Texas Health Steps Dental Services Implement Significant Changes Effective March 1, 2025

New Benefits Introduced to Enhance Oral Health Education and Accessibility

Starting March 1, 2025, Texas Health Steps will implement significant changes to its dental services, expanding benefits to include oral health education, teledentistry services, and separate reimbursements for First Dental Home (FDH) visits. The update aims to enhance oral health accessibility and education for children and young clients across Texas.

Key Updates to Dental Benefits

1. Introduction of New Dental Procedure Codes

Procedure Code D9994 – Now covers patient education to improve oral health literacy, reimbursable for clients aged 6 to 35 months to federally health centers (FQHC), Texas Health steps dental, and local health department providers for in-office service.

Procedure Code D9995 – Used to indicate that a dental service was performed via teledentistry and must be billed with:

• D0120 (Periodic Oral Evaluation) – for clients aged 3 to 20 years.
• D0140 (Limited Problem-Focused Oral Evaluation) – for clients from birth through 20 years.

Reimbursement for these services is available to Federally Qualified Health Centers (FQHCs), Texas Health Steps dental providers, oral maxillofacial surgeons, and local health departments when services are provided in an office setting.

2. First Dental Home (FDH) Program Enhancements

The FDH program, which ensures that young children have an established “dental home,” now allows for separate reimbursement of additional services when provided during an FDH visit. These include but are not limited to:

• Oral Evaluation (Procedure Code D0145) – Available every 60 days for clients 6 to 35 months old.
• Dental Case Management & Patient Education (D9994) – This course is specifically for oral health literacy improvement when anticipatory guidance is provided.
• Dental Prophylaxis (D1120) & Topical Fluoride Application (D1206) – These can now be separately reimbursed when provided during an FDH visit.

Restrictions on Frequency

• D0145 services are limited to individual dentists certified by the Texas Health Steps dental program.
• D1120 and D1206 may be performed every 60 days for clients aged 6 to 35 months but are limited to once every 6 months for older clients (35 months and above).
• D1208 (Topical Fluoride) is limited to once every six months per provider.

Teledentistry is now an officially recognized benefit under Texas Medicaid. Providers must adhere to the Texas Dental Practice Act and regulations set by the Texas Board of Dental Examiners (TSBDE).

Teledentistry Guidelines & Billing

• When dental services are provided via teledentistry, the following must be billed together:
• D0120 or D0140 (oral evaluations) + D9995 (teledentistry indicator).
• The teledentistry platform must meet HIPAA compliance to ensure patient data security.
• The client or their parent/guardian must consent before receiving teledentistry services.

Synchronous (Real-Time) Teledentistry Requirements

D9995 (Real-Time Encounter Indicator) must be included on the claim form.

Additional documentation in the dental record is required, including:

• The name and credentials of the healthcare provider.
• The location of the dentist at the time of service.

Eligibility for Teledentistry Services

Periodic Oral Evaluation (D0120) – Available via teledentistry for clients aged 3 to 20 years, provided that:

• The teledentistry platform is operated by a trained dental hygienist at the patient’s site.

Limited Problem-Focused Oral Evaluation (D0140) – Available via teledentistry for clients from birth through 20 years, provided that:

• The teledentistry platform is operated by a trained dental assistant or hygienist.

Reimbursement & Denials

• Procedure Code D9995 is not separately reimbursable but must be submitted with D0120 or D0140 for teledentistry services.
• Services exceeding the periodicity schedule may still be reimbursed if medically necessary and criteria for D0120 or D0140 are met.
• Several procedure codes (D0120, D0150, D0160, D0170, D0180, D1208, D8660) will be denied if billed incorrectly on the same date as other designated services.

Next Steps for Providers

Providers offering services under Texas Health Steps should update their billing practices and review the benefit criteria with their Medicaid Managed Care Organization (MCO) for specific authorization and reimbursement policies.

For more details, visit TMHP News or contact the TMHP Contact Center at 800-925-9126.