consciousness of unspecified duration
80309
Other closed skull fracture without mention of intracranial injury, with
concussion, unspecified
80310
Other closed skull fracture with cerebral laceration and contusion, with unspecified state of consciousness
8481
Jaw sprain
87320
Open wound of nose, unspecified site, uncomplicated
87321
Open wound of nasal septum, uncomplicated
87322
Open wound of nasal cavity, uncomplicated
87323
Open wound of nasal sinus, uncomplicated
87329
Open wound of multiple sites, uncomplicated
87330
Open wound of nose, unspecified site, complicated
87331
Open wound of nasal septum, complicated
87332
Open wound of nasal cavity, complicated
87333
Open wound of nasal sinus, complicated
87339
Open wound of multiple sites, complicated
87340
Open wound of face, unspecified site, uncomplicated
87341
Open wound of cheek, uncomplicated
87342
Open wound of forehead, uncomplicated
87343
Open wound of lip, uncomplicated
CPT only copyright 2005 American Medical Association. All rights reserved.
8
8–17
Chapter 8
Diagnosis Code
Description
87344
Open wound of jaw, uncomplicated
87349
Open wound of other and multiple sites, uncomplicated
87350
Open wound of face, unspecified site, complicated
87351
Open wound of cheek, complicate
87352
Open wound of forehead, complicated
87353
Open wound of lip, complicated
87354
Open wound of jaw, complicated
87359
Open wound of other and multiple sites, complicated
87360
Open wound of mouth, unspecified site, uncomplicated
87361
Open wound of buccal mucosa, uncomplicated
87362
Open wound of gum (alveolar process), uncomplicated
87363
Open wound of tooth (broken), uncomplicated
87364
Open wound of tongue and floor of mouth, uncomplicated
87365
Open wound of palate, uncomplicated
87369
Open wound of other and multiple sites, uncomplicated
87370
Open wound of mouth, unspecified site, complicated
87371
Open wound of buccal mucosa, complicated
87372
Open wound of gum (alveolar process), complicated
87373
Open wound of tooth (broken), complicated
87374
Open wound of tongue and floor of mouth, complicated
87375
Open wound of palate, complicated
87379
Open wound of other and multiple sites, complicated
8738
Other and unspecified open wound of head without mention of complication
8739
Other and unspecified open wound of head, complicated
8744
Open wound of pharynx, without mention of complication
8745
Open wound of pharynx, complicated
9062
Late effect of superficial injury
920
Contusion of face, scalp, and neck except eye(s)
9350
Foreign body in mouth
95901
Other and unspecified injury to head
95909
Other and unspecified injury to face and neck
• Reviewing procedures billed with a noncovered dental restoration/rehabilitation diagnosis for clients
older than 21 years of age:
8–18
Diagnosis Code
Description
52100
Dental caries, unspecified
52101
Dental caries limited to enamel
52102
Dental caries extending into dentine
52103
Dental caries extending into pulp
52104
Arrested dental caries
52105
Odontoclasia
52109
Other dental caries
52512
Excessive attrition, extending into dentine
52513
Excessive attrition, extending into pulp
CPT only copyright 2005 American Medical Association. All rights reserved.
Dental
• Reviewing procedures billed with a noncovered mental retardation diagnosis for clients 0 through
20 years of age:
Diagnosis Code
Description
317
Mild mental retardation
3180
Moderate mental retardation
3181
Severe mental retardation
3182
Profound mental retardation
319
Unspecified mental retardation
• 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
D2140
D2150
D2160
D2161
D2330
D2331
D2332
D2335
D2391
D2392
D2393
D2394
D2542
D2650
D2651
D2652
D2662
D2663
D2664
D2780
D2781
D2782
D2783
D2930
D2932
D2934
• 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:
8
Procedure Codes
D2140
D2150
D2160
D2161
D2330
D2331
D2332
D2335
D2390
D2391
D2392
D2393
D2394
D2542
D2650
D2651
D2652
D2662
D2663
D2664
D2931
D2932
D2933
D2934
• 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
D2150
D2160
D2161
D2330
D2331
D2332
D2335
D2390
D2391
D2392
D2393
D2394
D2542
D2650
D2651
D2652
D2662
D2663
D2664
D2931
D2932
D2933
D2934
• Denying procedures billed more than once per year per client by any provider: procedure codes
5-88240, 5-88241, 5-88271, 5-88272, 5-88723, 5-88724, 5-88275, D1330, D9951, and 1-J9219.
• 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, D0277,
and D0330.
• Reviewing procedures that are limited to once in a lifetime (dental exams/panorex codes for clients
from 3 through 20 years of age): procedure code D0330.
• Limiting posterior crowns to four per lifetime, any type, any provider: procedure codes D2710,
D2720, D2722, D2740, D2750, D2751, D2752, D2790 D2791, D2792, and D2794.
• Limiting anterior crowns to two per lifetime, any type, any provider: procedure code D2751.
CPT only copyright 2005 American Medical Association. All rights reserved.
8–19
Chapter 8
• Reviewing sealants billed on a previously restored surface or on a tooth previously crowned or
extracted.
• The following CPT procedure codes are benefits of the CSHCN Services Program for physicians and
dentists when provided in the following payable POS:
Procedure Code
POS
Procedure Code
POS
2–20520
1, 3, 5
5–88331
1, 3, 5, 6
4–70380
1, 5
I–88331
3, 5
I–70380
1, 3, 5
T–88331
6
T–70380
1
5–88332
1, 3, 5, 6
5–88305
1, 3, 5, 6
I–88332
3, 5
I–88305
3, 5
T–88332
6
T–88305
6
8.4 Summary of Authorization Requirements
Dental services listed in Section 8.4.1 require prior authorization. All orthodontia must also be prior
authorized as specified in preceding sections of this chapter. The CSHCN Services Program 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. Additional documentation, including current periapical radiographs, must be maintained in
the client’s medical/dental record and submitted to the CSHCN Services Program on request. Authorization is not required for preventative dental services.
Dental radiographs document medical necessity for all therapeutic procedure codes. When radiographs
are necessary but cannot be obtained, intraoral photographs should be obtained instead. These radiographs or intraoral photographs must be maintained in the client’s record as documentation of medical
necessity.
Radiographs or intraoral photographs must be taken before commencing treatment and must be of
diagnostic quality or sufficient quality for a prudent dentist to make an appropriate diagnosis. Digital
radiographs are not considered appropriate documentation of medical necessity.
The number of radiographic 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 over 12 years of age
require 12 to 20 films to be considered an intraoral series. A panoramic film (procedure code D0330)
plus a minimum of four bitewing films (procedure code D0274) may be considered equivalent to a
complete intraoral series including bitewings (procedure code D0210).
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 B, “Request for Dental Authorization or Orthodontia Prior Authorization,” on
page B-28, for an example of this form.
Tip: Photocopy this form and retain the original for future use.
8.4.1 Prior Authorization Required
Procedure codes and details concerning authorization requirements are listed below under their
respective titles.
8.4.1.1 Diagnostic Procedures
Use procedure code D0999 when billing for unspecified diagnostic procedures.
8–20
CPT only copyright 2005 American Medical Association. All rights reserved.
Dental
8.4.1.2 Restorative Procedures
Prior authorization is required for inlay/onlay restorations and crowns—single restorations only
(permanent teeth only), in excess of four in a lifetime, any provider. For example, if a client received
three inlays (procedure code D2610) and one crown (procedure code D2710), prior authorization is
necessary for any further inlay/onlay restorations or crowns—single restorations only. Use procedure
code D2999 when billing for restorative procedures not adequately described by a code.
8.4.1.3 Endodontic Procedures
Use procedure codes D3346, D3347, D3348, D3460, D3470, and D3999.
Procedure code D3460 is a benefit for clients 16 years of age and older when regular treatment has
failed. Prior authorization is required. Documentation of medical necessity must include the following:
the anatomy is such that no other fixed or removable prosthodontic alternatives are available
(e.g., anodontia, a result of trauma, or birth defect) and regular treatment failure.
8.4.1.4 Periodontic Procedures
Use the following procedure codes for periodontic procedures:
Procedure Codes
D4245
D4249
D4266
D4267
D4270
D4271
D4273
D4274
D4276
D4999
8.4.1.5 Prosthodontic (Removable) Procedures
Use the following procedure codes for prosthodontic (removable) procedures:
8
Procedure Codes
D5110
D5120
D5130
D5140
D5211
D5212
D5213
D5214
D5281
D5510
D5520
D5710
D5711
D5720
D5721
D5810
D5811
D5820
D5821
D5850
D5851
D5860
D5861
D5862
D5899
8.4.1.6 Maxillofacial Prosthodontic Procedures
Use the following procedure codes for maxillofacial prosthodontic procedures:
Procedure Codes
D5911
D5912
D5913
D5914
D5915
D5916
D5919
D5922
D5923
D5924
D5925
D5926
D5927
D5928
D5929
D5931
D5932
D5933
D5934
D5935
D5936
D5937
D5951
D5952
D5953
D5954
D5955
D5958
D5959
D5960
D5982
D5983
D5984
D5985
D5986
D5987
D5988
D5999
8.4.1.7 Implant Procedures
Use the following procedure codes for implant procedures:
Procedure Codes
D6010
D6040
D6050
D6055
D6056
D6057
D6080
D6090
D6095
D6100
D6199
CPT only copyright 2005 American Medical Association. All rights reserved.
8–21
Chapter 8
8.4.1.8 Prosthodontic (Fixed) Procedures
Use the following procedure codes for prosthodontic (fixed) procedures:
Procedure Codes
D6210
D6211
D6212
D6240
D6241
D6242
D6245
D6250
D6251
D6252
D6545
D6548
D6720
D6721
D6722
D6740
D6750
D6751
D6752
D6780
D6781
D6782
D6783
D6790
D6791
D6792
D6920
D6930
D6940
D6950
D6970
D6971
D6972
D6973
D6975
D6976
D6977
D6980
D6999
8.4.1.9 Oral and Maxillofacial Surgery
Use the following procedure codes for oral and maxillofacial surgery procedures:
Procedure Codes
D7260
D7272
D7280
D7285
D7286
D7290
D7291
D7310
D7320
D7340
D7350
D7410
D7411
D7412
D7413
D7414
D7440
D7441
D7450
D7451
D7460
D7461
D7472
D7530
D7540
D7550
D7560
D7820
D7880
D7899
D7955
D7960
D7970
D7971
D7972
D7980
D7983
D7997
D7999
8.4.1.10 Orthodontic Procedures
Refer to: Section 8.3.2, “Dental Orthodontics,” on page 8-4.
8.4.1.11 Adjunctive General Services
Use the following procedure codes for adjunctive general services:
Procedure Codes
D9220
D9221
D9310
D9420
D9610
D9630
D9920
D9940
D9950
D9952
D9974
D9999
Note: Invasive procedures for clients with cleft palate/lip and/or craniofacial anomalies must be prior
authorized and performed by enrolled cleft/craniofacial teams or enrolled affiliated providers. See
Section 3.1.8, “Specialty Team/Center Enrollment,” on page 3-3 and Section 17.1.4, “Specialty
Team/Center,” on page 17-4, for additional information.
8–22
CPT only copyright 2005 American Medical Association. All rights reserved.
Dental
8.4.2 Prior Authorization Not Required
The following procedure codes do not require authorization or prior authorization and may be used when
submitting claims:
8.4.2.1 Diagnostic Procedures
The following diagnostic procedures do not require authorization or prior authorization:
Procedure Codes
D0120
D0140
D0150
D0160
D0170
D0210
D0220
D0230
D0240
D0250
D0260
D0270
D0272
D0274
D0277
D0290
D0310
D0320
D0321
D0322
D0330
D0340
D0350
D0460
D0470
8.4.2.2 Preventive Procedures
The following are billable preventive procedure codes:
Procedure Codes
D1110
D1120
D1201
D1203
D1204
D1205
D1330
D1351
D1510
D1515
D1520
D1525
D1550
8
Tobacco counseling (D1320) and dental nutrition counseling (D1310) are not benefits of the CSHCN
Services Program as separate procedures.
Dental Sealants
Dental sealants may be a benefit for clients under 21 years of age. Sealants may be applied to the
occlusal, buccal, and lingual pits and fissures of any tooth. 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 will be on a per-tooth basis, regardless of the
number of surfaces sealed. Tooth numbers and surfaces must be indicated on the claim form.
Replacement sealants are not reimbursed.
If, upon claims processing or retrospective review, the finding of the claim/narrative/documentation/charting, by a provider, of terms/acronyms indicating preventive resin or combination of similar
words, the procedure will be reimbursed as a dental sealant only and not for any of the restorative
procedures.
Dental Prophylaxis
The following dental prophylaxis services are a benefit of the CSHCN Services Program:
Procedure Codes
D1110
D1120
D1201
D1204
D1205
D1330
D1203
The following preventive dental codes will not be payable on the same date of service as any D4000
series (periodontal) procedure codes:
Procedure Codes
D1110
D1120
D1201
D1204
D1205
D1351
D1203
Oral Hygiene Instruction (OHI)
Procedure code D1330 for OHI may be a benefit of the CSHCN Services Program 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 have been directed toward the client’s care.
OHI (procedure code D1330) is limited to once per year by any provider.
CPT only copyright 2005 American Medical Association. All rights reserved.
8–23
Chapter 8
OHI is denied when billed on the same day as dental prophylaxis (procedure codes D1110 and D1120)
and topical fluoride treatments with prophylaxis (procedure codes D1201 and D1205) by the same
provider.
Space Maintainers
Space maintainers are designed to prevent tooth movement and may be a benefit of the CSHCN
Services Program in the following situations:
• After premature loss of deciduous/primary tooth first and/or second molar(s), TID: A, B, I, J, K, L, S,
and T for clients 1 through 12 years of age
• After loss of a permanent first molar(s) (TID 3, 14, 19 and 30) for clients 3 through 20 years of age
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 permanent tooth.
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/dental necessity.
Space maintainers may be reimbursed with procedure codes D1510, D1515, D1520, and D1525.
When procedure codes D1510 or D1515 have been previously reimbursed, the recementation of space
maintainers may be considered for reimbursement to either the same or a different CSHCN Services
Program dental provider when billed with procedure code D1550.
8.4.2.3 Restorative Procedures
Note: Prior authorization is required for inlay/onlay restorations and single crown restorations
(permanent teeth only) in excess of four in a lifetime, any provider.
Use the following procedure codes when billing restorative procedures:
Procedure Codes
D2140
D2150
D2160
D2161
D2330
D2331
D2332
D2335
D2390
D2391
D2392
D2393
D2394
D2410
D2420
D2430
D2510
D2520
D2530
D2542
D2543
D2544
D2610
D2620
D2630
D2642
D2643
D2644
D2650
D2651
D2652
D2662
D2663
D2664
D2710
D2720
D2721
D2722
D2740
D2750
D2751
D2752
D2780
D2781
D2782
D2783
D2790
D2791
D2792
D2794
D2910
D2915
D2920
D2930
D2931
D2932
D2933
D2934
D2940
D2950
D2951
D2952
D2953
D2954
D2955
D2957
D2960
D2961
D2962
D2980
8.4.2.4 Endodontic Procedures
Use the following procedure codes when billing endodontic procedures:
Procedure Codes
8–24
D3110
D3120
D3220
D3230
D3240
D3310
D3320
D3330
D3351
D3352
D3353
D3410
D3421
D3425
D3426
D3430
D3450
D3910
D3920
D3950
CPT only copyright 2005 American Medical Association. All rights reserved.
Dental
8.4.2.5 Periodontic Procedures
Use the following procedure codes when billing periodontic procedures:
Procedure Codes
D4210
D4211
D4240
D4241
D4260
D4261
D4273
D4275
D4320
D4321
D4341
D4342
D4355
D4381
D4910
D4920
8.4.2.6 Prosthodontic (Removable) Procedures
Use the following procedure codes when billing prosthodontic procedures:
Procedure Codes
D5410
D5411
D5421
D5422
D5610
D5620
D5630
D5640
D5650
D5660
D5670
D5671
D5730
D5731
D5740
D5741
D5750
D5751
D5760
D5761
8.4.2.7 Oral and Maxillofacial Surgery
Use the following procedure codes when billing oral and maxillofacial surgeries:
Procedure Codes
D7111
D7140
D7240
D7241
D7250
D7261
D7270
D7282
D7510
D7520
D7670
D7910
D7911
D7912
D7972
8
8.4.2.8 Adjunctive General Services Procedures
Use the following procedure codes when billing adjunctive general services:
Procedure Codes
D8660
D9110
D9210
D9211
D9212
D9215
D9230
D9430
D9440
D9910
D9930
D9951
8.5 Dental Treatment in Hospitals and/or Ambulatory Surgical
Centers
All inpatient hospital admissions require prior authorization.
8.5.1 Dental Hospital Call
A dental hospital call may be reimbursed for clients requiring medically necessary anesthesia and/or
dental treatment in the inpatient or outpatient hospital setting. Use procedure code D9420.
Documentation supporting the medical necessity of a dental hospital call must be retained in the
patient’s record. 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. All client
records are subject to retrospective review.
8.5.2 Dental Surgeries Performed in ASCs/HASCs
Except for those procedures that require prior authorization, admission to freestanding ambulatory
surgical centers (ASCs) or outpatient hospital ambulatory surgical centers (HASCs) for the purpose of
performing dentistry services must be authorized by TMHP.
CPT only copyright 2005 American Medical Association. All rights reserved.
8–25
Chapter 8
Anesthesiologists should bill using procedure code 7-00170. Facilities (ASCs or HASCs) should bill
using procedure code F-41899.
8.6 Doctor of Dentistry Services as a Limited Physician
The CSHCN Services Program 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 Services 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
Services Program rules for cleft/craniofacial specialty team/center enrollment and be members of or
affiliated with a cleft/craniofacial center team.
Refer to: Section 3.1.8.2, “Requirements for Cleft/Craniofacial (C/C) Center Team Enrollment,” on
page 3-4, Section 8.6.2, “Cleft/Craniofacial Surgery,” on page 8-28, and Section 17.1.4,
“Specialty Team/Center,” on page 17-4, 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.
8.6.1 Surgery
The following surgery CPT procedure codes are payable to a dentist enrolled in the CSHCN Services
Program as a dentist physician:
Procedure Codes
2-10060
2-10061
2-10120
2-10121
2-10140
2-10160
2-10180
2-11000
2-11001
2-11040
2-11044
2-11440
2-11441
2-11442
2-11443
2-11444
2-11446
2-11640
2-11646
2-12011
2-12013
2-12014
2-12015
2-12016
2-12017
2/8-12018
2-12051
2-12052
2-12053
2-12054
2-12055
2-12056
2/8-12057
2-13131*
2-13132*
2/8–13133*
2-13150
2-13151
2-13152
2/8-13153
2-14040*
2-14060
2-14061
2-15000
2-15115
2-15120
2-15121
2-15240
2-15400
2-15850
2-15852
2-20000
2-20005
2-20200
2–20205
2-20220
2-20240
2-20520
2-20600
2-20605
2-20670
2/8-20680
2-20693
2-20694
2-20900
2/8-20902
2-20912
2-21010
2-21015
2-21025
2-21026
2-21029
2-21030
2-21031
2--21032
2/8-21034
2-21040
2/8-21044
2/8-21045
2/8-21050
2/8-21060
2-21070
2-21116
2/8-21240
2/8-21242
2/8-21243
2-21310
2/8-21343
2/8-21344
2-21345
2-21346
2/8-21347
2/8-21348
2-21355
2/8-21356
2/8-21360
* Payable only for repairs to the forehead, cheeks, chin, mouth, and neck.
8–26
CPT only copyright 2005 American Medical Association. All rights reserved.
Dental
Procedure Codes
2/8-21365
2/8-21366
2/8-21385
2-21386
2-21387
2/8-21390
2/8-21395
2-21400
2-21401
2-21406
2/8-21407
2/8-21408
2-21421
2/8-21422
2/8-21423
2/8-21431
2/8-21432
2/8-21433
2/8-21435
2/8-21436
2-21440
2-21445
2-21450
2-21451
2-21452
2-21453
2-21454
2/8-21461
2/8-21462
2/8-21465
2/8-21470
2-21480
2-21485
2/8-21490
2-29800
2-29804
2-30130
2-30140
2-30400
2-30450
2-30520
2-30580
2-30600
2-30630
2-30801
2-30802
2-30930
2-31020
2-31030
2-40490
2-40500
2-40510
2-40520
2-40530
2-40650
2-40702
2-40800
2-40801
2-40804
2-40805
2-40806
2-40808
2-40810
2-40812
2-40814
2-40816
2-40819
2-40820
2-40830
2-40831
2-40840
2-40842
2-40843
2-40844
2-40845
2-41000
2-41005
2-41006
2-41007
2-41008
2-41009
2-41010
2-41015
2-41016
2-41017
2-41018
2-41100
2-41105
2-41108
2-41110
2-41112
2-41113
2-41114
2-41115
2-41116
2/8-41130
2-41250
2-41251
2-41252
2-41520
2-41800
2-41806
2-41822
2-41823
2-41827
2-41830
2-41850
2-42000
2-42100
2-42104
2-42106
2-42107
2/8-42120
2-42160
2-42180
2-42182
2-42281
2-42300
2-42305
2-42310
2-42320
2-42330
2-42335
2-42340
2-42400
2-42405
2/8-42410
2/8-42415
2/8-42425
2/8-42440
2-42505
2-42550
2-42600
2-42650
2-42660
2-42665
2-42700
2-42720
2-42725
2-42810
2-42900
2-42960
2-42970
2-64400
2-64600
2-64722
2-64736
2/8-64740
5/I/T-88305
5/I/T-88331
5/I/T-88332
2-92511
8
* Payable only for repairs to the forehead, cheeks, chin, mouth, and neck.
CPT only copyright 2005 American Medical Association. All rights reserved.
8–27
Chapter 8
8.6.2 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 cleft/craniofacial team.
Refer to: Section 3.1.8.2, “Requirements for Cleft/Craniofacial (C/C) Center Team Enrollment,” on
page 3-4, Section 8.6.2, “Cleft/Craniofacial Surgery,” on page 8-28, and Section 17.1.4,
“Specialty Team/Center,” on page 17-4 for more information.
All of the following cleft/craniofacial surgery procedures must be prior authorized:
Procedure Codes
2-21079
2-21080
2-21081
2-21082
2-21083
2-21084
2-21085
2-21086
2-21087
2-21088
2-21089
2-21100
2-21110
2/8-21120
2/8-21121
2/8-21122
2/8-21123
2/8-21125
2/8-21127
2/8-21137
2/8-21138
2/8-21139
2/8-21141
2/8-21142
2/8-21143
2/8-21145
2/8-21146
2/8-21147
2/8-21150
2/8-21151
2/8-21154
2/8-21155
2/8-21159
2/8-21160
2/8-21172
2/8-21175
2/8-21179
2/8-21180
2/8-21181
2/8-21182
2/8-21183
2/8-21184
2/8-21188
2/8-21193
2/8-21194
2/8-21195
2/8-21196
2/8-21198
2/8-21199
2/8-21206
2/21208
2/8-21209
2/8-21210
2-21215
2/8-21230
2/21235
2/8-21244
2-21245
2-21246
2/8-21247
2-21248
2-21249
2/8-21255
2/8-21256
2/8-21260
2/8-21261
2/8-21263
2/8-21267
2/8-21268
2-21270
2-21275
2-21280
2-21282
2-21295
2-21296
2/8-21299
2-30460
2-30462
2-30520
2-40650
2-40652
2-40654
2-40700
2-40701
2-40702
2-40720
2-42200
2-42205
2/8-42210
2-42215
2-42220
2-42225
2-42226
2-42227
2-42235
2-42260
8.6.3 Evaluation and Management
The following evaluation and management service procedure codes are payable to a dentist physician:
Procedure Codes
1-99201
1-99202
1-99203
1-99204
1-99205
1-99211
1-99212
1-99213
1-99214
1-99215
1-99218
1-99219
1-99220
1-99221
1-99222
1-99223
1-99231
1-99232
1-99233
1-99238
3-99241
3-99242
3-99243
3-99244
3-99245
3-99251
3-99252
3-99253
3-99254
3-99255
1-99281
1-99282
1-99283
1-99284
1-99285
8.6.4 X-ray Procedures
The following diagnostic X-ray procedure codes are payable to a dentist physician:
Procedure Codes
8–28
4/I/T-70100
4/I/T-70110
4/I/T-70120
4/I/T-70130
4/I/T-70140
4/I/T-70150
4/I/T-70160
4/I/T-70170
4/I/T-70190
4/I/T-70200
CPT only copyright 2005 American Medical Association. All rights reserved.
Dental
Procedure Codes
4/I/T-70250
4/I/T-70260
4/I/T-70300
4/I/T-70310
4/I/T-70320
4/I/T-70328
4/I/T-70330
4/I/T-70332
4/I/T-70336
4/I/T-70350
4/I/T-70355
4/I/T-70370
4/I/T-70371
4/I/T-70380
4/I/T-70390
4/I/T-73100
4/I/T-76375
8.6.5 Anesthesia by Dentist Physician
In addition to the CDT codes discussed under “Benefits and Limitations” in this chapter, anesthesia
CPT procedure codes 1-99100, 1-99116, 1-99135, and 1-99140 are payable to a dentist physician.
8.7 Claims Information
Providers billing for dental services may bill electronically or use the ADA Dental Claim Form.
Refer to: Appendix B, “ADA Dental Claim Form Example,” on page B-19.
8.7.1 Dental Claim Electronic Billing
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
Electronic Data Interchange (EDI) Help Desk at 1-888-863-3638.
8
8.7.2 Dental Claim Paper Billing
All participating CSHCN Services Program dental providers must use the ADA Dental Claim Form
(Copyright 2002, American Dental Association) for paper claim submissions to the CSHCN Services
Program and can obtain copies of this form 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-digit provider identifier. The
billing provider’s full name and address must be entered in Block 48 of the ADA Dental Claim Form, and
the nine-digit provider identifier must be entered in Block 49. A claim without a provider name, address,
or provider identifier cannot be processed.
Refer to: Appendix B, “ADA Dental Claim Form Example,” on page B-19.
8.7.3 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 (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.
CPT only copyright 2005 American Medical Association. All rights reserved.
8–29
Chapter 8
8.7.4 Dental Claim Form Instructions
The Dental Claim Form Instructions describe the information that must be entered in each of the block
numbers of the ADA Dental Claim Form. Complete the dental claim form according to the instructions
to facilitate prompt and accurate reimbursement and reduce followup inquiries. Providers can review
the “ADA Dental Claim Form Example,” on page B-19, and the “Instructions for Completing the ADA
Dental Claim Form,” on page B-16.
8–30
CPT only copyright 2005 American Medical Association. All rights reserved.