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D4355 undergoes major changes in CDT 2023

March 28, 2023
There have been changes to D4355 nearly every year since it came out in 1994. The confusing language may have finally been corrected in CDT 2023.
Author's note: The 2023 revisions are illustrated here:D4355 full mouth debridement to enable a comprehensive oralperiodontal evaluation and diagnosis on a subsequent visit.

Full mouth debridement involves the preliminary removal of plaque and calculus that interferes with the ability of the dentist to perform a comprehensive oral evaluation. Not to be completed on the same day as D0150, D0160, or D0180. 

When D4355, full-mouth debridement, was first introduced in CDT-2 in 1994, the title was, “Full-mouth debridement to enable comprehensive periodontal evaluation and diagnosis.” The descriptor was simple: “The removal of subgingival and/or supragingival plaque and calculus which obstructs the ability to perform an oral evaluation. This is a preliminary procedure and does not preclude the need for other procedures.” 

Every year since it was introduced, the ADA Code Maintenance Committee has received submissions seeking to amend the language because of so much confusion. Significant amendments were made, changed, and changed again in CDT-3 (1999), CDT-4 (2002), CDT 2005 (2004), CDT 2018 (2017), and most recently, CDT 2023. This current amendment deletes the descriptor, which opens the door for more opportunities to use this procedure, especially in the public health sector and for clinicians providing direct access care outside the traditional dental setting. 

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According to the ADA Guide to Reporting Full Mouth Debridement, version 2, “These revisions clarify that full-mouth debridement is a procedure reported with its own unique code (D4355). A comprehensive periodontal evaluation is a separate procedure reported with code D0180. As the D0180 procedure must include periodontal probing and charting delivery, during a subsequent visit allows time for gingival tissues to heal so that findings are accurate.” 

The American Academy of Oral Medicine submitted this change for a number of reasons, including but not limited to: the previous language restricted the dentist’s clinical judgement and defined decision making/sequencing of care that may not be appropriate; it limited access of needed oral health care to vulnerable patient groups prior to medical/surgical procedures; behavioral constraints where adjunctive anesthesia may be necessary; and patients in rural areas who lack transportation may have only one appointment time to accomplish necessary treatment. 

During deliberations at the March 2022 CMC meeting, it was clear that by amending the nomenclature (title) to delete the reference to a comprehensive oral evaluation (D0150) and reference the periodontal evaluation, the clinician could provide all elements identified in the D0150 procedure code descriptor except probing at the first appointment. In that respect a more complete diagnosis could be completed, minus any periodontal therapy needs. 

Many authors are publishing articles describing their interpretation of the changes to this procedure code. Clinicians are encouraged to be cautious when reading these articles and refer to the ADA Guide to Reporting Full Mouth Debridement, version 2 to decide whether to perform a D4355 procedure. 

Here's what we concluded

Taking into consideration the testimony and discussions during the CMC meeting, as well as the ADA Guidelines version 2, here are our conclusions: 

A D0150 comprehensive oral evaluation may be delivered on the same date as a D4355 procedure if all components listed in the descriptor of the procedure code have been completed. “It may include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, existing prostheses, occlusal relationships, periodontal conditions (including periodontal screening and/or charting), hard and soft tissue anomalies, etc.” (See page 4 of CDT 2023 for a more complete list of all components.) In the opinion of the CMC, a screening could be a select six-point periodontal screening to determine the presence or absence of periodontal disease. 

If a person presents with signs and symptoms of periodontal disease or risk factors such as diabetes or smoking, the CMC recommends using alternative evaluation procedure code D0191 assessment of a patient, which is a prediagnostic service. The descriptor states (page 5 in CDT 2023), “A limited clinical inspection that is performed to identify possible signs of oral or systemic disease, malformation, or injury, and the potential need for referral for diagnosis and treatment.” Then the patient will return for reevaluation, and the D0180 comprehensive periodontal evaluation–new or established patient would be used after initial healing has occurred and a complete periodontal evaluation has been completed. 

D0180 requires complete periodontal charting that includes but is not limited to six-points-per-tooth pocket depths, recessions, furcations, mobilities, bleeding points, and periodontal diagnosis. D0180 can be used for both new and established patients as the nomenclature reads. 

D0191 would be the most appropriate procedure code to use in cases of limited access, such as nursing homes, hospitals, or home-care settings. This would allow direct access dental hygienists to seek reimbursement from third-party payers if needed. 

If the patient’s chief complaint is pain or bleeding gums stemming from the accumulation of plaque or calculus, D0140 limited oral evaluation—problem-focused (page 3, CDT 2023) can be appropriately used. It also leads to the need for D4355 at the same appointment followed by scheduling D0180 at a later time. 

As dental professionals adapt to new opportunities to treatment plan patients for this procedure, third-party payers will be adapting their reimbursement policies. It’s up to clinicians, whether dentists, hygienists, or others whose state practice acts allow them to perform this service, to treatment plan what is medically necessary and appropriate for their patients, not what reimbursement rates the insurance carriers offer.

About the Author

Kathy S. Forbes, BS, RDH

Kathy S. Forbes, BS, RDH, has been a dental hygienist, educator, speaker, author, consultant, seminar, and study club leader for more than 40 years. She holds a license with the ADA for Current Dental Terminology, which allows her to provide the most up-to-date understanding of current procedure codes. Kathy currently serves as a director for the Dental Codeology Consortium, reviewing and developing procedure codes relevant to dental hygiene practice that are presented to the Code Maintenance Committee of the American Dental Association in March each year. 

About the Author

Connie Simmons, MA, BSDH, RDH

Connie Simmons, MA, BSDH, RDH, earned her BSDH from The Ohio State University and her MA in aging studies from Wichita State University. She’s worked in clinical hygiene for almost 35 years and has other roles in clinical training, sales, speaking, and writing. Her knowledge of dental insurance and coding grew while working with an insurance carrier, and she’s now part of the Dental Codeology Consortium and an associate productivity coach with Inspired Hygiene. She’s also an expert in the clinical use of silver diamine fluoride. Reach her at [email protected].

Updated August 10, 2023