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Covered and Noncovered Services : Medicine Services

Topic #501

Fluoride — Topical Applications

Topical application of fluoride to a child's teeth is a safe and effective way to prevent tooth decay as part of a comprehensive oral health program.

Coverage

Wisconsin Medicaid recommends that children under age 5 who have erupted teeth receive topical fluoride treatment. Children at low or moderate risk of early childhood caries should receive one or two applications per year; children at higher risk should receive three or four applications per year.

The most accepted mode of fluoride delivery in children under age 5 is a fluoride varnish. OTC mouth rinses are not covered.

Submitting Claims

When submitting claims for topical fluoride treatment, indicate procedure code D1206 (Topical fluoride varnish; therapeutic application for moderate to high caries risk patients) or D1208 (Topical application of fluoride). Providers may also submit claims with HealthCheck and office visit HCPCS procedure codes for these services.

In cases where more than two fluoride treatments per year are medically necessary, providers are required to retain supporting clinical documentation in the member's file indicating the need for additional treatments.

Ancillary staff (e.g., physician assistants, nurse practitioners) are required to follow certain billing procedures.

Wisconsin Medicaid will separately reimburse providers for the appropriate level office visit or preventive visit at which the fluoride application was performed.

Training Materials

An Oral Health Provider Training guide describing how providers may perform lift-the-lip oral screenings, apply fluoride varnish to a small child's teeth, and provide basic oral health guidance to parents is available.



 
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