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Fluoride Varnish Application Under Medi-Cal Program
The California Department of Health Services announced recently that effective June 1, HCPCS code D1203 (topical application of fluoride [prophylaxis not included], child) is a Medi-Cal benefit for children under six years of age, up to three times an a 12-month period. Reimbursement for code D1203 is $18.00 and includes the materials and supplies needed for the procedure. Physicians, nurses, and other non-specified medical personnel are legally permitted to apply the varnish when the attending physician prescribes the procedure and establishes a protocol. When the procedure is performed in the absence of other medical services, the billing office may be reimbursed additionally for an office visit ($24.98 for a new child patient or $13.09 for an established child patient).
Under the Denti-Cal program, by comparison, a child may receive up to two topical fluoride applications in a 12-month period, so long as provided as part of an oral prophylaxis (Procedure 061). In February of 2005 the DHS clarified that “an oral prophylaxis can be performed using gauze, cloth, toothbrush, or rubber cup on the incisors of an infant only. Once the molars have begun to erupt, manual or power toothbrush, rubber cup, and/or hand instruments, followed by site-specific flossing maybe used.” Until such time as Denti-Cal implements Current Dental Terminology (CDT) procedure codes, there is no reimbursement under Denti-Cal for a topical fluoride application in the absence of an oral prophylaxis. Reimbursement for a child oral prophylaxis without topical fluoride application is $28.50; a child oral prophylaxis including topical fluoride application is $33.25.
There is no “coordination of benefits” between the Medi-Cal medical and dental programs and a child under 6 six years of age could receive (and the respective providers reimbursed for) three fluorides varnish applications by a physician and two topical fluoride applications (accompanied by an oral prophylaxis) by a dentist in each 12 month period.
Under state statute, physicians cannot be reimbursed under Denti-Cal and dentists cannot be reimbursed under Medi-Cal.
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