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Medicaid of Georgia Reimbursement for Fluoride Varnish


Patients at risk for caries include those with: insufficient sources of dietary fluoride; high carbohydrate diets; caretakers
who transmit decay-causing bacteria to children via their saliva; areas of tooth decalcification; reduced salivary flow; and poor oral hygiene.

Fluoride varnish acts to retard, arrest, and reverse the caries process. The teeth absorb the fluoride varnish, strengthening the enamel and helping prevent cavities. It is not a substitute for fluoridated water or toothpaste.

HCPCS Code: D1206

HCPCS Description: Topical fluoride varnish; therapeutic application for moderate to high caries risk patients.

Who can bill CPT / CDT D1206 ?

Providers and PCPs enrolled in these GA Medicaid programs may bill D1206 (effective 1/1/2010):

Dentists: under category of service 450

Physicians: under category of service 430

Physician Assistants (PA): under category of service 431

Advanced Registered Nurse Practitioners (ARNP): under category of service 740

Limitations:

Limited to Medicaid or PeachCare for Kids recipients 1 month of age to 13 years, 11 months of age.

Allowed twice a year but will deny if D1203 (topical fluoride) has been billed and combined total will exceed child’s fluoride reimbursement benefit of two (2) per year (confirm for Fee-For-Service members with Health Check Profile / Appointment Tracking system or claims system).

Providers may not bill for an Evaluation and Management (E/M) visit in addition to billing for the application of fluoride varnish, if the sole purpose of the visit was to apply the fluoride varnish. In this instance, the provider may bill for the fluoride varnish code only.

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