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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. 7–18 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. 7–19 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. 7–20