BY DIANNE GLASSCOE WATTERSON, RDH, BS, MBA
Dear Dianne,
I understand that after I complete periodontal scaling on my patient, the next step is three-month maintenance. However, here is where I have a problem. I really do not like to wait three whole months to see my patient again. What I prefer is to see the patient about three to four weeks following the completion of the quadrant scaling, after the tissue has had a chance to heal.
The problem is there isn't a code that we can use for this visit. I feel it's best for the patient to be seen sooner than three months, but the front-desk lady in my office gives me a hard time over this. Am I the only hygienist who feels three months is too long of a time gap after completing root planing and scaling? What do you suggest?
Kathryn, RDH
Dear Kathryn,
I agree with you. I've always felt three months was too long after completing definitive scaling to do a follow-up visit with the patient.
I worked in a fee-for-service group practice for many years, and the doctors gave the hygienists flexibility to see the patient for a follow-up visit before the definitive maintenance phase began. We simply built the cost of the additional visit into our root planing and scaling fee.
After completion of the final quadrant scaling visit, I would tell my patient that our next visit was for "follow-up and polishing" and that there would not be an additional charge. Depending on the patient, we would have a 40- to 60-minute visit at four weeks. The purpose was to reassess home care and healing, provide any necessary scaling, and polish the patient's teeth. Using the power scaler, I would thoroughly debride the whole mouth to disrupt and remove any pathogens that had repopulated. Almost without exception, I would find calculus that I had missed earlier.
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I felt it was also important to spend time helping the patient perfect his/her home-care routine. After all, what good have we done if all we do is remove debris from the tooth surfaces but do not teach the patient how to take care of him/herself at home? Since the fee had been built into the total fee for scaling, we did not charge an additional fee for the follow-up visit.
Interestingly, my friend, Charles Blair, DDS (who is probably the most knowledgeable person I know regarding coding issues), pointed out to me recently that there is no reason this follow-up visit (before definitive maintenance begins) cannot be coded D1110. If you read the current code descriptor, it says:
"Removal of plaque, calculus, and stains from the tooth structures. It is intended to control local irritational factors."
We have felt for many years that this code should only be used with "healthy" or "nonperio" patients and that it is only to be used in the preventive context. However, the current descriptor is so broad and general that it could be applied to other uses as well. Dr. Blair pointed out to me that code D1110 could be used for the follow-up visit before definitive maintenance begins.
Many of my client offices have reported to me that some insurance companies have instructed them to alternate codes D4910 and D1110 for patients needing three-month disease-control visits. In the past, we would have frowned on alternating these codes, as D4910 is considered therapeutic and D1110 is considered preventive. Some of us have even gone so far as to suggest that alternating these codes is fraudulent.
However, if we read the current descriptor again for D1110, it is clear that we indeed remove plaque, calculus, and stains in a periodontal maintenance visit with the purpose of controlling local irritational factors. Where's the fraud? Believe me, insurance companies have their fraud antennae engaged at all times, and it would not be in their best interest to instruct dental practices to commit fraud.
Now if you feel uncomfortable with what I've just suggested, consider another alternative. Some policies provide reimbursements for two - D4910 and D1110 - during a 12-month period. If the patient requires three-month maintenance appointments, it is possible to bill the D4910 each time but request an alternate benefit of D1110 every other time since four distinct procedures are part of the plan. The narrative would read: "If D4910 is denied, please provide the alternative benefit of a prophylaxis. The ongoing periodontal maintenance visit included prophylaxis (D1110)." The D1110 is considered part of the D4910 by payers. The clinical record should reflect the fact that a "prophylaxis" was completed as part of the overall D4910 procedure. (Coding with Confidence, Charles Blair, DDS, 2015; drcharlesblair.com)
When we have the patient's best interest as our overall goal, we provide the treatment necessary to bring the patient back to a state of good oral health. If there were no third-party payers to deal with, it would be a simple matter. Just do whatever needs to be done, and charge an appropriate fee. However, the reality is that many of our patients are dependent on their benefits to assist with their dental care, and sometimes we struggle with finding the right code to match what we have provided within a very narrow scope. After all, we only have five codes to describe the definitive care we provide - D1110, D4341, D4342, D4910, and D4355. Sometimes the care we provide doesn't fit any of those "boxes" very well. It becomes a semantics game after a while.
Patients with periodontal disease are often "dental cripples" when they come to us. They need intensive periodontal debridement and customized home-care instructions. Bringing them back to a state of good oral health takes serious effort from the hygienist and the patient. Sometimes I feel that advanced cases would benefit from a follow-up debridement even more often than once every three months. It's hard enough trying to get patients to understand the necessity of being seen quarterly for professional care.
There are two things we know: (1) Patients with periodontitis cannot maintain their dentition with personal home care alone, and (2) Tooth loss in periodontal patients is inversely related to frequency of supportive periodontal therapy (SPT). So seeing a periodontal patient three to four weeks following completion of the definitive phase is not unreasonable.
I congratulate you on your determination to help periodontal patients on their road to recovery, and I hope you will be able to work out a system to see your patients for a follow-up visit at the three- to four-week point, following completion of definitive treatment. RDH
All the best,
Dianne
DIANNE GLASSCOE WATTERSON, RDH, BS, MBA, is a professional speaker, writer, and consultant to dental practices across the United States. Dianne's new book, "The Consummate Dental Hygienist: Solutions for Challenging Workplace Issues," is now available on her website. To contact her for speaking or consulting, call (301) 874-5240 or email [email protected]. Visit her website at www.professionaldentalmgmt.com.
