The periodontal maintenance patient and how to get perio maintenance covered by insurance
Picture this: Medieval England and the English guards find that Humpty Dumpty has fallen off the wall and is lying in a mass of egg yolk, staring up at them from among his broken shells. The guards calmly look at each other, look down at Humpty, and matter-of-factly say, "It's not that we can't put you back together . . . it's that the King's Health Care Plan doesn't cover it." (From The Flying McCoys cartoon, Glenn and Gary McCoy, 2011)
This is the dilemma that many dental offices face when it comes to receiving reimbursement for periodontal maintenance procedures. Before tackling this ongoing and common dilemma, it's important to understand what dental insurance is and what it is not.
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Dental insurance is not insurance! A simple definition of "insurance" is protection against the occurrence of an infrequent, catastrophic event. It was originally designed to provide compensation for large-scale risks such as fire damage and loss of property, then loss of life, then auto and health. But the intent was always to reimburse for "infrequent, catastrophic events." Dentistry typically involves the frequent occurrence of noncatastrophic events. So what is dental "insurance"?
Dental insurance should be described as either a "dental benefit" or a form of "health-care financing," and patients must be clear as to what this means. A simple, real-world analogy could be the following: You have just been given a $2,000 scholarship to the school of your choice. The scholarship committee has determined that up to 50% can be used for tuition, 20% for books, 10% for lab fees, and 20% toward room, board, and miscellaneous. Anything above these amounts is your responsibility. If you do not use the entire amount, it will be returned to the committee to award to another student.
This is essentially how dental insurance plans work. The employee is provided a maximum amount to be spent on dental procedures, and the insurance company will determine how it is apportioned. The employee will either use it or lose it. Typically, the majority of patients who have dental insurance do NOT maximize their benefits and inadvertently return any balance to their insurance carriers.
With that in mind, consider the dilemma of reimbursement for periodontal maintenance appointments. Dental insurance carriers have a history of limiting benefits on procedures frequently provided. Historically, these limitations can be based on any of the following:
- Paid according to a negotiated contract between employer and insurance company
- Paid based on a percent of the UCR (usual, customary, and reasonable) computed by the company
- Paid by relying on some form of evidence-based research
- Who knows what!
There is no simple answer to receiving reimbursement for periodontal maintenance procedures since there are too many variables. It is important to understand the definition in order to be sure specific protocols are being followed. The ADA's CDT-2013 defines procedure D4910 as:
This procedure is instituted following periodontal therapy and continues at varying intervals, determined by the clinical evaluation of the dentist, for the life of the dentition or any implant replacements. It includes removal of the bacterial plaque and calculus from supragingival and subgingival regions, site-specific scaling and root planing where indicated, and polishing the teeth. If new or recurring periodontal disease appears, additional diagnostic and treatment procedures must be considered.
This procedure follows scaling and root planing procedures (D4341/D4342), gingival flap surgery (D4240/D4241), or osseous surgery (D4260/D4261). It also provides for isolated scaling and root planing where indicated.
Notice that the definition is clear in stating that this procedure is to be instituted for the life of the dentition. Therefore, the statement, "Once perio, always perio" is true. If a patient completes nonsurgical treatment of their periodontal disease with scaling and root planing, the management of their condition is treated and correctly identified as periodontal maintenance for each subsequent appointment. This applies to any patient whether the scaling and root planing is completed in your practice or elsewhere. If a new patient has a history of SRP, he or she will automatically be a periodontal maintenance patient in your practice.
Periodontal maintenance is the ongoing and therapeutic procedure performed at intervals of three months, four months, or six months. Frequency of payment is highly variable among insurance carriers. You are required to report what you perform, NOT what the insurance carrier may pay. It is extremely important to communicate to your patients the limitations that may exist with their plans, and that you are bound by law (per HIPAA requirements) to submit the appropriate procedure code.
Some of the limitations that an office may encounter include (from "Coding with Confidence" by Charles Blair, DDS, 2013):
- Some payers may not reimburse D4910 at all or some may reimburse two or four times during a 12-month period.
- Some policies provide reimbursements for two -- D4910 and D1110 (adult prophylaxis) -- during a 12-month period.
• "If periodontal maintenance (D4910) is denied, please provide the alternative benefit of a prophylaxis. The ongoing periodontal maintenance visit included prophylaxis (D1110)."
• A prophylaxis (D1110) is considered a part of D4910 by payers in the ongoing periodontal maintenance regime. The clinical record should reflect the fact that a "prophylaxis" was completed as part of the overall D4910 procedure.> Do not alternate codes because you do not want to be guilty of unbundling this procedure by billing only an adult prophy in order to receive benefits. Unbundling is considered an act of insurance fraud.
• Unbundling is defined as separating dental procedures so the benefits of the component parts total more than the procedures would normally be reimbursed.
• Example: Patient's plan pays 100% of a $112 adult prophylaxis. The same plan pays 50% of a $198 periodontal maintenance (or $99), and deductibles and/or copays apply. Since a prophylaxis is considered part of the periodontal maintenance procedure, the office unbundles and bills for only the prophylaxis. The office received $13 more than they were entitled to receive, along with not collecting the patient's portion as per the contract.
When submitting claims for periodontal maintenance, it is helpful to provide certain documentation at the onset in order to mitigate denials down the road. Consider the following:
- A current and complete periodontal charting (including pocket depths, recession, bleeding points, mobilities, furcation involvement, suppuration, etc.). Including past readings will be helpful to show changes.
- Include the American Academy of Periodontology Disease Classification for the patient. (This is from the 1999 World Workshop, from categories I-VIII. Usually it will be from II Chronic Periodontitis with specific descriptors.)
- Include the billing category for the patient. (This would be from the 1989 World Workshop that had previously been used by insurance carriers, Categories I-V.)
- Identify the date that SRP was started and completed or osseous surgery was performed. Consider a narrative:
If benefit plans change or there is a change in employment, it is important to provide the new payer a narrative for the first D4910 claim (to turn the periodontal coverage switch on) describing a history of scaling and root planing (SRP) or osseous surgery. Provide this same information from the patient's history when the patient returns from the periodontal office. When previous periodontal treatment history is not noted in the remarks section, D4910 may be denied by the subsequent plan.
Periodontal disease is episodic and the patient's periodontal status may improve and be classified as stable. There is much discussion suggesting that when this happens, alternating codes (D1110 and D4910) or even totally moving the patient to regular prophylaxis appointments is reasonable. Even insurance carriers are moving to various modes of reimbursements, so much so that it is difficult to keep it all straight. To keep things simple, always bill for the procedure you provided. Periodontal maintenance is the appropriate procedure, especially for the life of the dentition.
There will be periodontal maintenance patients whose treatment could be considered easy due to minimal calculus, bleeding, or active disease, and there will be periodontal maintenance patients who jeopardize your schedule by arriving late, not following the recommended recall schedule, and not following through with home-care recommendations. The fee for that one-hour appointment is still the same. It is important to establish a fee that is an average and fair fee, reflecting the technical expertise and skill that hygienists provide.
There is no creative way to ensure that carriers reimburse patients for periodontal maintenance procedures. This procedure has become a moving target for insurance carrier reimbursement, and it is virtually impossible for all contingencies to be covered. A dental practice would be best served by:
- Educating patients as to their periodontal disease status, treatment options, and maintenance requirements in order to manage their disease for the life of their dentition.
- Documenting the patient's disease status with legible, accurate, and complete information.
- Educating patients as to the provisions of their dental insurance related to periodontal maintenance appointments and specific limitations that may be reflected in their plans.
- Providing financial options for payment of any deductible or balance due for these appointments. Let them know that their family's budget is important to your office as well.
- Refusing to bill a procedure that you did not provide (adult prophy instead of the periodontal maintenance) when anyone suggests that is what you should do. Remember, doing so is called unbundling and could be a risk management issue.