Table 3.
Summary of Reimbursement Status of Topical Fluoride Varnish (FV) Codes D1206 and CPT 99188 as of May 22, 2019.
| ID | Payor | Topical FV Code Used | Primary Diagnosis Associated With topical FV Code (ICD-9/-10 codes) | Billed Amount for FV ($) | Paid Amount for FV ($) |
|---|---|---|---|---|---|
| 1 | Medicaid | D1206 | Well Child Check [V20.2] | 33.00 | 13.95 |
| 2 | Medicaid HMO | D1206 | V20.2 | 33.00 | 13.95 |
| 3 | Medicaid | D1206 | V20.2 | 33.00 | 13.95 |
| 4 | Medicaid | D1206 | V20.2 | 33.00 | 13.95 |
| 5 | Medicaid | D1206 | V20.2 | 33.00 | 13.95 |
| 6 | BCBS | CPT 99188 | Prophylactic fluoride administration [Z29.3] | 35.00 | 21.00 |
| 7 | BCBS | CPT 99188 | Z29.3 | 35.00 | 21.00 |
| 8 | Medicaid MCO (AMG) | CPT 99188 | Z29.3 | 35.00 | 13.95 |
| 9 | Medicaid MCO (AMG) | CPT 99188 | Z29.3 | 35.00 | 13.95 |
| 10 | BCBS | CPT 99188 | Z29.3 | 35.00 | 21.00 |
| 11 | Medicaid MCO (UHC) | CPT 99188 | Z29.3 | 35.00 | Denied; child is 36 months or older outside the payable window |
| 12 | Medicaid MCO (UHC) | CPT 99188 | Z29.3 | 35.00 | Denied; child is 36 months or older outside the payable window |
| 13 | BCBS | CPT 99188 | Z29.3 | 35.00 | 21.00 |
| 14a | Medicaid MCO (AMG) | CPT 99188 | Z29.3 | 35.00 | 13.95 |
| 14a | Medicaid MCO (AMG) | CPT 99188 | Z29.3 | 35.00 | 13.95 |
| 15 | BCBS | CPT 99188 | Z29.3 | 35.00 | 26.00 |
| 16 | BCBS | CPT 99188 | Z29.3 | 35.00 | 21.00 |
| 17 | BCBS | CPT 99188 | At high risk for dental caries [Z91.843] | 35.00 | 21.00 |
| 18 | Medicaid MCO (UHC) | CPT 99188 | Z29.3 | 35.00 | 13.95 |
| 19 | BCBS | CPT 99188 | Z29.3 | 35.00 | 21.00 |
| 20 | Medicaid MCO (AMG) | CPT 99188 | Z29.3 | 35.00 | 13.95 |
| 21 | Medicaid MCO (AMG) | CPT 99188 | Z29.3 | 35.00 | 13.95 |
| 22 | Medicaid MCO (UHC) | CPT 99188 | Encounter for routine child health examination with abnormal findings [Z00.121] | 35.00 | Denied; child is 36 months or older outside the payable window |
| 23 | UHC Commercial | CPT 99188 | Z29.3 | 35.00 | 35.00 |
| 24 | Self Pay | CPT 99188 | Z29.3 | 35.00 | Balance at collections |
| 25 | BCBS | CPT 99188 | Z29.3 | 35.00 | 21.00 |
| 26 | Medicaid MCO (UHC) | CPT 99188 | Z29.3 | 35.00 | 13.95 |
| 27 | Medicaid MCO (UHC) | CPT 99188 | Z29.3 | 35.00 | Denied; child is 36 months or older outside the payable window |
| 28 | Medicaid MCO (AMG) | CPT 99188 | Z29.3 | 35.00 | Balance transferred to patient due to noncompliance with request for a signed authorization and assignment form |
| 29 | Medicaid MCO (UHC) | CPT 99188 | Z29.3 | 35.00 | 13.95 |
| 30 | BCBS | CPT 99188 | Z29.3 | 35.00 | 21.00 |
| 31 | BCBS | CPT 99188 | Z29.3 | 35.00 | 35.00 |
| 32 | Medicaid MCO (UHC) | CPT 99188 | Z29.3 | 35.00 | 13.95 |
| 33 | Medicaid MCO (UHC) | CPT 99188 | Z29.3 | 35.00 | 13.95 |
| 34 | UHC Commercial | CPT 99188 | Z29.3 | 35.00 | 35.00 |
| 35 | UHC Commercial | CPT 99188 | Z29.3 | 35.00 | 35.00 |
| 36 | UHC Commercial | CPT 99188 | Z29.3 | 35.00 | 35.00 |
| 37 | Medicaid MCO (AMG) | CPT 99188 | Z29.3 | 35.00 | 35.00 |
| 38 | Medicaid MCO (AMG) | CPT 99188 | Z29.3 | 35.00 | 35.00 |
| 39 | BCBS | CPT 99188 | Z29.3 | 35.00 | 35.00 |
Abbreviations: AMG, Amerigroup; BCBS, Blue Cross Blue Shield; CPT, Current Procedural Terminology; HMO, health maintenance organization; MCO, managed care organization; UHC, United Healthcare.
a
Indicates the same patient.