Chapter 8 Dental - TMHP.com

8Dental 

8.1 Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-2 

8.2 Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-2 

8.2.1 Tooth Identification (TID) and Surface Identification (SID) Systems . . . . . . . . . . . 8-2 

8.2.2 Supernumerary Tooth Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-2 

8.3 Benefits and Limitations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-3 

8.3.1 Anesthesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-3 

8.3.2 Dental Orthodontics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-4 

8.3.3 Coverage/Policy Clarifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-8 

8.4 Summary of Authorization Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-20 

8.4.1 Prior Authorization Required. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-20 

8.4.1.1 Diagnostic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-20 

8.4.1.2 Restorative Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-21 

8.4.1.3 Endodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-21 

8.4.1.4 Periodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-21 

8.4.1.5 Prosthodontic (Removable) Procedures . . . . . . . . . . . . . . . . . . . . . . . . . 8-21 

8.4.1.6 Maxillofacial Prosthodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . 8-21 

8.4.1.7 Implant Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-21 

8.4.1.8 Prosthodontic (Fixed) Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-22 

8.4.1.9 Oral and Maxillofacial Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-22 

8.4.1.10 Orthodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-22 

8.4.1.11 Adjunctive General Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-22 

8.4.2 Prior Authorization Not Required. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-23 

8.4.2.1 Diagnostic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-23 

8.4.2.2 Preventive Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-23 

8.4.2.3 Restorative Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-24 

8.4.2.4 Endodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-24 

8.4.2.5 Periodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-25 

8.4.2.6 Prosthodontic (Removable) Procedures . . . . . . . . . . . . . . . . . . . . . . . . . 8-25 

8.4.2.7 Oral and Maxillofacial Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-25 

8.4.2.8 Adjunctive General Services Procedures . . . . . . . . . . . . . . . . . . . . . . . . 8-25 

8.5 Dental Treatment in Hospitals and/or Ambulatory Surgical Centers . . . . . . . . . . . . . . 8-25 

8.5.1 Dental Hospital Call . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-25 

8.5.2 Dental Surgeries Performed in ASCs/HASCs. . . . . . . . . . . . . . . . . . . . . . . . . . 8-25 

8.6 Doctor of Dentistry Services as a Limited Physician . . . . . . . . . . . . . . . . . . . . . . . . . 8-26 

8.6.1 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-26 

8.6.2 Cleft/Craniofacial Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-28 

8.6.3 Evaluation and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-28 

8.6.4 X-ray Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-28 

8.6.5 Anesthesia by Dentist Physician. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-29 

8.7 Claims Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-29 

8.7.1 Dental Claim Electronic Billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-29 

8.7.2 Dental Claim Paper Billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-29 

8.7.3 Dental Emergency Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-29 

8.7.4 Dental Claim Form Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-30 

CPT only copyright 2005 American Medical Association. All rights reserved. 

Chapter 

8

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. 

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 6 7 8 9 10 11 12 13 14 15 16 

Super # 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 

8–2 CPT only copyright 2005 American Medical Association. All rights reserved.

Permanent Teeth Lower Arch 

Tooth # 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 

Super # 82 81 80 79 78 77 76 75 74 73 72 71 70 69 68 67 

Primary Teeth Upper Arch 

Tooth # A B C D E F G H I J 

Super # AS BS CS DS ES FS GS HS IS JS 

Primary Teeth Lower Arch 

Tooth # T S R Q P O N M L K 

Super # TS SS RS QS PS OS NS MS LS KS 

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. 

8.3.1 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 

Dental 

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8.3.2 Dental Orthodontics 

Orthodontic procedures require prior authorization and may be reimbursed for the following diagnosis 

codes: 

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 



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: 

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) 



8


When a diagnostic workup is not approved, individual components may be considered for separate 

reimbursement. Use the following procedure codes: 

CDT Procedure Code 

D0330 

Remarks Code Description 

D0340 

D0350 

D0470 

Z2010 Diagnostic workup, not approved 

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: 


1033D Mandibular, fixed, 2x4 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: 


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: 


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): 

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 


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 

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 



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 

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 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 D4260 

D4341 D7310 D7320 D9221 

• Denying follow-up visit procedure codes listed below if billed within 90 days of radiation treatment 

provided by the same provider: 


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: 


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: 


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: 


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 



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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 
















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 

• Reviewing for medical necessity any visits/consults billed by a dentist for a diagnosis other than the 

following dental diagnosis codes: 


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 



8



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 



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 















8




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 



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 



8



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 



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 



8



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: 


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 


• Reviewing procedures billed with a noncovered mental retardation diagnosis for clients 0 through 

20 years of age: 


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: 


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: 


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: 


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. 



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. 


8.4.1.2 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: 


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: 


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: 


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: 


D6010 D6040 D6050 D6055 D6056 

D6057 

D6199 

D6080 D6090 D6095 D6100 



8


8.4.1.8 Prosthodontic (Fixed) Procedures 

Use the following procedure codes for prosthodontic (fixed) procedures: 


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: 


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: 


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. 


8.4.2 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: 


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: 


D1110 D1120 D1201 D1203 D1204 

D1205 D1330 D1351 D1510 D1515 

D1520 D1525 D1550 

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: 


D1110 D1120 D1201 D1203 

D1204 D1205 D1330 

The following preventive dental codes will not be payable on the same date of service as any D4000 

series (periodontal) procedure codes: 


D1110 D1120 D1201 D1203 

D1204 D1205 D1351 

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. 



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: 


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: 


D3110 D3120 D3220 D3230 D3240 

D3310 D3320 D3330 D3351 D3352 

D3353 D3410 D3421 D3425 D3426 

D3430 D3450 D3910 D3920 D3950 


8.4.2.5 Periodontic Procedures 

Use the following procedure codes when billing periodontic procedures: 


D4210 D4211 D4240 D4241 D4260 

D4261 D4273 D4275 D4320 D4321 

D4341 

D4920 

D4342 D4355 D4381 D4910 

8.4.2.6 Prosthodontic (Removable) Procedures 

Use the following procedure codes when billing prosthodontic procedures: 


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: 


D7111 D7140 D7240 D7241 D7250 

D7261 D7270 D7282 D7510 D7520 

D7670 D7910 D7911 D7912 D7972 

8.4.2.8 Adjunctive General Services Procedures 

Use the following procedure codes when billing adjunctive general services: 


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. 



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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: 


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. 



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 

* Payable only for repairs to the forehead, cheeks, chin, mouth, and neck. 



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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: 


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 

2-42260 

2-42225 2-42226 2-42227 2-42235 

8.6.3 Evaluation and Management 

The following evaluation and management service procedure codes are payable to a dentist physician: 


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: 


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 



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. 


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. 

8.7.2 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. 


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. 



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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.

Chapter 8 Dental - TMHP.com

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