Article Highlights
This article reviews coding for services that support a child’s dental health.
Oral health services included in preventive medicine services
Oral health services that may be separately reported
Screening for social determinants of oral health
Coming soon: silver diamine fluoride application in primary care practices
Resources for practices
Although dental visits for young children have increased in the United States, disparities continue and access to dental care is difficult for many children. This message and more were published in “Maintaining and Improving the Oral Health of Young Children,” a clinical report recently released by the American Academy of Pediatrics (AAP) (https://doi.org/10.1542/peds.2022-060417). Perhaps surprisingly, dental caries is the most common chronic condition in childhood. Based on this, the report concludes, “Because dental caries is such a common and consequential disease process in the pediatric population and such an integral part of the overall health of children, it is essential that pediatricians include oral health in their daily practice of pediatrics.”
The conclusion that oral health should be included in daily practice may raise the question of whether physicians and other qualified health care professionals (QHPs) can obtain payment for services to prevent dental disease and interventions to maintain or restore oral health.
Oral Health Services Included in Preventive Medicine Services
Some oral health service recommendations for pediatricians are included in the preventive medicine evaluation and management (E/M) service when provided during the same encounter. Preventive medicine services include
Screening of the lips, tongue, teeth, gums, inside of the cheeks, and roof of the mouth to identify oral disease without diagnostic E/M
Anticipatory guidance for oral health as an integral part of comprehensive patient counseling
Counseling parents/caregivers and patients on ways to reduce the frequency of exposure to sugars in foods and drinks (eg, not putting a baby to bed with a bottle)
Recommending that every child has a dental home by 1 year of age
Quality Reporting and Fluoride Varnish Application
Health plans often offer incentives to physicians to provide and report services that are included in Healthcare Effectiveness Data and Information Set (HEDIS) measures.
The percent of health plan members 1 to 4 years of age who received at least 2 fluoride varnish applications during a measurement period is a new HEDIS measure. The percentage of members for whom the measure was met may be assessed based on receipt of claims containing code 99188.
Separately Reported Oral Health Services
Counseling on prevention and risk factor reduction for oral health problems at encounters other than preventive E/M services (eg, office visit addressing a health problem) may be reported with preventive counseling codes 99401–99404. Modifier 25 is appended to the code for preventive counseling when another E/M service is provided on the same date. Do not report 99401–99404 for counseling provided on the date of a preventive E/M service. Payer policy may limit the extent of preventive counseling to that described by codes 99401 and 99402.
| 99401 | Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes |
| 99402 | approximately 30 minutes |
TIP
Time for preventive counseling is met when the midpoint between codes is passed. Report 99401 when 8 to 22 minutes of counseling is documented; report 99402 for 23 to 37 minutes of counseling.
Most health plans and all Medicaid plans provide preventive benefits for fluoride varnish administration in early childhood. Plans may provide coverage to all children up to 6 years of age. Some Medicaid plans provide coverage for application up to 4 times a year for high-risk patients until the 21st birthday. Code 99188 is reported for application of fluoride varnish in a physician practice.
| 99188 | Application of topical fluoride varnish by a physician or other qualified health care professional |
Payment policies for fluoride varnish application may include the following guidelines:
May be performed by trained clinical staff under the direct supervision of a treating physician or other QHP.
Specific training for application of fluoride varnish is typically required (usually free online training).
May be limited to application during a routine child health examination or other office E/M service by some Medicaid plans.
Plans may require concurrent counseling for oral health as an inclusive component of application of fluoride varnish (ie, not separately reported).
Defining Direct Supervision
Direct supervision is a term that is defined by Medicare and some other payers to mean that the individual supervising the service must be present in the office suite at the time of service and immediately available to provide assistance and direction to the clinical staff during the performance of the supervised service. This is the opposite of general supervision, which does not require physical presence in the office suite but rather availability (eg, by telephone or messaging).
TIP
As with many services, payment policies will vary by payer and/or health plan. Practices should have processes in place to verify benefits for preventive oral health care services prior to provision of services.
Payer policies for topical fluoride administration may also specify the diagnosis code that should be linked to the charge for this service. Some plans note that when fluoride administration is provided on the date of a preventive medicine encounter, the codes for routine child health examination are required. However, other codes may be specified, such as Z29.3.
| Z00.121 | Encounter for routine child health examination with abnormal findings |
| Z00.129 | Encounter for routine child health examination without abnormal findings |
| Z29.3 | Encounter for prophylactic fluoride administration |
| Z41.8 | Encounter for other procedures for purposes other than remedying health state |
| Z01.20 | Encounter for dental examination and cleaning without abnormal findings |
| Z01.21 | Encounter for dental examination and cleaning with abnormal findings |
Although codes Z01.20 and Z01.21 specify dental examination and cleaning, a plan may require these codes to be used whenever fluoride varnish is applied. When reporting code Z01.21, report an additional code(s) for the abnormal findings. Abnormal findings of an oral screening may also be reported in addition to code Z00.121 and provide an indication of the child’s oral health risk. Examples of codes for abnormal findings include the following:
| K00.2 | Abnormalities of size and form of teeth |
| K00.6 | Disturbances in tooth eruption |
| K02.51 | Dental caries on pit and fissure surface limited to enamel (white spots, initial caries) |
| K02.61 | Dental caries on smooth surface (white spots, initial caries) |
| F45.8 | Other somatoform disorders (bruxism that is not sleep-related) |
| G47.63 | Sleep related bruxism (teeth grinding) |
| F98.8 | Other specified behavioral and emotional disorders with onset usually occurring in childhood and adolescence (eg, thumb-sucking) |
Other diagnosis codes that may be reported secondary to codes for a routine child health examination or fluoride application describe medical conditions and/or social determinants of health that increase the child’s risk of poor oral health. Examples include the following:
| K21.9 | Gastroesophageal reflux disease without esophagitis |
| K05.00 | Acute gingivitis, plaque induced (eg, gingivitis, not otherwise specified) |
| K05.10 | Chronic gingivitis, plaque induced |
| ◘Z59.6 | Low income |
| ◘Z59.5 | Extreme poverty |
| ◘Z75.2 | Other waiting period for investigation and treatment |
| ◘Z75.3 | Unavailability and inaccessibility of health-care facilities |
Health plans may separately pay for administration of a standardized instrument to assess a patient’s oral health risks (eg, AAP Oral Health Risk Assessment Tool [https://downloads.aap.org/AAP/PDF/oralhealth_RiskAssessmentTool.pdf], American Academy of Pediatric Dentistry caries risk assessment forms [www.aapd.org/media/Policies_Guidelines/BP_CariesRiskAssessment.pdf]). Link code Z13.84 to code 96160 when this service is provided.
| 96160 | Administration of patient-focused health risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument |
| Z13.84 | Encounter for screening for dental disorders |
Payer policies, especially Medicaid plans, may require that modifiers be appended to the code for oral health screening, counseling, or fluoride application services. Examples of modifiers included in some payer policies include the following:
| DA | Oral health assessment by a licensed health professional other than a dentist |
| EP | Services provided as part of Medicaid EPSDT program |
| KZ | New coverage not implemented by managed care (May be applicable when charges are billed to a state Medicaid plan because a child’s Medicaid managed care plan has not yet implemented a coverage policy for the service.) |
| SC | Medically necessary service or supply |
In addition to modifiers, some Medicaid plans will specify 2-digit codes that indicate referral for dental care and provide instructions regarding where these codes are to be reported on the claim (eg, shaded area of field 24h) (see example).
EXAMPLE
Enter the applicable 2-character Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) referral code (eg, YD, dental) for referrals made or needed as a result of the screen in field 10d of the CMS 1500 claim form.
| 10d. CLAIM CODES (Designated by NUCC) YD |
Abbreviation: NUCC, National Uniform Claim Committee.
Coming Soon? Silver Diamine Fluoride
A new Category III (emerging technology) code, 0792T, will be implemented for reporting the application of silver diamine fluoride to dental caries when the service is provided on and after July 1, 2023. While primarily applied in dental practices, limited access to pediatric dental health care in some areas has resulted in a need for physicians and other QHPs to receive training for and adopt application of silver diamine fluoride for the purpose of arresting (stopping progression of) cavities.
| ● 0792T | Application of silver diamine fluoride, 38%, by a physician or other qualified health care professional |
Payer coverage for application in pediatric practices may initially be limited. However, if approved by the US Food and Drug Administration, use of silver diamine fluoride to arrest caries may become a common practice by physicians and other QHPs when caring for patients for whom access to dental care is restricted and/or for patients who would otherwise resist or require anesthesia for restorative dental care.
Dig Deeper
For more information on promoting oral health in conjunction with preventive medicine services, see “Promoting Oral Health” from Bright Futures (https://downloads.aap.org/AAP/PDF/Bright%20Futures/BF4_OralHealth.pdf).
The AAP Oral Health Practice Tools (www.aap.org/en/patient-care/oral-health/oral-health-practice-tools) include the AAP Oral Health Risk Assessment Tool in English and Spanish as well as useful information on setting up oral health care services, such as administration of fluoride varnish, in a primary care practice.
Key Takeaways
Pediatricians can get paid for certain oral health services and should be aware of the following:
Anticipatory guidance for oral health is an integral part of the comprehensive patient counseling included in a preventive medicine service.
Counseling on prevention and risk factor reduction for oral health problems at encounters other than preventive E/M services (eg, office visit addressing a health problem) may be reported with preventive counseling codes 99401–99404.
Code 99188 is reported for application of fluoride varnish in a physician practice.
Payer policies for topical fluoride administration may also specify the diagnosis code that should be linked to the charge for this service (eg, codes for routine child health examination or Z29.3 [encounter for prophylactic fluoride administration]).
