Understanding Dental Code D0604

When to Use D0604 dental code

The D0604 dental code is designated for "antigen testing for a public health related pathogen, including coronavirus." This CDT code is used when a dental practice performs rapid antigen testing on a patient to identify pathogens that have public health significance, such as COVID-19. D0604 is not limited to coronavirus but can be applied to other public health pathogens as directed by regulatory guidance. Dental offices should use this code when the test is performed in the dental setting and is medically necessary for patient care, infection control, or compliance with public health protocols.

Documentation and Clinical Scenarios

Accurate documentation is essential when billing D0604. The patient’s chart should clearly indicate:

• The reason for the antigen test (e.g., symptoms, exposure, pre-procedure screening).
• The type of test administered and the specific pathogen targeted.
• Date and time of specimen collection and test administration.
• Test results and any follow-up actions taken.

Common clinical scenarios include pre-operative screening for COVID-19 prior to aerosol-generating procedures, testing symptomatic patients, or screening staff and patients during public health emergencies. Always ensure the test is performed in accordance with CDC, OSHA, and state guidelines.

Insurance Billing Tips

Billing for D0604 requires attention to payer policies, as not all dental or medical plans cover in-office antigen testing. Here are best practices for maximizing reimbursement:

• Insurance Verification: Before performing the test, verify with the patient’s insurer whether D0604 is a covered benefit under their dental or medical plan. Document the verification in the patient’s record.
• Claim Submission: Submit claims with accurate CDT coding and supporting documentation. If required, attach clinical notes or a narrative explaining the necessity of the test.
• Coordination of Benefits: If the patient has both dental and medical coverage, determine which plan is primary for public health testing. Some payers may require submission to medical insurance first.
• Handling Denials: If a claim is denied, review the Explanation of Benefits (EOB) for the denial reason. If appropriate, submit a claim appeal with additional documentation, such as public health advisories or CDC recommendations supporting the test.

Staying current with payer updates and public health guidance ensures compliance and optimal reimbursement for D0604 claims.

Example Case for D0604

Case Study: A patient presents for a dental cleaning and reports recent exposure to a COVID-19 positive individual. The dental team, following office protocol, performs a rapid antigen test prior to treatment. The test is administered in-office, and the result is negative. The procedure is documented in the patient’s chart, including the reason for testing, type of test, and result. The claim is submitted using D0604, with supporting documentation attached. The insurer initially denies the claim, but after submitting a claim appeal with CDC guidance and office policy documentation, the claim is approved and paid.

This example highlights the importance of thorough documentation, proactive insurance verification, and persistence in claim follow-up to ensure proper reimbursement for D0604.