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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.