Georgia Medicaid and Oral Health

Effective January 1, 2016, the Georgia Department of Medical Assistance Programs will adopt the AAP 2015 Bright Futures “Recommendations for Pediatric Health Care” Periodicity Schedule.  In addition, Georgia’s Medicaid EPSDT program requires that children be referred to a dentist for routine dental care for members as early as 12 months of age. However, if indicated, a dental referral may be made at any age. An inspection of the mouth must be a part of each screen. If HealthCheck provider identifies any spot during oral exam, refer the member to a dentist immediately. Discuss the importance of good oral hygiene with member/caregiver.

At the 6 and 9 month visits, conduct an oral health risk assessment. Encourage the parent to select a dental home.  For the 12, 18, 24, and 30 month visits, risk assessments should continue if a dental home has not been established. Document a referral or inability to refer to a dental home if one has not been established. For those at high risk, consider application of fluoride varnish for caries prevention.  At 3 and 6 years: Determine if the patient has a dental home. If not, a referral must be made. If a dental home has not been established, perform a risk assessment.

The updated 2015 Periodicity Schedule added the subheading “Fluoride Varnish” under the “Oral Health” heading. In accordance with the US Preventive Services Task Force recommendations , once teeth are present, fluoride varnish may be applied to all children every 3 to 6 months in the primary care or dental office. Indications for fluoride use are noted in the 2014 AAP clinical report “Fluoride Use in Caries Prevention in the Primary Care Setting”.

Effective January 1, 2015, the application of topical fluoride varnish by a physician or other qualified health care professional may be billed with the new CPT code 99188. This applies to providers enrolled in and filing claims under GA Medicaid programs 430, 431, and 740.

Only providers enrolled in and filing claims under GA Medicaid programs 430, 431, 450, and 740 may bill Code D1206 Fluoride Varnish (eff. 1/1/2010).

  • Dentists: under category of service 450
  • Physicians: under category of service 430
  • Physician Assistants (PA): under category of service 431
  • Nurse Practitioners: under category of service 740

The  American Academy of Pediatrics is committed to helping pediatricians and other health providers learn how to identify oral disease, provide caries prevention services, and when to refer a to a dentist.

Pediatricians and other medical providers can play an important role in children’s oral health outcomes and improve the overall health of children. Children who may not have the opportunity to see a dentist are well served by pediatricians who are knowledgeable about oral health.

The American Academy of Pediatrics’ new Bright Futures Recommendations for Preventive Pediatric Health Care indicates that an oral health risk assessment be done at ages 6 and 9 months. A referral to a dental home (if available) should be made at 12, 18, 24 and 30 months. If a dental home is not available at those ages, an oral health risk assessment should be done.

Click here to locate a pediatric dentist at Georgia Academy of Pediatric Denistry