Wiki Procedure 99188 and 99401

[kvankuren]

Our physicians want to offer to our patient's dental evaluations and dental varnish in our office at same time they are doing a well check. The dental services would be for children 3 and under and for patient's who have a commercial insurance. Procedure codes are 99188 and 99401 dx Z41.8. We want to let our patient's know ahead of time of the service and have them sign a form stating if their carrier does not cover the service then the parent is responsible for the not covered service. Some practices in our area are doing these services and if the insurance denies the claim because it is outside of there benefits plan they (I have been told) are either writing it off or reducing the charge. I was under the impression that if a service is medically necessary and recommended that we have to bill the patient for the not covered service(regardless of whether the provider informs them or not). Need a little compliance guidance.

 

[Cynthia Hughes]

fluoride

I would like to offer a few thoughts for consideration as your practice implements these services. You note that the fluoride counseling will be provided in conjunction with a well-child visit. Code 99401 would not be reported separately on the same date as a preventive medicine service per CPT prefatory language for the preventive medicine codes. Also billing for preventive counseling separately from the preventive medicine service will likely not be allowed under payer policy/bundling edits and such denial is typically not billable to the patient. Application of fluoride varnish by the primary care physician is a recommended preventive service (Grade B) and so should be covered by health plans subject to the Affordable Care Act.

I hope this is helpful.