$45.00
D2951 Not allowed on primary teeth.
A 4-20, PXR
$12.50
D2952 Not payable with D2950. Not allowed on primary teeth.
A 13-20, CCP, PXR
$87.50
D2953 Must be used with D2952. Not allowed on primary teeth.
A 13-20
$43.75
D2954* Not payable with D2952 or D3950 on the same TID by the same
provider. Not allowed on primary teeth. A 13-20, N, CCP, PXR
$75.00
D2955 For removal of posts (for example, fractured posts) not to be used in
conjunction with endodontic retreatment (D3346, D3347, D3348). Not allowed on primary teeth.
A 4-20, CCP, PXR
$75.00
D2957 Must be used with D2954. Not allowed on primary teeth.
A 13-20, PXR, CCP
$37.50
D2960 A 13-20, N, PPXR, CCP $112.50
D2961 A 13-20, N, PPXR, CCP $181.25
Procedure
Code Limitations Maximum Fee
A=Age range limitations, N=Narrative required, FMX=Full-mouth radiographs (nonpanoramic),
MTID=Missing tooth ID(s), PPXR=Preoperative and postoperative radiographs required, PXR=Preoperative radiographs required, PHO=preoperative and postoperative photographs required, PC=Periodontal charting required, PATH=Pathology report required and must be retained in the client’s record, CCP=Comprehensive Care Program, NC=No charge to Medicaid and may not bill the client, and *= Services payable to an FQHC for a client encounter
4.2.15 Endodontics Services
Therapeutic pulpotomy (procedure code D3220) and apexification and recalcification procedures (procedure codes D3351, D3352, and D3353) are considered part of the root canal (procedure codes D3310, D3320, and D3330) or retreatment of a previous root canal (procedure codes D3346, D3347, and D3348). When therapeutic pulpotomy or apexification and recalcification procedures are submitted with root canal codes, the reimbursement rate is adjusted to ensure that the total amount reimbursed does not exceed the total dollar amount allowed for the root canal procedure.
Reimbursement for a root canal includes all appointments necessary to complete the treatment. Pulpotomy and radiographs performed pre, intra, and postoperatively are included in the root canal reimbursement.
Root canal therapy that has only been initiated, or taken to some degree of completion, but not carried to completion with a final filling, may not be submitted as a root canal therapy code. It must be submitted using code D3999 with a narrative description of what procedures were completed in the root canal therapy.
Documentation supporting medical necessity must be kept in the client’s record and include the following: the medical necessity as documented through periapical radiographs of tooth treated showing pre-treatment, during treatment, and post-treatment status; the final size of the file to which the canal was enlarged; and the type of filling material used. Any reason that the root canal may appear radio- graphically unacceptable must be documented in the client's record.
If the client is pregnant and does not want radiographs, use alternative treatment (temporary) until after delivery.
D2962 A 13-20, N, PPXR, CCP $212.50
D2970 May be reimbursed once per lifetime for each tooth, any provider. $200.00
D2971* May be reimbursed up to four services per lifetime for each tooth.
Payable to any THSteps dental provider who performed the original cementation of the crown. A 13-20
$112.50
D2980 A 1-20, PXR (permanent teeth only) $50.00
D2999 A 1-20, N, CCP, PXR Manually
priced
Procedure
Code Limitations Maximum Fee
Pulp Capping
Procedure codes D3110 and D3120 will not be reimbursed when submitted with the following procedure codes for the same tooth, for the same DOS, by the same provider: D2952, D2953, D2954, D2955, D2957, D2980, D2999, D3220, D3230, D3240, D3310, D3320, or D3330.
A=Age range limitations, N=Narrative required, FMX=Full-mouth radiographs (nonpanoramic),
MTID=Missing tooth ID(s), PPXR=Preoperative and postoperative radiographs required, PXR=Preoperative radiographs required, PHO=preoperative and postoperative photographs required, PC=Periodontal charting required, PATH=Pathology report required and must be retained in the client’s record, CCP=Comprehensive Care Program, NC=No charge to Medicaid and may not bill the client, and *= Services payable to an FQHC for a client encounter
Procedure
Code Limitations Maximum Fee
A=Age range limitations, N=Narrative required, FMX=Full-mouth radiographs (nonpanoramic),
MTID=Missing tooth ID(s), PPXR=Preoperative and postoperative radiographs required, PXR=Preoperative radiographs required, PHO=preoperative and postoperative photographs required, PC=Periodontal charting required, PATH=Pathology report required and must be retained in the client’s record, CCP=Comprehensive Care Program, NC=No charge to Medicaid and may not bill the client, and *= Services payable to an FQHC for a client encounter
D3110 A 1-20, N, PXR, CCP $16.25
D3120 A 1-20, N, PXR, CCP $30.00
Pulpotomy
D3220* Denied when performed within six months of D3230, D3240,
D3310, D3320, or D3330 for the same primary TID, same provider. Denied when performed within six months of D3310, D3320, or D3330 on the same permanent TID, same provider. A Birth-20, PXR
$87.96
D3221 Denied as global fee to any endodontic procedure. NC
Endodontic Therapy on Primary Teeth
D3230* Anterior primary incisors and cuspids.
TIDs #C-H; M-R. A 1-20, PXR
$38.75
D3240* Posterior first and second molars.
TIDs #A, B, I, J, K, L, S, T. A 1-20, PXR
$43.98
Endodontic Therapy (including Treatment Plan, Clinical Procedures, and Follow-up Care)
D3310* A 6-20, PPXR $355.98
D3320* A 6-20, PPXR $412.50
D3330* A 6-20, PPXR $624.26
D3331 Not payable, use retreatment codes. NC
D3332 Not payable, use retreatment codes. NC
D3333 Not payable, use retreatment codes. NC
Endodontic Retreatment D3346* A 6-20, PPXR $156.25 D3347* A 6-20, PPXR $206.25 D3348* A 6-20, PPXR $275.00 Apexification/Recalcification Procedures D3351* A 6-20, N, PXR, CCP $75.00 D3352* A 6-20, N, PXR, CCP $50.00 D3353* A 6-20, PPXR, CCP $100.00 Apicoectomy/Periradicular Services D3410 A 6-20, N, PPXR, CCP $131.25 D3421 A 6-20, N, PPXR, CCP $162.50 D3425 A 6-20, N, PPXR, CCP $162.50 D3426 A 6-20, N, PPXR, CCP $75.00 D3430 A 6-20, N, PPXR, CCP $50.00 D3450 A 6-20, N, PXR, CCP $75.00
D3460 Prior authorization required. Submit request with periapical radio-
graphs, for each tooth involved. A 16-20, N, PPXR, CCP
$212.50 Procedure
Code Limitations Maximum Fee
A=Age range limitations, N=Narrative required, FMX=Full-mouth radiographs (nonpanoramic),
MTID=Missing tooth ID(s), PPXR=Preoperative and postoperative radiographs required, PXR=Preoperative radiographs required, PHO=preoperative and postoperative photographs required, PC=Periodontal charting required, PATH=Pathology report required and must be retained in the client’s record, CCP=Comprehensive Care Program, NC=No charge to Medicaid and may not bill the client, and *= Services payable to an FQHC for a client encounter
4.2.16 Periodontal Services
Procedure codes D4210 and D4211, when submitted for clients who are 12 years of age and younger, will be initially denied, but may be appealed with documentation of medical necessity. Preoperative and postoperative photographs are required for the following procedure codes: D4210, D4211, D4270, D4271, D4273, D4275, D4276, D4355, and D4910.
Preoperative and postoperative photographs are required when medical necessity is not evident on radiographs for the following procedure codes: D4240, D4241, D4245, D4266, and D4267. Documen- tation is required when medical necessity is not evident on radiographs for the following procedure codes: D4210, D4211, D4240, D4241, D4245, D4266, D4270, D4271, D4273, D4275, D4276, D4267, D4355, and D4910.
Claims for preventive dental procedure codes D1110, D1120, D1203, D1204, D1206, and D1351 will be denied when submitted for the same DOS as any D4000 series periodontal procedure codes.
Procedure codes D4266 and D4267 may be appealed with documentation of medical necessity. Medical necessity for third molar sites are:
• Medical or dental history documenting need due to inadequate healing of bone following third molar extraction, including the date of third molar extraction.
• Secondary procedure several months postextraction. • Position of the third molar preoperatively.
• Postextraction probing depth to document continuing bony defect. • Postextraction radiographs documenting continuing bony defect. • Bone graft and barrier material used.
Medical necessity for other than third molar sites are:
• Medical or dental history documenting comorbid condition (e.g., juvenile diabetes, cleft palate, avulsed tooth or teeth, traumatic oral injuries).
• Intra- or extra-oral radiographs of treatment site(s).
• If not radiographically evident, intraoral photographs are optional unless requested preoperatively by HHSC or it's agent.
• Periodontal probing depths.
• Number of intact walls associated with an angular bony defect.
D3470 A 6-20, N, PXR, CCP $125.00
Other Endodontic Procedures
D3910 A 1-20, N, CCP $18.75 D3920 A 6-20, N, PXR, CCP $81.25 D3950 A 6-20, N, PXR, CCP $50.00 D3999 A 1-20, N, PXR, CCP Manually priced Procedure
Code Limitations Maximum Fee
A=Age range limitations, N=Narrative required, FMX=Full-mouth radiographs (nonpanoramic),
MTID=Missing tooth ID(s), PPXR=Preoperative and postoperative radiographs required, PXR=Preoperative radiographs required, PHO=preoperative and postoperative photographs required, PC=Periodontal charting required, PATH=Pathology report required and must be retained in the client’s record, CCP=Comprehensive Care Program, NC=No charge to Medicaid and may not bill the client, and *= Services payable to an FQHC for a client encounter
• Bone graft and barrier material used. Procedure
Code Limitations Maximum Fee
Surgical Services (Including Usual Postoperative Care)
D4210 A 13-20, N, PPXR, PHO, CCP $162.50
D4211 A 13-20, N, PHO, CCP $50.00
D4230 A 13-20, N, PHO, PXR, CCP $162.50
D4231 A 13-20, N, PHO, PXR, CCP $97.50
D4240 A 13-20, N, FMX, PXR, PHO when medical necessity is not evident
on radiographs, PC, CCP
$181.25
D4241 Limited to once per year. A 13-20, N, FMX, PXR, PHO when
medical necessity is not evident on radiographs, PC
$55.00
D4245 Per quadrant. A 13-20, N, PXR, PHO when medical necessity is not
evident on radiographs, CCP
$181.25
D4249 A six- to eight-week healing period following crown lengthening
before final tooth preparation, impression making, and fabrication of a final restoration is required for claims submission of this code. A 13-20, N, PPXR, CCP
$162.50
D4260 A 13-20, N, FMX, PXR, PC, CCP $225.00
D4261 Limited to once per year. A 13-20, N, FMX, PXR, PC $67.00
D4265 Denied as global to other services. NC
D4266 A 13-20, N, PXR, PHO when medical necessity is not evident on
radiographs, CCP
$275.00
D4267 A 13-20, N, PXR, PHO when medical necessity is not evident on
radiographs, CCP
$325.00
D4270 A 13-20, N, PXR, PHO, CCP $193.75
D4271 A 13-20, N, PXR, PHO, CCP $206.25
D4273 This procedure is performed to create or augment gingiva, to obtain
root coverage or to eliminate frenum pull, or to extend the vesti- bular fornix. A 13-20, N, PXR, PHO, CCP
$225.00
D4274 This procedure is performed in an edentulous area adjacent to a
periodontally involved tooth. Gingival incisions are used to allow removal of a tissue wedge to gain access and correct the underlying osseous defect and to permit close flap adaptation.