texas health steps (thsteps) therapeutic dental …

TEXAS HEALTH STEPS (THSTEPS) THERAPEUTIC

DENTAL SERVICES

This drafted policy is open for a two‐week public comment period. This box is not

part of the drafted policy language itself, and is intended for use only during the

comment period as a means to provide readers with a summarized list of the new

policy.

HHSC is performing a targeted review of the Texas Health Steps Dental Therapeutic

Services policy for specific covered services for Medicaid clients.

The following is a summary of changes in scope for this policy review:

• Clarification of how prior authorizations may be submitted to TMHP

• Added language on how repetitive procedure codes must be submitted for prior

authorization

• Added language for other surgical codes W‐D7280 and W‐D7283 to specify prior

authorization requirements and benefit limitations

• Updated frequency limitations on direct amalgam and resin‐based composite

restorations and prefabricated stainless steel crowns

• Updated dental anesthesia language regarding appropriate anesthesia level permits

Some policy language that is out of scope for this review is included in this document for

context. New policy language has been underlined and deleted language has been struck‐

through to highlight proposed policy changes.

Note: The current language regarding services covered under this targeted review of the Texas

Health Steps Dental Therapeutic Services Policy can be found in the Texas Medicaid Provider

Procedures Manual (TMPPM), Vol 2: Children’s Services Handbook, Section 4 Texas Health Steps

(THSteps) Dental.

Statement of Benefits

1 All dental providers must comply with the rules and regulations of the Texas State Board

of Dental Examiners (TSBDE), including standards for documentation and record

maintenance as stated in the TSBDE Rules §108.7 Minimum Standards of Care, General

and 108.8 Records of the Dentist.

2 Clients who are 14 years of age or younger must be accompanied to all medical and

dental checkups/ visits by the client's parent, legal guardian, or an adult authorized by

the parent or legal guardian. The authorized adult may be the client's relative. The

individual accompanying the client must wait for the client while the appointment takes

place. This policy does not apply to services provided by a school health clinic, Head

Start program, or child‐care facility if the clinic, program, or facility providing the

services (Human Resources Code):

2.1 Obtains valid written consent for services from the client's parent or legal

guardian within the one‐year period prior to the date the services are provided.

2.2 Encourages parental involvement in, and the management of, the health care

of the children receiving services from the clinic, program, or facility.

3 As with all Medicaid services, a provider acknowledges compliance with all Medicaid

requirements when he or she submits a claim for reimbursement.

Substitute Dentist

4 Dentists may bill for the services of a substitute dentist pursuant to 42 CFR 447.10.

5 This arrangement is one in which a substitute dentist covers for the primary dentist on

an occasional basis when the primary dentist is unavailable to provide services. The

primary dentist (who is the billing agent dentist) may only bill for services furnished by a

substitute dentist on a temporary basis, for no longer than a 90‐day consecutive period.

Under this temporary basis, the billing agent dentist may not submit a claim for services

furnished by a substitute dentist to address long‐term vacancies in a dental practice. A

billing agent dentist may submit claims for the services of a substitute dentist for longer

than 90 consecutive days, if the billing agent dentist has been called or ordered to active

duty as a member of a reserve component of the Armed Forces. Medicaid accepts

claims from the billing agent dentist for services provided by the substitute dentist for

the duration of the billing agent dentist's active duty as a member of a reserve

component of the Armed Forces.

6 The substitute dentist must be licensed to practice in the state of Texas. Consistent with

the requirements of Title 1, Texas Administrative Code (TAC) §371.1605 and §371.1705

(relating to Provider Responsibility and Mandatory Exclusion, respectively), the

substitute dentist must be enrolled in Medicaid and not be on the Medicaid or Title XX

provider exclusion list.

7 The billing agent dentist must bill substitute dentist services on a different claim form

from his or her own services. The billing agent dentist services cannot be billed on the

same claim form as substitute dentist services.

8 The dental claim form must include the substitute dentist's National Provider Identifier

(NPI) number in Block 35. When the billing agent dentist uses a substitute dentist, they

must file dental claims using modifier U5. Modifier U5 must be entered in Block 19 on

the dental claim form. The billing agent dentist's name, address, and NPI number must

appear in Blocks 53, 54, and 56 on the dental claim form. The billing agent dentist may

recover no more than the actual administrative cost of submitting the claim on behalf of

the substitute dentist. This cost is not reimbursable by Medicaid.

9 Dentists must familiarize themselves with these requirements and document

accordingly. Those services not supported by the required documentation as detailed

above will be subject to recoupment.

Dental Anesthesia

10 All dental providers must comply with the rules and regulations of the TSBDE, including

the standards for documentation and record maintenance for dental anesthesia. There

are four levels of anesthesia:

Table A: Levels of Sedation

Level Description of Level Permit Privileges

Nitrous Oxide/Oxygen

Inhalation Conscious

Sedation

Stand Alone Permit

Level 1 Minimal Sedation Stand Alone Permit

Level 2 Moderate Enteral Automatically qualifies for

Level 1 and Level 2 Permit

privileges.

Level 3 Moderate Parenteral Automatically qualifies for

Level 1, Level 2, and Level 3

Permit privileges

Level 4 Deep Sedation/General

Anesthesia

Automatically qualifies for

Level 1, Level 2, Level 3, and

Level 4 Permit privileges

Provider Type(s)

03 County Indigent Health Care Program

46 Federally Qualified Health Centers (FQHC)

48 Texas Health Steps ‐ Dental

90 Orthodontist

91 Oral Maxillofacial Surgeon

92 Texas Health Steps Dental ‐ Group

Place(s) of Service

1 Office

3 Inpatient Hospital

5 Outpatient Hospital

Authorization Requirements

11 Prior authorization requests may be submitted to the TMHP Prior Authorization

Department via mail, fax, or the electronic portal. Prescribing or ordering providers,

dispensing providers, clients' responsible adults, and clients may sign prior authorization

forms and supporting documentation using electronic or wet signatures. For additional

information about electronic signatures, please refer to the 'Electronic Signatures in

Prior Authorizations' medical policy.

11.1 Each distinct dental procedure code to be performed that requires prior

authorization must be listed on the THSteps Dental Mandatory Prior

Authorization Request Form. Repetitive dental procedure codes must be listed

to indicate the total quantity to be performed. Claims submitted with

unauthorized codes will be denied, but may be appealed with documentation

of medical necessity.

12 All Level 4 sedation services by a dentist, procedure codes W‐D9222 and W‐D9223, and

any anesthesia services provided by an anesthesiologist (M.D./D.O.) or certified

registered nurse anesthetist (CRNA), procedure code 7‐00170, with U3 modifier, to be

provided in conjunction with dental therapeutic services for Medicaid dental clients

from ages 0 through 6 years of age, must be prior authorized. The dentist performing

the therapeutic procedure is responsible for obtaining prior authorization from TMHP.

Prior authorization for both dental services and Level 4 sedation/general anesthesia

service is mandatory for the reimbursement of either service. The dentist performing

the dental therapeutic service is also responsible for providing the anesthesia prior

authorization information to the anesthesiology provider. The current process of scoring

22 points on the Criteria for Dental Therapy Under General Anesthesia form does not

guarantee authorization or reimbursement for the age group.

13 Client specific documents and information to be submitted for prior authorization

include but are not limited to:

13.1 The completed Criteria for Dental Therapy Under General Anesthesia form

13.2 The completed THSteps Dental Mandatory Prior Authorization Request Form

13.3 Location where procedures will be performed (in office, or inpatient/outpatient

hospital facility)

13.4 Narrative unique to the client detailing reasons for the proposed level of

anesthesia sedation including

history of prior treatment, failed attempts at other levels of sedation, behavior

in the dental chair, proposed restorative treatment (tooth ID and surfaces),

urgent need to provide comprehensive dental treatment based on extent of

diagnosed dental caries, and any relevant medical condition(s)

13.5 Diagnostic quality radiographs and/or photographs

13.5.1 When appropriate radiographs and/or photographs cannot be taken

prior to

general anesthesia, the narrative must support the reasons for an

inability to perform diagnostic services. For these special cases that

receive authorization, diagnostic quality radiographs/photographs will

be required for payment and will be reviewed by the TMHP Dental

Director.

NOTE: In cases of an emergency medical condition, accident or trauma, prior

authorization is not necessary, but a narrative and appropriate pre and post

treatment radiographs/photographs must be submitted with the claim and will

be reviewed by the TMHP Dental Director for appropriateness prior to payment.

14 Procedure code W‐D7280 (exposure of unerupted tooth) and W‐D7283 (placement of

device to facilitate eruption of impacted tooth) do not require prior authorization. Code W‐

D7283 is for permanent dentition only (TID 2‐15 and 18‐31) and requires prior authorization. To

obtain prior authorization, a prior authorization request form along with a copy of an

authorized Medicaid orthodontic treatment plan must be submitted along with a current

panoramic radiograph to determine medical necessity.

15 Procedure code W‐D7280 will be denied unless billed with an authorized procedure

code W‐D7283, for the same tooth, on the same day, by the same provider.

16 Crowns, onlays, endodontic endosseous implants, and fixed prosthodontics require

mandatory prior authorization.

Authorization is valid up to 90 days. To obtain prior authorization, a prior authorization

request form together with documentation supporting medical necessity and

appropriateness must be submitted. Required documentation includes, but is not

limited to:

16.1 The THSteps Dental Mandatory Prior Authorization Request Form

16.2 Current, dated, pre‐operative periapical radiographs completely showing the

apex of the tooth to be treated

16.3 Current, dated, pre‐operative full arch radiographs are required for fixed

prosthodontics

16.4 Documentation supporting that the mouth is free of disease; no untreated

periodontal or endodontic disease, or rampant caries

16.5 Documentation supporting only one virgin abutment tooth; at least one tooth

must require a crown unless a Maryland Bridge is being considered

16.6 Provider documentation supporting the medical necessity and appropriateness

of the recommended treatment

16.7 Tooth Identification (TID) System noting only permanent teeth

16.8 Documentation supporting that a removable partial is not a viable option to fill

the space between the teeth

17 Prior authorization is required for the use of codes W‐D4341 and W‐D4342. A current

periodontal charting, a current set of full mouth x‐rays (FMX), and a narrative describing the

periodontal diagnosis must be submitted to determine medical necessity.

18 Removable prosthodontics (procedure codes W‐D5951, W‐D5952, W‐D5953, W‐

D5954, W‐D5955, W‐D5958, W‐D5959, and W‐D5960) for clients who have cleft lip or cleft

palate require prior authorization with a completed THSteps Dental Mandatory Prior

Authorization Request Form and narrative documenting the medical need for these appliances.

Additional information may be requested by the TMHP Dental Director if necessary before

making a determination.

19 When the treatment plan is interrupted and services are not completed, prior

authorization is not transferable from the original provider to the new provider. The new

provider must obtain prior authorization to complete the treatment plan initiated by the

original provider.

20 Prior authorization will not be given when:

20.1 Films show two good abutment teeth (virgin teeth do not require a crown,

except for Maryland Bridge)

20.2 There is untreated periodontal or endodontic disease, or rampant caries, which

would contraindicate the treatment

21 An endodontic endosseous implant (procedure code W‐D3460):

21.1 Is not a benefit of THSteps Dental but is reimbursed under CCP for children who

are 16 through 20 years of age

21.2 Requires prior authorization by the Texas Medicaid & Healthcare Partnership

(TMHP) Dental Medical Director. The criteria used by the Dental Medical Director are

as follows:

21.2.1 Anatomy is such that no other fixed or removable prosthodontic

alternatives are available (e.g., anodontia, a result of trauma, birth defect)

21.2.2 Regular treatment failed

Reimbursement

22. The following American Dental Association (ADA) Current Dental Terminology (CDT) codes

are used in reference to this policy.

Table B: Procedure Codes—Amalgam Restorations– Direct (Including Polishing)

Procedure Code

W‐D2140* W‐D2150*

W‐D2160* W‐D2161*

22. Procedure code W‐D2140 and W‐D2150 are benefits under THSteps Dental for clients

who are birth though 20 years of age and clients who are 21 years of age or older residing in an

ICF‐IID facility.

Table C: Procedure Codes—Resin-Based Composite Restorations - Direct

Procedure Code

W‐D2330* W‐D2331* W‐D2332*

W‐D2335* W‐D2390* W‐D2391*

W‐D2392* W‐D2393* W‐D2394*

23 Procedure codes W-D2140, W-D2150, W-D2330, W-D2331, W-D2390, and W-D2391, and

W-D2392 are benefits under THSteps-Dental for clients birth through 20 years of age and

clients who are 21 years of age or older residing in an ICF-IID facility.

24 Procedure codes W-D 2160, W-D2161, W-D2332, W-D2335, W-D2392, W-D2393, and W-D2394 are

benefits under THSteps-Dental for clients 1 year through 20 years of age and clients who are 21 years of

age or older residing in an ICF-IID facility

25 Procedure codes W‐D2140, W‐D2150, W‐D2160, W‐D2161, W‐D2330, W‐D2331, W‐

D2332, W‐D2391, W‐D2392, W‐D2393 and W‐D2394 are limited to once per rolling year,

same TID, any same provider.

26 Procedure codes W‐D2335 and W‐D2390 when provided to primary teeth are limited to

once per lifetime, same TID, any provider.

27 Procedure codes W‐D2335 and W‐D2390 will deny if any of the following anterior

restorations have been paid within that a per within a rolling year, W‐D2140, W‐D2150, W‐

D2160, W‐D2161, W‐D2330, W‐D2331, W‐D2332, W‐D2335, and W‐D2390, W‐D2930, W‐

D2931, W‐D2932, W‐D2933, and W‐D2934.

28 Total reimbursement for direct restorations cannot exceed the total dollar amount allowed

for a stainless steel crown, per TID, per date of service. This limitation does not apply to

procedure code W‐D2335

Total reimbursement for restorative services of a primary tooth over a 6 month period will not

exceed the fee for a stainless steel crown (exception: D‐2335 and D‐2933), when provided by

the same dentist or dentists within a dental group. Exceptions will be considered when

pretreatment and x‐ray images, intraoral photos, and narrative documentation clearly support

the medical necessity for the retreatment dental services during pre‐payment review.

Restorative of a primary tooth through the use of stainless steel crown is considered to be a

once in a lifetime restoration. Exceptions will be considered when pretreatment x‐ray images,

intra oral photos, and narrative documentation clearly support the medical necessity for the

replacement of the stainless steel crown during the pre‐payment review.

Method for Counting Minutes for Timed Procedure Codes

29 Method for Counting Minutes for Timed Procedure Codes in 15 ‐ Minute Units

29.1 All claims for reimbursement of procedure codes paid in 15 minute increments

are based on the actual amount of billable time associated with the service. For

those services for which the unit of service is 15 minutes (1 unit = 15 minutes),

partial units would be rounded up or down to the nearest quarter hour. See

Table D below.

29.2 Procedure code W‐D9239 (intravenous moderate (conscious)

sedation/anesthesia ‐ first 15 minutes) is limited to 1 unit.

29.3 Procedure code W‐D9243 (intravenous moderate (conscious)

sedation/anesthesia ‐ subsequent 15 minute increment) is limited to 5 units.

29.4 Procedure code W‐D9222 (deep sedation/general anesthesia ‐ first 15 minutes)

is limited to 1 unit.

29.5 Procedure code W‐D9223 (deep sedation/general anesthesia ‐ each

subsequent 15 minute increment) is limited to 11 units of time.

29.6 Time intervals for 1 through 12 units are as follows:

Table D: Units-Counting Minutes for Timed Procedure Codes in 15-Minute Unit

Units Number of Minutes

0 units 0 minutes through 7 minutes

1 unit 8 minutes through 22 minutes











29.7 Documentation must be maintained in the client's dental record to support the

necessity of services and is subject to retrospective review.

29.8 Documentation must include the sedation record that indicates sedation start

and end times in accordance with the American Academy of Pediatric Dentistry

(AAPD) guidelines.

Inlay/Onlay Restorations and Crowns – Single Restorations Only (CCP)

Inlay/Onlay Restorations

Table E: Procedure Codes

Procedure Code

W‐D2510 W‐D2520 W‐D2530

W‐D2542 W‐D2543 W‐D2544

W‐D2650 W‐D2651 W‐D2652

W‐D2662 W‐D2663 W‐D2664

Crowns ‐ Single Restorations Only

Table F: Procedure Codes

Procedure Code

W‐D2710 W‐D2720 W‐D2721

W‐D2722 W‐D2740 W‐D2750*

W‐D2751* W‐D2752 W‐D2780

W‐D2781 W‐D2782 W‐D2783

W‐D2790 W‐D2791* W‐D2792*

W‐D2794

30 Procedure codes W‐D2510, W‐D2910, W‐D2952, W‐D2954, W‐D2960, W‐D2961,

W‐D2962, W‐ D2971, W‐D4910, W‐D4920, W‐D5130, W‐D5140, W‐D9950, W‐D9951,

W‐D9952, and W‐D9970 are restricted to clients who are 13 through 20 years of age for

Texas Medicaid.

31 Procedure code W‐D9944 is restricted to clients who are 16 through 20 years of age for

Texas Medicaid.

32 Procedure code W‐D2980 is a benefit under THSteps‐Dental for clients who are 1

through 20 years of age and clients who are 21 years of age or older residing in an ICF‐

IID facility.

33 Crowns ‐ single restoration only procedure code W‐D2791 is a benefit under THSteps‐

Dental for clients who are 13 through 20 years of age and clients who are 21 years of

age or older residing in an ICF‐IID facility.

34 Inlay/onlay restorations (procedure codes W‐D2520, W‐D2530, W‐D2542, W‐D2543,

W‐D2544, W‐ D2650, W‐D2651, W‐D2652, W‐D2662, W‐D2663, and W‐2664) and crowns

‐ single restorations only Procedure codes W‐D2710, W‐D2720, W‐D2721, W‐D2722, W‐

D2780, W‐D2781, W‐D2782, W‐ D2783, W‐D2790, W‐D2791, W‐D2792, and W‐D2794)

are benefits of CCP for clients who are 13 through 20 years of age and clients who are 21

years of age or older residing in an ICF‐IID facility.

35 Porcelain fused to metal crowns ‐ single restorations only (procedure codes W‐D2740, W‐

D2750, W‐ D2751, and W‐D2752) are benefits of the CCP for clients who are 13 through

20 years of age and clients who are 21 years of age or older residing in an ICF‐IID facility.

36 Inlay/onlay restorations and crowns ‐ single restorations only, are benefits when

performed on permanent teeth.

37 Inlay/onlay restorations and crowns ‐ single restorations only, are reimbursed with a

maximum fee. This fee includes the actual inlay, onlay, or crown; any provisional crown

and any preparatory work prior to the seating of the permanent crown.

38 Using the TID System, porcelain inlay and onlays may be applied to any tooth (#1

through #32).

39 Using the TID System, porcelain crowns (procedure codes W‐D2740, W‐D2750,

W‐D2751, and W‐D2752) may be applied only to teeth #4 through #13 and #20 through

#29.

40 A post‐operative bitewing radiograph (for posterior teeth) and a post‐operative

periapical radiograph (for anterior teeth) will need to be submitted with the claim(s)

that the provider submits to TMHP for reimbursement of the services to verify the

restoration meets the standard of care.

41 Radiographs must be reviewed by TMHP staff with an active Texas Dental License to

verify that the restoration meets both medical necessity and standard of care to

approve reimbursement.

42 Reimbursement for crowns and onlay restorations are payable once per client, per tooth

every ten years.

Table G: Procedure Codes—Other Dental

Procedure Code

W‐D2910 W‐D2915 W‐D2920 W‐D2930*

W‐D2931* W‐D2932* W‐D2933* W‐D2934*

W‐D2940* W‐D2950* W‐D2951 W‐D2952

W‐D2953 W‐D2954* W‐D2955 W‐D2957

W‐D2960 W‐D2961 W‐D2962 W‐D2971

W‐D2980 W‐D2999

43 Procedure codes W‐D2930, W‐D2933, W‐D2934, and W‐D2940 are benefits under

THSteps‐Dental for clients who are birth through 20 years of age and clients who are 21

years of age or older residing in an ICF‐IID facility.

44 Procedure codes W‐D2931 and W‐D2932 are a benefit under THSteps‐Dental for clients

who are 1 year of age through 20 years of age and clients who are 21 years of age or

older residing in an ICF‐IID facility.

45 Procedure code W‐D2932 is a benefit for both primary teeth C‐H and M‐R, and all

permanent teeth.

46 Procedure code W‐D2933 is a benefit for primary teeth only.

47 Direct restoration of a primary tooth through the use of a prefabricated crown is

considered to be a once in a lifetime restoration, same TID, any provider. Exceptions

may be considered when pre‐treatment x‐ray images, intra‐oral photos, and narrative

documentation clearly support the medical necessity for the replacement of the

prefabricated crown (procedure codes W‐D2930, W‐D2932, W‐D2933, W‐D2934, during

pre‐payment review.

48 Procedure codes W‐D2930, W‐D2932, W‐D2933 and W‐D2934 will deny if the following

procedure codes have been billed with in that per within a rolling year, same TID;

W‐D2140, W‐D2150, W‐D2160, W‐D2161, W‐D2330, W‐D2331, W‐D2332, W‐D2335,

W‐D2390, W‐D2391, W‐D2392, W‐D2393 or W‐D2394.

49 Procedure codes W‐D2933 and W‐D2934 will deny if the following procedure codes

have been billed within a rolling year, same TID; W‐D2140, W‐D2150, W‐D2160,

W‐D2161, W‐D2330, W‐D2331, W‐D2332, W‐D2335 or W‐D2390.

50 Procedure codes W‐D2931 and W‐D2932 will deny if the following procedure

codes have been billed within a rolling year, same TID; W‐D2140, W‐D2150, W‐D2160,


W‐D2393, W‐D2394, W‐D2931 or W‐D2932.

51 Procedure code W‐D2971 will be reimbursed four times per lifetime for each tooth, any

provider.

52 Procedure code W‐D2920 is payable to any THSteps dental provider including who

performed the original cementation of the crown.

Endodontic Treatments

54 Most endodontic treatments are reimbursed under THSteps‐Dental. Those services not covered

under THSteps‐Dental are covered under CCP if the services are medically necessary,

appropriate, and allowable as provided in the TAC.

Internal Bleaching of a Tooth (Endodontic) (CCP)

55 Procedure code W‐D9974, internal bleaching ‐ per tooth, must be used when billing for

the endodontic bleaching of a tooth.

56 Internal bleaching of a discolored tooth is an accepted endodontic treatment. It is

intended to remove and change the organic material in the enamel of an infected or

traumatized tooth. It is considered medically necessary when chemical change of the

contents in the interior of the tooth is judged necessary to complete an endodontic

treatment to a tooth. This is for therapeutic and not cosmetic purposes.

57 Internal bleaching of a discolored tooth does not refer to the bleaching of the exterior of

the tooth. This procedure code is not intended to allow for reporting and claim

reimbursement for the cosmetic treatment of the exterior surface of the tooth.

58 Internal bleaching of a discolored tooth:

58.1 Is not a benefit of THSteps‐Dental but is reimbursed under CCP for children

who are 13 through 20 years of age

58.2 Does not require prior authorization

58.3 Is considered for reimbursement when the claim is filed with documentation

supporting medical necessity. Claims filed without documentation supporting

medical necessity will be denied as incomplete

Pulp Caps

59 Direct pulp caps (procedure code D3110) may be reimbursed separately from any final

tooth restoration performed on the same tooth (as noted by the TID System) on the

same date of service by the same provider.

60 Procedure code W‐D3110 will be reimbursed when billed with procedure codes








W‐D2931, W‐D2932, W‐D2933, W‐D2934, W‐D2940, W‐D2950, or W‐D2951 for the

same tooth, on the same day, by the same provider.

61 Procedure codes W‐D3110 and W‐D3120 will be denied when billed with procedure

codes W‐D2952, W‐D2953, W‐D2954, W‐D2955, W‐D2957, W‐D2980, W‐D2999,

W‐D3220, W‐D3230, W‐D3240, W‐D3310, W‐D3320, or W‐D3330 for the same tooth, on

the same day, by the same provider.

Table H: Procedure Codes

Procedure Code

W‐D3110 W‐D3120

Pulpotomy

62The following procedure codes must be used when billing for a pulpotomy:

Table I: Procedure Codes

Procedure Code

W‐D3220* W‐D3230* W‐D3240*

63 Procedure code W‐D3220 is a benefit under THSteps‐Dental for clients who are birth

through 20 years of age and clients who are 21 years of age or older residing in an

ICF‐IID facility.

64 Procedure codes W‐D3220, pulpotomy, will deny when billed or performed within six

months of the pulpal therapy (procedure codes W‐D3230 and W‐D3240) same primary

TID, same provider.

65 Procedure codes W‐D3220, pulpotomy, will deny when billed or performed within six

months of the root canal therapy (procedure codes W‐D3310, W‐D3320, and W‐D3330)

on the same permanent TID, same provider.

Root Canal Therapy and Retreatment of Previous Root Canal Therapy

NOTE: * = Services payable to a FQHC for a client encounter.

66 The following procedure codes must be used when billing for an initial root canal

therapy and a retreatment of previous root canal therapy:

Table J: Procedure Codes

Procedure Code

W‐D3310* W‐D3320* W‐D3330* W‐D3346*

W‐D3347* W‐D3348* W‐D3351* W‐D3352*

W‐D3353* W‐D3410 W‐D3421 W‐D3425

W‐D3426 W‐D3430 W‐D3450 W‐D3460

W‐D3470 W‐D3910 W‐D3920 W‐D3950

W‐D3999


W‐D3351, W‐ D3352, W‐D3353, W‐D3410, W‐D3421, W‐D3425, W‐D3426, W‐D3430,

W‐D3450, W‐D3470, W‐D3920, and W‐D3950 are restricted to clients who are 6 through

20 years of age.

68 Procedure code W‐D3220 is considered to be a once per lifetime treatment per primary

tooth (tooth IDs A‐T). Consideration will be given during pre‐payment review for re‐

treatment performed by a dentist not associated with the original treating dentist or

dental practice.

69 Re‐treatment claims for incomplete pulpotomy will be considered for reimbursement on

appeal with documentation of medical necessity and incomplete initial pulpotomy and

must include a written narrative and pre and post treatment x‐rays which will be

reviewed by a Texas licensed dentist.

NOTE: The identified original treating dentist will not be eligible for payment.

70 An initial root canal therapy (procedure codes W‐D3310, W‐D3320, and W‐D3330) or

retreatment of previous root canal therapy (procedure codes W‐D3346, W‐D3347, and

W‐D3348):

70.1 Is a benefit under the THSteps‐Dental when provided to a permanent tooth

70.2 Is not a benefit under the THSteps‐Dental when provided to a primary tooth

70.3 Is limited to four permanent teeth when billed under THSteps‐Dental

70.4 Reimbursement for additional root canals (in addition to the four services

covered under the THSteps‐Dental) is available, under CCP. Providers must

send documentation supporting medical necessity when filing the claim

70.5 Documentation supporting medical necessity must be kept in the client's dental

record and include the following: the medical necessity prior to treatment,

during treatment and post treatment, periapical radiographs, the final size of

the file to which the canal was enlarged, and the type of filling material used. If

there is any reason that the root canal may appear radiographically

unacceptable, then this must be documented in the client's dental record.

71 Any of the services listed below performed to a tooth within the six‐month period

preceding a root canal is considered part of the root canal. The claims suspend to an

adjudicator who performs an adjustment to the reimbursement rate to ensure that the

total amount reimbursed does not exceed the total dollar amount allowed for a root

canal therapy (procedure codes W‐D3310, W‐D3320, and W‐ D3330) or retreatment of

previous root canal (procedure codes W‐D3346, W‐D3347, and W‐ D3348).

71.1 Therapeutic pulpotomy (procedure code W‐D3220)

71.2 Apexification and recalcification procedures (procedure codes W‐D3351,

W‐D3352, and W‐D3353)

72 The services listed below billed after the root canal therapy (procedure codes W‐D3310,

W‐D3320, and W‐D3330) or retreatment of previous root canal (procedure codes

W‐D3346, W‐D3347, and W‐D3348) are reimbursed in addition to the root canal therapy

(procedure codes W‐D3310, W‐D3320, and W‐D3330) or retreatment of previous root

canal (procedure codes W‐D3346, W‐D3347, and W‐D3348).

72.1 Apicoectomy (procedure codes W‐D3410, W‐D3421, W‐D3425, and W‐D3426)

73 The reimbursement rate for a root canal (procedure codes W‐D3310, W‐D3320,

W‐ D3330, W‐D3346, W‐D3347, and W‐D3348) includes all appointments necessary to

complete the treatment. These include:

73.1 Pulpotomy

73.2 Radiographs performed pre, intra‐, and postoperatively

74 The reimbursement rate for a root canal (procedure codes W‐D3310, W‐D3320,

W‐D3330, W‐D3346, W‐D3347, and W‐D3348) does not include the services listed

below. The following are reimbursed in addition to the root canal:

74.1 Diagnostic evaluation

74.2 Radiographs performed at the initial, periodic, or emergency service visits

75 Root canal therapy not carried to completion with a final filling should not be billed

using a root canal therapy procedure code. Providers must bill procedure code W‐D3999

and file the claim with a narrative description of the procedures completed.

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

to claim filing guidelines, providers must file within the 95‐day period following the date

of service, in this case, the date the service was initiated.

Endodontic Endosseous Implant (CCP)

77 An endodontic endosseous implant must be billed with procedure code W‐D3460,

endodontic endosseous implant.

Periodontal Services

78The eligible age range for the following procedure codes is 13 through 20 years of age:

Table K: Procedure Codes

Procedure Code

W‐D4210 W‐D4211 W‐D4240 W‐D4241

W‐D4245 W‐D4249 W‐D4260 W‐D4261

W‐D4266 W‐D4267 W‐D4270 W‐D4273

W‐D4274 W‐D4275 W‐D4276 W‐D4277

W‐D4278 W‐D4341 W‐D4283 W‐D4285

W‐D4342 W‐D4355* W‐D4381 W‐D4999

79 Procedure codes W‐D4210 and W‐D4211, when billed for clients who are 12 years of

age or younger, will be initially denied, but may be appealed with documentation of

medical necessity.

80 Procedure codes W‐D4260 and W‐D4261 are limited to once per quadrant, per day, by

the same provider.

81 Procedure code W‐D4275 is limited to once per day, by the same provider.

82 Additionally, pre‐ and postoperative photographs will be required for the following

procedure codes: W‐D4210, W‐D4211, W‐D4270, W‐D4273, W‐D4275, W‐D4276,

W‐D4277, W‐D4278, W‐D4283, W‐D4285, W‐D4355, and W‐D4910.

83 Procedure code W‐D4278 must be billed on the same date of service as procedure code

W‐D4277 or it will be denied.

84 Pre‐ and postoperative photographs will be required when medical necessity is not

evident on radiographs for the following procedure codes; W‐D4240, W‐D4241,

W‐D4245, W‐D4266, and W‐D4267.

85 Procedure codes W‐D4283 and W‐D4285 have a limitation of three teeth per site.

Procedure code W‐D4283 is not payable unless procedure code W‐D4273 is also billed

and procedure code W‐D4285 is not payable unless procedure code W‐D4275 is also

billed.

86 Procedure code W‐D0350 (2D oral/facial photographic image obtained intra‐orally or

extra‐orally) must be used for billing for photographs.

87 Documentation will be required when medical necessity is not evident on radiographs

for the following procedure codes; W‐D4210, W‐D4211, W‐D4240, W‐D4241, W‐D4245,

W‐D4266, W‐D4267, W‐

D4270, W‐D4273, W‐D4275, W‐D4276, W‐D4277, W‐D4278, W‐D4283, W‐D4285,

W‐D4355, and W‐D4910.

88 Procedure codes W‐D4266 and W‐D4267 may be appealed with documentation of

medical necessity as below.

88.1 Medical necessity for third molar sites are:

88.1.1 Medical/dental history documenting need due to inadequate healing of

bone following third molar extraction, including date of third molar

extraction

88.1.2 Secondary procedure several months post extraction

88.1.3 Position of the third molar preoperatively

88.1.4 Post extraction probing depths to document continuing bony defect

88.1.5 Post extraction radiographs documenting continuing bony defect

88.1.6 Bone graft and barrier material utilized

88.2 Medical necessity for other than third molar sites are:

88.2.1 Medical or dental history documenting comorbid condition (e.g.,

juvenile diabetes, cleft palate, avulsed tooth or teeth, traumatic oral

injuries)

88.2.2 Intra‐ or extra‐oral radiographs of treatment site(s)

88.2.3 If not radiographically evident, intraoral photographs would be

appropriate to request; otherwise, intraoral photographs are optional

unless requested preoperatively by HHSC or its agent

88.2.4 Periodontal probing depths

88.2.5 Number of intact walls associated with an angular bony defect

88.2.6 Bone graft and barrier material utilized

89 Procedure code W‐D4341 and W‐D4342 will not be reimbursed on the same date of

service as procedure code W‐D4355.

90 Procedure code W‐D4341 will deny when billed on the same date of service as any

W‐D4000 series codes except for W‐D4341 and W‐D4342.

91 Procedure code W‐D4342 will deny when billed on the same date of service as any

W‐D4000 series codes except for W‐D4341 and W‐D4342.

92 Procedure code W‐D4355 will deny when billed on the same date of service as any of

the following procedure codes W‐D4210, W‐D4211, W‐D4230, W‐D4231, W‐D4240,



W‐D4320, W‐D4321, D4381, W‐D4910, W‐D4920, and W‐D4999.

93 The preventive dental procedure codes W‐D1110, W‐D1120, W‐D1206, W‐D1208,

W‐D1351, and W‐D1352 will be denied when billed on the same date of service as any

W‐D4000 series periodontal procedure codes.

94 The age range is 1 through 20 years of age for the following procedure codes:

Table L: Procedure Codes

Procedure Code

W‐D4320 W‐D4321

95The age range is 13 years through 20 years for the following CCP procedure codes:

Table M: Procedure Codes

Procedure Code

W‐D4910 W‐D4920

96 Procedure code W‐D4910 is payable only following active periodontal therapy by any

provider as evidenced either by a billed claim for procedure code W‐D4240, W‐D4241,

W‐D4260, W‐D4261, or by evidence through client records of periodontal therapy while

not Medicaid eligible.

97 Procedure code W‐D4910 is limited to once per 12 calendar months for the same

provider.

Prosthodontics (Removable) (CCP)

98 Local anesthesia will be denied as part of removable prosthodontic procedures, and use

the following American Dental Association (ADA) procedure codes when billing

removable prosthodontic procedures.

Table N: Procedure Codes

Procedure Code

W‐D5110 W‐D5120 W‐D5130 W‐D5140 W‐D5211*

W‐D5212* W‐D5213 W‐D5214 W‐D5410 W‐D5411

W‐D5421 W‐D5422 W‐D5511 W‐D5512 W‐D5520

W‐D5611* W‐D5612* W‐D5630* W‐D5640* W‐D5650*

W‐D5660* W‐D5670* W‐D5671* W‐D5710 W‐D5711

W‐D5720* W‐D5721* W‐D5730 W‐D5731 W‐D5740*

W‐D5741* W‐D5750 W‐D5751 W‐D5760* W‐D5761*

W‐D5810 W‐D5811 W‐D5820 W‐D5821 W‐D5850

W‐D5851 W‐D5862 W‐D5863 W‐D5864 W‐D5865

W‐D5866 W‐D5899 W‐D5911 W‐D5912 W‐D5913

W‐D5914 W‐D5915 W‐D5916 W‐D5919 W‐D5922

W‐D5923 W‐D5924 W‐D5925 W‐D5926 W‐D5927

W‐D5928 W‐D5929 W‐D5931 W‐D5932 W‐D5933

W‐D5934 W‐D5935 W‐D5936 W‐D5937 W‐D5951

W‐D5952 W‐D5953 W‐D5954 W‐D5955 W‐D5958

W‐D5959 W‐D5960 W‐D5982 W‐D5983 W‐D5984

W‐D5985 W‐D5986 W‐D5987 W‐D5988 W‐D5992*

W‐D5993* W‐D5999

99 Cost of repairs cannot exceed replacement costs.

100 Denture reline procedures are allowed whether or not the denture was obtained

through THSteps or ICF‐IID dental services if the reline makes the denture serviceable.

101 Procedure code W‐D5670 will be denied as part of procedure codes W‐D5211, W‐D5213

and W‐D5640.

102 Procedure code W‐D5671 will be denied as part of procedure codes W‐D5212, W‐D5214

and W‐D5640.

Fixed Dental Prosthetics (CCP)

103 Fixed prosthetics are not a benefit of THSteps‐Dental, but are reimbursed under

CCP for clients who are 16 through 20 years of age and clients who are 21 years of age

or older and residing in an ICF‐IID facility. The client must be old enough to have mature

teeth and minimal jaw growth remaining.

104 Fixed prosthetics (pontics, retainers, and abutments ‐ procedure codes W‐ D6210,


W‐D6252, W‐D6545, W‐

D6548, W‐D6549, W‐D6720, W‐D6721, W‐D6722, W‐D6740, W‐D6750, W‐D6751,

W‐D6752, W‐D6780, W‐D6781, W‐D6782, W‐D6783, W‐D6790, W‐D6791, and

W‐D6792 are reimbursed with a maximum fee. This fee includes any preparatory work

prior to the placement of the fixed prosthetic.

105 Using the TID System, porcelain pontics and crowns may be applied to any tooth (#1

through #32).

Prosthodontics, Fixed

106 Each abutment and each pontic constitutes a unit in a fixed partial denture bridge

(bridgework).

107 Fixed Partial Denture Pontics:

Table O: Procedure Codes

Procedure Code

W‐D6210 W‐D6211 W‐D6212

W‐D6240 W‐D6241 W‐D6242

W‐D6245 W‐D6250 W‐D6251

W‐D6252

109 Fixed Partial Denture Retainers:

Table P: Procedure Codes

Procedure Code

W‐D6545 W‐D6548 W‐D6549

110 Fixed Partial Denture Retainers ‐ Crowns:

Table Q: Procedure Codes

Procedure Code

W‐D6720 W‐D6721 W‐D6722

W‐D6740 W‐D6750 W‐D6751

W‐D6752 W‐D6780 W‐D6781

W‐D6782 W‐D6783 W‐D6790

W‐D6791 W‐D6792

111 Other Fixed Partial Denture Services:

Table R: Procedure Codes

Procedure Code

W‐D6920 W‐D6930 W‐D6940

W‐D6950 W‐D6980 W‐D6999

Oral and Maxillofacial Surgery

NOTE: All oral surgery procedures include local anesthesia and visits for routine postoperative

care.

Table S: Procedure Codes—Extractions (Includes Local Anesthesia, Suturing (if needed), and

Routine Postoperative Care)

Procedure Code

W‐D7111 W‐D7140* W‐D7210*

W‐D7220* W‐D7230* W‐D7240

W‐D7241 W‐D7250*

Table T: Procedure Codes—Other Surgical Procedures

Procedure Code

W‐D7260 W‐D7261 W‐D7270*

W‐D7272 W‐D7280 W‐D7282

W‐D7283 W‐D7285 W‐D7286*

W‐D7290 W‐D7291

Table U: Procedure Codes—Alveoloplasty – Surgical Preparation of Ridge for Dentures

Procedure Code

W‐D7310 W‐D7320

Table V: Procedure Codes—Vestibuloplasty

Procedure Code

W‐D7340 W‐D7350

Table W: Procedure Codes—Surgical Excision of soft Tissue Lesions

Procedure Code

W‐D7410 W‐D7411

W‐D7413 W‐D7414

Table X: Procedure Codes—Surgical Excision of Intraosseous Lesions

Procedure Code

W‐D7440 W‐D7441

W‐D7450 W‐D7451

W‐D7460 W‐D7461

W‐D7465

Table Y: Procedure Codes—Excision of Bone Tissue

Procedure

Code

W‐D7472

Table Z: Procedure Codes—Surgical Incision

Procedure Code

W‐D7510* W‐D7520

W‐D7530 W‐D7540

W‐D7550* W‐D7560

W‐D7670

Table AA: Procedure Codes—Reduction of Dislocation and Management of Other

Temporomandibular Joint Dysfunctions

Procedure Code

W‐D7820 W‐D7880 W‐D7899

Table AB: Procedure Codes—Repair of Traumatic Wounds

Procedure

Code

W‐D7910*

Table AC: Procedure Codes—Complicated Suturing (Reconstruction Requiring Delicate Handling

of Tissues and Wide Undermining for Meticulous Closure) Reconstruction requiring delicate

handling of tissues and wide undermining for meticulous closure

Procedure

Code

W‐D7911

Table AC: Procedure Codes—Complicated Suturing (Reconstruction Requiring Delicate Handling

of Tissues and Wide Undermining for Meticulous Closure) Reconstruction requiring delicate

handling of tissues and wide undermining for meticulous closure

Procedure

Code

W‐D7912

Table AD: Procedure Codes—Other Repair Procedures

Procedure Code

W‐D7960 W‐D7970*

W‐D7971* W‐D7972

W‐D7980 W‐D7983

W‐D7997* W‐D7999*

Adjunctive General Services

Unclassified Treatment

112 Procedure code W‐D9110 is emergency service only. The type of treatment rendered

and TID must be indicated. It must be for a service other than a prescription or topical

medication. Each claim submitted for payment must be marked as “Trauma” or

“Emergency” in the Description field, Block 30, the original date of treatment or incident

must be referenced in the Remarks field, Block 35, the appropriate box must be checked

in the Treatment Resulting From field, Block 45 if applicable and modifier ET must be

used, indicating emergency.

113 Documentation to support the emergency and the treatment performed for W‐D9110

must be maintained in the client's dental medical record.

114 Procedure code W‐D9110 is payable for the following:

114.0.1 Sedative or periodontal dressing

114.0.2 Starting root canal procedure; i.e., open and drain tooth or re‐

medication of previously opened tooth

114.0.3Smoothing fractured tooth that is cutting lips or cheek

114.0.4Debridement or curettage of wound

114.0.5Excision of operculum over an erupting tooth

114.0.6 Limited gingivectomy

114.0.7Suture removal by dentist other than the dentist who placed suture(s)

114.0.8 Placement of a temporary crown by other than the patient's regular

dentist and one who is not in the process, has not previously, or does

not in the future intend to perform an acrylic, polycarbonate, stainless

steel or cast crown on this same tooth

114.0.9Tissue conditioning of a full or partial denture

114.0.10Removal of spontaneously or post‐surgically sequested bone spicule

114.0.11Spot or limited scaling and root planing

114.0.12Procedures necessary to treat a dry socket

114.0.13Procedures necessary to control bleeding

114.0.14Non‐surgical reduction of TMJ dislocation

114.0.15 Procedures necessary to relieve pain associated with pericoronitis,

particularly third molars

114.1Procedure code W‐D9110 is not payable for the following:

114.1.1 Prescription written

114.1.2 Medication given or administered

114.1.3Application of topical medication to teeth or gums

114.1.4 Occlusal adjustments

114.1.5 Oral hygiene instructions

Dental Anesthesia

115 Providers must comply with all Texas State Board of Dental Examiners (TSBDE) Rules and

American Academy of Pediatric Dentistry (AAPD) guidelines.

116 Providers must have a Level 4 permit and an anesthesiology residency recognized by the

American Dental Board of Anesthesiology to bill the enhanced rate for procedure code

W‐D9222 and W‐D9223.

117 All providers must have the appropriate anesthesia permit when proceeding with the

following procedure codes listed in Table AE. Providers must have the appropriate

anesthesia permit to bill for the following anesthesia codes.

Table AE: Procedure Codes

Procedure Code

W‐D9211 W‐D9212

W‐D9222 W‐D9223

W‐D9230

Table AE: Procedure Codes

Procedure Code

W‐D9239 W‐D9243 W‐D9248


W‐D9239, W‐D9243, and W‐D9248 are benefits under THSteps‐Dental for clients 1

through 20 years of age, and clients 21 years of age and older residing in an ICF‐IID

facility.

119 Local anesthesia in conjunction with operative or surgical services (procedure code

W‐D9215) is all inclusive with any other dental service and is not separately

reimbursable.

120 Reimbursement for conscious sedation services procedure code W‐D9239 (intravenous

moderate (conscious) sedation/analgesia ‐ first 15 minutes) is limited to fifteen minutes

per day. Reimbursement for conscious sedation services procedure code W‐D9243

(intravenous moderate (conscious) sedation/ analgesia ‐ each subsequent 15 minute

increment) is limited to one hour and fifteen minutes per day. Procedure code W‐D9243

will be denied unless billed with procedure code W‐D9239 on the same day by the same

provider.

121 All levels of sedation (procedure codes listed in Table AE) must have clinical

documentation and a narrative in the client's dental record to support the necessity of

the service. The client's dental record must be available for review by representatives of

HHSC or its designee.

122 Reimbursement for dental general anesthesia (procedure codes W‐D9222, W‐D9223 or

7‐00170 with

the U3 modifier) is limited to once per six calendar months, per client, any provider.

Procedure code W‐D9223 will be denied unless billed with procedure code W‐D9222 on

the same day by the same provider.

123 Procedure code W‐D9222 (deep sedation/general anesthesia ‐ first 15 minutes) is

limited to fifteen minutes per day. Procedure code W‐D9223 (deep sedation/general

anesthesia ‐ each 15 minute increment) is limited to two hours and forty‐five minutes

per day.

124 Procedure code W‐D9248 is limited to two times per year.

125 The following procedure codes (W‐D9210, W‐D9211, W‐D9212, W‐D9222, W‐D9230,

W‐D9239, and W‐D9920) will be denied when billed for the same date of service as non‐

IV conscious sedation (procedure code W‐D9248).

126 Procedure code W‐D9239 (Intravenous moderate (conscious) sedation) will deny when

billed on the same day, by the same provider as procedure code W‐D9222 (Deep

sedation/general anesthesia).

127 THSteps‐Dental reimburses for dental services to clients who are birth through 20 years

of age. Dental rehabilitation and restoration services requiring general anesthesia may

be performed in an office or in an inpatient or outpatient hospital facility.

128 General anesthesia services for procedure codes W‐D9222, W‐D9223 and 7‐00170 with

the U3 modifier must reflect compliance with the Criteria for Dental Therapy Under

General Anesthesia, and a copy of the Criteria for Dental Therapy Under General

Anesthesia form (Table AF) must be maintained in the client's dental record. The client's

dental record must be available for review by representatives of HHSC or its designee.

129 When proceeding with Level 4 sedation/general anesthesia, the dental provider is

required to maintain the following documentation in the client's dental record:

129.1 The medical evaluation justifying the need for anesthesia

129.2 Description of relevant behavior and reference scale

129.3 Other relevant narratives justifying the need for general anesthesia

129.4 Client’s demographics, including date of birth

129.5 Relevant dental and medical history

129.6 Dental radiographs, intraoral/perioral photography and/or diagram of dental

pathology

129.7 Proposed dental plan of care

129.8 Consent signed by parent/guardian giving permission for the proposed dental

treatment and acknowledging that the reason for the use of IV sedation or

general anesthesia for dental care has been explained

129.9 Completed Criteria for Dental Therapy Under General Anesthesia form

129.10 The parent/guardian dated signature on the Criteria for Dental Therapy Under

General Anesthesia form attesting that they understand and agree with the

dentist’s assessment of their child’s behavior

129.11 Dentist's attestation statement and signature, which may be put on the bottom

of the Criteria for Dental Therapy Under General Anesthesia form or included in

the client's dental record as a stand‐alone form

NOTE: Total points needed to justify hospitalization for general anesthesia = 22.

Table AF: Criteria for Dental Therapy Under General Anesthesia

Criteria Points

Age of Patient at Time of Examination

Less than four years of age 8

Four and five years of age 6

Six and seven years of age 4

Eight years of age and older 2

Treatment Requirements

1‐2 teeth or one sextant 3

3‐4 teeth or 2‐3 sextants 6

5‐8 teeth or 4 sextants 9

9 or more teeth or 5‐6 sextants 12

Behavior of Patient**

Definitely Negative ‐ unable to complete exam, patient unable to cooperate

due to lack of physical or emotional maturity, and/or disability

10

Somewhat Negative ‐ defiant; reluctant to accept treatment; disobeys

instruction; reaches to grab or deflect operator’s hand, refusal to take

radiographs

4

Other behaviors such as moderate levels of fear, nervousness, and cautious

acceptance of treatment should be considered as normal responses, and

are not indications for treatment under general anesthesia.

0

Additional Factors

Presence of oral\perioral pathology (other than caries), anomaly, or

trauma requiring surgical intervention**

15

Failed conscious sedation** 15

Medically compromising or handicapping condition** 15

** Requires that narrative fully describing circumstances be present in the patient’s record.

130 Prior authorization is required for clients who are in need of a general anesthetic who do not

meet the 22‐point threshold. The Criteria for Dental Therapy Under General Anesthesia form

and supporting documentation, including the appropriate narrative, must be submitted to

HHSC or its designee for prior authorization.

Dental Hospital Call

131 THSteps dental hospital call (procedure code W‐D9420) may be reimbursed for clients

who require medically necessary general anesthesia and dental treatment in the

inpatient or outpatient hospital setting.

Procedure code W‐D9420

Dental Hospital Call

132 THSteps dental hospital call (procedure code W‐D9420) may be reimbursed for clients

who require medically necessary general anesthesia and dental treatment in the

inpatient or outpatient hospital setting.

133 Procedure code W‐D9420 is a benefit under THSteps‐Dental for clients 1 through 20

years of age, and clients 21 years of age and older residing in an ICF‐ IID facility.

134 Procedure code W‐D9420 is limited to two times per rolling year, per client, any

provider.

135 Procedure code W‐D9248 will deny when billed on the same date of service as

W‐D9420.

136 Documentation supporting the medical necessity of a dental hospital call (procedure

code W‐D9420), including any medical, physical (e.g., traumatic event), mental or

behavioral disability, and a description of the service performed, which required a

hospital call, must be retained in the client's dental record and will be subject to

retrospective review. Charts are subject to retrospective review.

Table AG: Procedure Codes—Miscellaneous Services

Procedure Code

W‐D9110* W‐D9210 W‐D9310 W‐D9410

W‐D9420 W‐D9430 W‐D9440 W‐D9610

W‐D9630 W‐D9910 W‐D9920 W‐D9930*

W‐D9944 W‐D9950 W‐D9951 W‐D9952

W‐D9970 W‐D9974* W‐D9999*

137 Procedure code W‐D9970 will be reimbursed one service per day, any provider.

138 Limited occlusal adjustment (procedure code W‐D9951) may be reimbursed once per

year, per client.

139 Complete occlusal adjustment (procedure code W‐D9952) may be reimbursed once per

lifetime, per provider.

140 Procedure code W‐D9910 is restricted to once per year and limited to clients who are 18

through 20 years of age for Texas Medicaid.

141 Dental behavior management (procedure code W‐D9920) is reimbursed when the client

has a diagnosis of an intellectual disability described as mild, moderate, severe,

profound or unspecified.

142 Documentation supporting the medical necessity and appropriateness of dental

behavior management (procedure code W‐D9920) must be retained in the client’s chart

and is subject to retrospective review. Documentation may include:

142.1 A current physician statement detailing the client’s intellectual disability,

signed and dated within one year prior to the dental behavior management

142.2 A description of the service performed, including the specific problem and the

behavior management technique applied

142.3 Personnel and supplies required to provide the behavioral management

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

143 Dental behavior management is not reimbursed with an evaluation, prophylactic

treatment, or radiographic procedure.

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