Insurance Coding

Codes and Coverage:

This page is about coding for the Phocal Fluoride Disks. Coding and coverage are NOT the same. Dental professionals are obligated to use the most accurate code available. Accurate coding does not guarantee coverage under a particular policy. CDT codes are risk and diagnosis based, not product based. To optimize coverage under a policy, a dental-medical necessity recorded in Box 35 Remarks is important. 

Dental/Medical Necessity ‘Twitter’ Style:

Dental-medical necessity narratives are not long and ponderous. They work best when writing is concise; brevity is the key. We can all take a lesson from the social media app, Twitter. Twitter posts can be a maximum of 140 characters; not 140 words. 140 is the total number of characters, punctuation and spaces that are allowed. 

Dental/Medical Necessity for Caries-Risk Assessment:

Risk assessment will help determine diagnosis. These can be considered modifier codes that support WHY for other care. There may/may not be coverage for these codes but should be submitted in conjunction with other codes.

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

The code nomenclature/name contains the word documentation. This dictates necessity of documentation of the dental/medical necessity for the care. In this case the method of determining caries risk is needed. A wide variety of quantifiable caries risk assessment tools are available: Paper/computer based Q&A, Saliva tests, Bacterial tests. 

 

Applicable Codes for Phocal Disks

Option 1: D1208 topical application of fluoride – excluding varnish.

All age-based information has been removed from codes several years ago. Policies may differ. To optimize coverage, document dental-medical necessity in Box 35 Remarks. The delivery system is not specified and any professionally applied fluoride can qualify under this code including Phocal Disks.

 

 

This code, while accurate, does not account for Phocal’s unique disk form of or insertion between the teeth and often is not limited to a single interproximal area.

 

Option 2 - More Accurate: D1354 interim caries arresting medicament application.

Conservative treatment of active, non-symptomatic carious lesion by topical application of a caries arresting or inhibiting medicament and without mechanical removal of sound tooth structure.

In some instances, after placement of a Phocal disk, the buccal or lingual portion can be coated with a protective varnish and can also be submitted for fluoride varnish.

 

 

 

Disclaimer: License to use ADA CDT 2017 codes granted to Patti DiGangi. The use of this statement enables the author to use codes herein. The dental procedures codes (“Code”) are owned and published by the ADA in its reference manual Current Dental Terminology (“CDT”). The ADA is the exclusive owner and copyright holder of the CDT, including the Code, as well as of the ADA Claim Form.