Medicine

Adult fluoride billing and coding strategies

Fluoride is not just for kids! As our population ages, the need for fluoride treatments is becoming more critical. The Oral Health in America report by the National Institutes of Health recently reported that by 2035, there will be more adults over the age of 65 than there will be youth in the US.

Adults are keeping their teeth longer and as they age, the financial burden of seeing a dental professional on a regular basis can be prohibitive. In addition, many have systemic health conditions that require a polypharmacy of medications to manage, many of which carry the side effects of xerostomia or hyposalivation.

Determining the need for any fluoride product requires a risk assessment. There are many examples of these assessments: Caries Management by Risk Assessment (CAMBRA); American Dental Association; California Dental Association, and others. These checklists provide an easy way to determine whether a patient is low risk, moderate risk, or high risk, and provide the perfect opportunity to show patients their risk for dental caries infection.

Once risk is determined, the CDT modifier code and any insurance claim forms should be added to the patient record. These serve as the documentation for the fluoride treatments or products that may be recommended.

  • D0601 caries risk assessment and documentation, with a finding of low risk
  • D0602 caries risk assessment and documentation, with a finding of moderate risk
  • D0603 caries risk assessment and documentation, with a finding of high risk

For many decades, dental insurance carriers denied fluoride benefits to anyone over 18. With that in mind, many dental professionals still do not offer fluoride treatments to adult patients because they assume it will not be covered. Whether a carrier does or does not provide benefits should not determine whether it’s offered. Dental pros are guilty of making assumptions about what patients will and will not accept. If adult patients are educated about the benefits of fluoride treatment as it relates to their oral health, they will accept treatment.

Fortunately, the mindset is changing, although slowly. Many of the major carriers are now providing adult fluoride coverage, although it is almost always limited to one time per benefit year.

How to select a fluoride

What is the why behind selecting a particular fluoride agent? V. Kim Kutsch, DMD, states in his book, Balance, “The primary goal when selecting the proper treatment strategy is to provide enough protection agents to outweigh any risk factors or biofilm challenge present and reverse the balance back toward health.” That is why there are now many “fluoride” or “preventive agent” procedure codes included in the CDT manual.

The key to being reimbursed is proper documentation of the risk assessment as well as the reason for providing the treatment. The purpose may include avoiding development of disease, promoting remineralization, or reducing the risk of recurrence. This determination will help guide the selection of the product as well as the proper CDT procedure code. It is important to understand that these procedure codes need to be selected based on their descriptor, not just their title. Dental software management systems typically do not include the descriptor.

D1206 topical application of fluoride varnish—Example: Profluorid varnish by Voco

D1208 topical application of fluoride, excluding varnish—Example: 1.23% acidulated phosphate fluoride

D1354 application of caries arresting medicament, per tooth—Descriptor: Conservative treatment of an active, nonsymptomatic carious lesion by topical application of a caries arresting or inhibiting medicament and without mechanical removal of sound tooth structure. An example: silver diamine fluoride (SDF)

D13545 caries preventive medicament application, per tooth—Descriptor: For primary prevention or remineralization. Medicaments applied do not include topical fluorides. Examples include SDF, silver mitrate (SN), thymol-chlorhexidine varnish, and topical povidone iodine (PVP-1)

D9630 Drugs or medicaments dispensed in the office for home use—Descriptor: Includes, but not limited to, oral antibiotics, oral analgesics, and topical fluoride, and does not include writing prescriptions. Example: Remin by Voco

Remember, fluoride isn’t just for kids! Clinicians need to be more diligent in recommending fluoride and preventive products that will benefit adult patients throughout their lifetimes.

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