Is it perio maintenance or a standard prophy?

Consistency in coding and documentation for both recordkeeping and insurance claims can reduce billing and payment problems.

by Carol D. Tekavec, RDH

Hygienists usually perform periodontal-maintenance procedures on patients who have undergone root-planing procedures or perio surgery. While these procedures are performed often, they are frequently misunderstood by patients, inadequately explained by staff members, and incorrectly billed to insurance carriers. It helps if perio maintenance is set up in a routine appointment format with all members of the staff "on the same page" regarding what the appointment will include. It also helps if patients are given detailed explanations … along with written informed consent forms and fee estimates … prior to the surgery or root-planing requiring the supportive therapy. Consistency in coding and documentation for both recordkeeping and insurance claims can reduce billing and payment problems.

Let's look further at these three important fundamentals.

Routine appointment format

Periodontal maintenance (following active therapy) is considered to be an integral part of effective perio treatment. The American Academy of Periodontology has developed parameters on periodontal maintenance that details what procedures should be included in a maintenance visit. (Parameters of Care 2000 may be obtained from the AAP Web site, www.perio.org.) These include, among others, an update of medical and dental histories, radiographic review, soft-tissue exam, dental exam, perio exam, plaque-control effectiveness, removal of subgingival and supragingival plaque and calculus, removal of microbes from pocket areas, and tooth-polishing. According to the AAP, the goal of maintenance is to minimize the progression of periodontal disease in patients previously treated for gingivitis and periodontitis, to reduce tooth loss, and to increase the probability of locating and treating any future disease.

The ADA defines periodontal maintenance procedures as "D4910-Periodontal Maintenance Procedures (following active therapy) … This procedure is for patients who have completed periodontal treatment (surgical and/or non-surgical periodontal therapies exclusive of D4355) and includes removal of bacterial flora from crevicular and pocket areas, scaling and polishing of the teeth, periodontal evaluation, and a review of the patient's plaque control efficiency. Typically, an interval of three months between appointments results in an effective treatment schedule, but this can vary depending on the clinical judgement of the dentist. When new or recurring periodontal disease appears, additional diagnostic and treatment procedures must be considered. Periodic maintenance treatment following periodontal therapy is not synonymous with a prophylaxis."

For practical purposes, the perio-maintenance appointment might follow a consistent format utilizing four effective chart forms or computer screens. These would be:

  1. An updatable medical and dental history form
  2. A dental examination form
  3. A periodontal form that documents probing, bleeding, furcations, recession, and mobility.
  4. A progress-notes form that includes all details of the appointment [For a complimentary sample of such forms, call (800) 548-2164.]

By using such a chart format, all required elements of the appointment can be effectively covered, with less chance of forgetting important segments. In addition, the patient undergoes a consistent "perio maintenance" experience which is not at all like a D1110-Adult Prophylaxis exam.

Patient complaints to state dental boards concerning differences between perio maintenance and standard prophys are on the rise. Patients who are unable to discern any difference between the two procedures … except for the fee … are taking their issues to both state boards and the malpractice court.

Written informed consent and fee estimates

One of the most neglected areas in dentistry is that of providing patients with a detailed explanation of the treatment they will be receiving and the fees they will be charged. Patients … with or without insurance … need to be informed of what procedures they will be undergoing, what and how often the perio maintenance therapy will be performed, and what the fees will be. It is unrealistic to expect patients to accept treatment without knowing what will be happening to them and how much they will be expected to pay. Patients also must understand that if their insurance does not pay, they are responsible for the total bill.

Informed consent does not have to be "browbeating" patients with unpleasant details that will scare them away. Informed consent should be a simple process of explanation and acceptance. When patients understand what treatment they will be receiving, they are much less likely to complain later to your office or the state dental board. The informed- consent process and fee estimate do not have to be done by the hygienist. Another staff member or the dentist can provide this information at the same time that all of the patient's treatment is being discussed. [Contact Stepping Stones to Success at (800) 548-2164 for an inexpensive booklet on informed consent.]

Coding and documentation for insurance claims

While it was expected that the 2000 edition of the ADA's Current Dental Terminology-3 book would change the description for D4910 to include a periodic oral evaluation (recall exam), this did not happen. Instead, a periodontal evaluation was added. A periodontal evaluation may imply a periodontal diagnosis or it may be considered as only one component of a total evaluation prior to a diagnosis. Greater clarification from the ADA is needed and hopefully will be included in the next CDT revision, possibly in 2005. As it now stands, periodontal-data collection in the form of periodontal probing and documentation of bleeding, furcations, recession, and mobility may be delegated to a hygienist if the state dental practice act approves these procedures. Diagnosis of such data legally remains the responsibility of the dentist.

Since the CDT-3 description of Code D4910 does not include a periodic evaluation, then a D0120-Periodic Oral Evaluation may be properly reported as a separate fee, as would any code or fee for radiographs. While the D0120 may be appropriately reported, it usually will not be covered by insurance. Whatever the ADA description, insurance carriers typically cover D4910 by providing a benefit twice per year, following documented surgical treatment or root-planing, and excluding a separate benefit for an exam.

A few carriers downcode payment to what they allow for a D1110-Prophylaxis-Adult. The patient then is responsible for the balance. Alternating codes between D1110 and D4910 is not reasonable; however, some insurance carriers encourage and/or accept it. Offices that do this may find that one day the patient's carrier may require evidence of further surgery prior to paying for a D4910 after a D1110.

Code D4910 is an important and usually adequately-paid code describing periodontal maintenance. Patients who require D4910 follow-up care should receive as many per year as advised for appropriate treatment, regardless of insurance coverage. Services not covered by the patient's insurance should be paid by the patient.


Points to Remember
  • Insurers usually pay for two "cleanings" of any type per year, and they include D4910 under that heading.
  • Insurers usually pay for two "exams" of any type per year and include a D0120 under that heading.
  • Insurers usually will not pay for a D0120 charged out on the same day as a D4910.
  • Code D4910 usually will not be paid unless performed at least three months following active therapy (i.e., either periodontal surgery or D4341, Periodontal Scaling and Root-Planing. The dates of active therapy should be included on the claim form.)


Submitting D4910 Claims

When submitting claims for payment of D4910, include the following:
  • Periodontal case type of at least Case Type III-Moderate Periodontitis (Be aware that the American Academy of Periodontology has changed reporting from "Case Types" to the "1999 Classification for Periodontal Disease and Conditions." However, insurance carriers are expected to continue to use "case types" for the near future.)
  • Dates of root-planing or surgery
  • Complete progressive periodontal probing depths, bleeding points, recession, furcations, and mobility. Attach a form with this information to the paper claim form or supply with an e-claim.
  • Assessment of home-care effectiveness (i.e., poor, adequate, good)

Carol D. Tekavec CDA, RDH, is the author of a new insurance coding manual, the Dental Insurance Coding Handbook-2000, designer of a dental chart, and a national lecturer with the ADA Seminar Series. Contact her at (800) 548-2164 or visit her Web site at www.steppingstonestosuccess.com.

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