QUEST Integration – Fluoride Varnish Application

Original Effective Date:

01/01/2014

Current Effective Date:

01/01/2015

Effective January 1, 2014 topical fluoride varnish is covered every six months for children beginning at age 1 year through 5 years when applied by qualified primary care providers (PCPs).The children must not have received a topical fluoride treatment by a dentist or qualified PCP within the previous six months.

Qualified PCPs include physicians and nurse practitioners, who may delegate under direct supervision to a physician assistant, registered nurse, licensed practical nurse, or Certified Medical Assistant (CMA). PCPs must have received Continuing Medical Education (CME) or CME-equivalent training in fluoride varnish application approved by either the American Academy of Pediatrics AAP) or the American Academy of Family Physicians (AAFP). Documentation of approved training must be available for review upon request.

Past fluoride treatment must be verified to ensure no treatment was received in the previous six months. Providers can rely on the last reported date of fluoride treatment if dental services are not available onsite, but should confirm this date if dental services are available onsite.The last reported or verified receipt of topical fluoride must be documented in the visit notes.

Referral Requirement

If a PCP is not able to provide this service, the patient should be referred to a provider who is qualified to do the service. If referring to another medical specialist, a referral must be registered with HMSA QUEST if required. See QUEST Integration – Referrals.

Federally-Qualified Health Centers (FQHC)

The service is considered an “incident to” procedure when provided within +/- 10 days of a medical prospective payment service (PPS) visit and payment will be included in the PPS rate for the visit.

Claims Information

• Bill on the CMS 1500 claim form
• Use procedure code D1206. Effective for services rendered on or after January 1, 2015, new CPT code 99188 (Application of topical fluoride varnish by a physician or other qualified health care professional) may be used.
• The global fee is $4.16 per fluoride varnish application.
• If provided as part of an EPSDT exam, the fluoride varnish is payable in addition to the EPSDT global fee. It’s recommended that the services be billed on the same claim to avoid processing delays.

Revision History