by Annette Ashley Linder, RDH, BS
A problem with your patient's health may be looming on the horizon, but will you get the support you need from the insurance company? Or will it be waiting for the brush fire to turn into a raging forest fire before anything is done? Or maybe there's a way to avoid 4910 woes altogether.
We have a problem with 4910 SPT (Supportive Periodontal Therapy) in our office. My patients won't return for care every three months because "the insurance will only pay for cleanings twice a year." Patients who went through active periodontal treatment two years ago are now presenting with full-blown perio again. What do I say and do now? Our insurance/financial coordinator is upset with me because the insurance isn't paying and patients are complaining to her. How do we get insurance to pay? How do I help my patients see that this appointment is different from a three-month prophy, and how is it different? Should we charge for an exam? Can we alternate with the prophy (1110) code?
If these are questions that you are asking, please know you are not alone! They are among the most frequently asked at my lectures and when consulting with a dental practice. Managing three-month periodontal therapy maintenance is a real and valid frustration for hygienists, and it is no fun for the financial/insurance coordinator.
Ongoing supportive periodontal maintenance is well established in the research as critical and key to long-term periodontal stability. Patients treated for periodontitis who comply with suggested SPT intervals experience less tooth loss and attachment loss than patients who do not comply. Because the progression of the disease is unpredictable, SPT protocols allow for close monitoring as well as professional procedures. In other words, ongoing and supportive periodontal maintenance is an integral part of the treatment plan. (Visit www.aap.org for tons of research.)
The challenge is getting this message through to the patient. How do we attack this problem? I would like to share some concepts and ideas for change that are already being successfully used by dental hygienists throughout the country.
Patients don't get it!
My research and consulting observations demonstrate that one of the contributing factors for low SPT compliance is the unilateral enrollment of the patient in periodontal treatment. What does this mean? In many dental practices, the patient is simply told by the dentist or the hygienist that they have a "gum problem" and they need to have "quadrants of scaling and root planning to remove the calculus from below the gum line." The patient is typically told that it will "require three to six appointments and cost around $900. The insurance may pay for 50 to 75 percent of the treatment." The patient often agrees to treatment but is actually thinking:
• Go ahead and fix it, hygienist.
• Your problem, hygienist, not really mine.
• Clean me up really well and I am on my way — and no lectures, please.
It is a set-up for a no-win hygiene scenario. Just what you need — another compliance battle. Suffice it to say that there will be no calculus on the root surfaces when you are done.
However, you and I know that a successful periodontal therapeutic outcome is very much dependent on what the patients do when they leave your chair. You can scale and root plane until you are blue in the face. But if the patient is not participating (performing exquisite daily bacterial plaque removal, for example), chances are slim for ongoing periodontal stability. Patients who accept perio treatment because the hygienist or the dentist said "to do it" are the patients who cancel appointments, do not perform home care, complain about money, and fail at three-month supportive care because "insurance only pays for two cleanings a year!" Our goal is to allow patients to take ownership of their health, periodontal or otherwise, and to coach them to be informed and pro-active health care clients.
Start at the beginning — beyond the roots
The solution starts at the very beginning, during the assessment and treatment proposal phase. Ideally, we would like everyone to say "yes" to treatment. But in the real world and for a variety of reasons, that is not likely. Trying to talk unwilling patients into treatment leads to another no-win scenario because these are the patients who do not comply with total treatment. When, and if, they return for care, they typically present with active disease again and require re-treatment. Back to ground zero for the hygienist who assumes all the blame and struggles to explain the situation to the patient. Talk about stress levels and burnout — this is not fair to the hygienist.
There are better and easier ways to achieve compliance. As hygienists, we are continually educating and discussing oral health with our patients. The interrelationship between existing health conditions, medications, and personal history all have an impact on the patient's periodontal status and should be discussed with the patient. Have research articles readily available in the reception area, treatment rooms, office newsletters, and office communications.
Periodontal disease is a condition with complex and interconnected causes. It is episodic in nature. Genetic, local and environmental factors, and the host immuno- inflammatory response all play a causative role. In other words, it is more than just the bacteria. Therefore, updated histories are an important part of data collection. Audit the patient record for an updated, complete health history. Discuss the significance of the patient's current health status, medications, life changes, stress factors, and periodontal health. Examples of a patient conversation might be:
• "John, you have indicated that you have been diagnosed with diabetes. We have a lot of new research information demonstrating a link between diabetes and periodontal infections in the mouth and the body. I would like to share that information with you ..."
• "Mary, you have indicated that you smoke. The latest research reports that smokers have the greatest risk for periodontal infections and tooth loss, and I would like to provide you with some information."
Periodontal evaluation is part of every dental hygiene appointment and part of the patient's record. Create an open environment of co-examination and co-discovery to bridge the gap between "the lecture" and the patient willingly saying "yes" because they value the goal of the treatment plan.
Prior to beginning the periodontal exam, remind the patient of clinical signs he or she can understand. This might include bleeding, pocket depth, bacteria getting deeper into the bone and connective tissue, causing infection, inflammation, and bone loss. Offer the patient a mirror so he or she may watch. Proceed through the periodontal exam, calling out the numbers, bleeding points and other clinical signs so the patient can see, hear, and participate in the examination. With a team member recording the data, it becomes time-efficient to complete the full mouth examination. Some patients will watch; others will not.
The important part is to allow the patient to hear any clinical signs of periodontal infection. Use the examination to educate and motivate. In this model, at the completion of the exam, most patients know what their problem is and want to correct it. The hygienist is then able to present the appropriate periodontal treatment plan. See the written "Periodontal information and treatment recommendations" form within this article, which includes an informed consent component. Notice that the form includes information on three-month ongoing care as part of the treatment plan.
At each therapy appointment, the patient receives written information to take home. This may be a professional pamphlet, a section of a research article, or your own office information forms. Each appointment is perio-focused, involving the patient every step of the way. Utilizing the intraoral camera or a hand-held mirror gives the patient the opportunity to "see" the difference between healthy tissue vs. infected tissue. At the final active therapy appointment, the patient receives a "Why maintenance is important" information letter. This says it all. See the copy of the letter within this article.
Positive written and verbal communications invite the patient to "own" his or her oral health, have greater responsibility and unburden the hygienist as the sole person responsible for the patient's "clean" teeth. The patient must be a willing participant in therapy. If he or she does not want the treatment, you cannot do it. Bottom line, we are no longer just scraping roots and cleaning teeth! Patients clean their own teeth. Today's hygienist is a periodontal therapist and partner in health care with the patient.
What is the difference?
The SPT appointment is a periodontal appointment. It is part of periodontal treatment. It is not a three-month prophy. It is more than a routine supragingival scaling and polish prophy. The definition, according to the American Academy of Periodontology (AAP) and the ADA CDT 3, is:
"This procedure is for patients who have completed periodontal treatment (surgical and or nonsurgical therapies exclusive of 4355) and includes medical history review, evaluation of periodontal status (charting), removal of bacterial flora from crevicular and pocket areas (i.e. scaling, root planing, debridement), scaling and polishing of 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 judgment 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."
Nuts and bolts insurance information
Once the patient has received periodontal treatment (4341), he or she is a 4910 patient. Only submit for 4910 after utilization of code 4341.
• The procedure is billed four times per year as 4910.
• Examination and radiographic analysis are charged separately.
• Use of a narrative is reported to help gain insurance payment.
• A supportive research statement is, "Following a course of active periodontal treatment, periodic ongoing care at regularly prescribed intervals is essential. Although the standard of care recognizes that these intervals may vary due to the nature of microbial plaque, calculus formation, and host factors, a three-month time interval for periodontal maintenance therapy remains the most generally accepted. The majority of clinical studies have shown that three months is most effective in controlling the disease." (American Academy of Periodontology)
• Another supportive research statement includes, "The successful long-term control of periodontal disease depends upon active and continuous maintenance therapy. It is not considered acceptable practice to establish patient care on the basis of an arbitrary fixed interval. Example: Six-month recall" (American Dental Association CDT-1)
Many carriers typically pay for two "cleanings" a year and include 4910 in this category. They are going to pay twice a year and that is it. Some will pay for 4910 four times a year and some contracts cover 4910 twice a year and modify the other visit codes to 1110. As with many ADA codes, the insurance will only reimburse for what is covered by the contract. You could send them a book of periodontal research, form a picket line in front of their office, or send some of your own blood, but it won't help. If it is not a covered benefit, too bad, but don't blame yourself. The contract is between the employer, the patient, and the insurance company.
When patients enter into the commitment of ongoing periodontal treatment because they value the benefits of maintaining optimum oral health, then insurance does not matter. The "two cleanings a year" mentality falls by the wayside, along with your feelings of frustration. Realistically speaking, we are not talking about thousands of dollars here. Typical SPT appointment fees are about the same as dinner for two at a nice restaurant. Be sure to remember to offer patients external financing help (companies such as CareCredit), if appropriate, for periodontal treatment, just as you would for clinical dentistry cases.
Documentation and submitting the claim
Always include a narrative and the date of the last 4341 with the 4910 claim. A sample narrative follows: "Patient completed active periodontal therapy on date of 4341 and is now receiving periodic and ongoing care as prescribed by the AAP."
Many offices are also including intraoral photos of bleeding, swollen, inflamed tissue with the periodontal claim submission and it appears to be having some positive effect.
According to Carol Tekavec in the March 2002 issue of Dental Economics, the 4910 claim should also include:
• Periodontal case type
• Dates of root planing and/or surgery
• Copy of the charting depicting and describing progression of the periodontal status
• Assessment of home care (poor, adequate, good)
Tekavec goes on to report, "Alternating between the codes 4910 and 1110 is not reasonable because the patient's insurance carrier may require evidence of further surgery prior to paying for a 4910 following a 1110."
The code 4910 includes a periodontal evaluation, not a periodic examination. Therefore, the periodic exam (0120) is performed and charged out separately, usually at six month intervals. The same is true for necessary radiographic evaluation. Will the insurance pay for the exam? They should, if preventive exams are covered twice a year. Again, it always depends on the insurance company and some do not pay for 0120 on the same day as 4910, even though the CDT 3 description is clear.
Don't hesitate to:
• Re-submit claims with letters of explanation, charts, pictures, documenting research.
• Tell patients to call their insurance company (after all, they are the customers) and find out why they are not paying.
• Always charge out for your services rendered.
• Re-treat active periodontal infection, as needed and site specifically. An example of this is the patient who completed active therapy (4341) several years ago. Regardless of whether or not the patient has maintained a three month 4910, he or she presents needing a quadrant or quadrants of therapy. Changes in medical history, stress factors, and poor compliance are all contributing risk factors. Remembering that periodontal disease is a chronic infection — incurable but often controllable — it is not extraordinary to have to re-treat quadrant(s) with mechanical and chemical therapy, 4341. Most carriers do not define 4341 as a once-in-a-lifetime procedure and many will reimburse the patient for 4341 procedures following an appropriate time interval (typically after 24 to 36 months).
This is the most exciting time to be in our profession. Thanks to technology and research, our role as oral health care educator and provider is expanding every day. Patients are finally beginning to realize that what is going on in the mouth is a reflection of what is going on in the body. Before I became a full-time consultant and speaker, I practiced clinical hygiene for 30 years. During those years, I learned the hard way that it was unrewarding to force a patient into periodontal treatment with the unilateral approach. These patients did not comply and I was always "the nagger." That did not feel very good to me, nor did my patients like it very much. Once I allowed the patient to be a full participant in the exam and gave them everything that I knew about perio, the "no" to treatment became a "yes" because it was wanted. Those who asked for treatment also complied with an appropriate interval of care, be it two or three months. Even my gingivitis patients returned for three month intervals until we (the patient and I) felt comfortable with lengthening that interval. The insurance did not pay for four perio visits, but my patients did not mind because they "felt so good" about their oral health.
Determining an appropriate interval of care for your patients is a decision based on current research and protocols, the patients' clinical presentation and risk factors, and what you think is best. I work with hygienists throughout the country who see many patients every 60 days, if that is what is best for the patient. The decision has been positively made in partnership by the patient and the clinical hygienist. That is a happy ending that we can all feel good about.
Annette Ashley Linder, BS, RDH is an internationally known speaker, author, and consultant. As a management consultant, Linder's program for Hygiene Department Development™ has helped hundreds of dental practices achieve clinical and productive excellence in hygiene. She may be reached via her Web site www.annettelinder.com or (804) 745-6015.
• Medical history review
•u Evaluation of periodontal status (perio charting)
• Removal of bacterial flora from crevicular and pocket areas
• Scaling and root planing where indicated
• Polishing of the teeth
• Review and re-instruction of patient's plaque control
• Records and documentation
"Why maintenance is important" letter
Thank you for your efforts during the active phase of your nonsurgical periodontal treatment. You are now ready for the important maintenance phase to monitor and stabilize your periodontal health.
What is the importance of maintenance therapy?
Periodontal disease can easily recur. The bacteria that caused the infection are present in your mouth and are ready to attack the teeth, bone, and gum tissues. Continual ongoing care is an absolute necessity to ensure that the periodontal infection does not re-activate. There is significant scientific evidence stating that the most important aspect of periodontal treatment is ongoing maintenance therapy.
According to the American Academy of Periodontology, "Following a course of active periodontal treatment, periodic ongoing care at regularly prescribed intervals is essential. Although the standard of care recognizes that these intervals may vary due to the nature of of microbial plaque, calculus formation and host factors, a three-month time interval for periodontal maintenance therapy remains the most generally accepted. The majority of clinical studies have shown that three months is most effective in controlling disease."
Everyone responds differently to treatment and the sequence for periodontal maintenance appointments depends on several factors:
• Clinical signs of control of the infection
• Degree of residual pocket depth and bone loss
• Plaque control effectiveness
• Individual susceptibility, host immune response system
• Health, medications, age, and other risk factors, including smoking, diet, and nutrition
Most people have a varying resistance to periodontal disease at different times in their lives. A person's resistance may be normal for years and then resistance may diminish, because periodontal disease is controllable but not curable. The host immune response and medical and other mediating factors contribute to the health risk.
"But everything feels fine to me ..."
When active periodontal disease recurs following treatment, it may do so without any clinical symptoms and often progresses much more rapidly and destructively. If the patient waits for discomfort before returning to the dentist, many times the problem is beyond successful treatment.
What occurs during preventive maintenance therapy appointments?
• Evaluation of the health of your gum tissues and check for any signs of disease recurrence through comprehensive periodontal examinations, appropriate occlusal analysis, necessary periodontal instrumentation, periodontal debridement, deplaquing, and antimicrobial therapies.
• Evaluation of disease control efforts, bacterial and plaque control, and review and recommendations for improvement.
• Provide you with dental aids to assist you in your daily homecare efforts.
• Perform all oral health examinations, including oral cancer examination and any necessary radiographic update.
Thank you for your continued commitment to good oral health! We look forward to serving your dental needs. Please do not hesitate to call if you have any questions. We welcome the opportunity to continue to serve you, your family and friends in providing optimum oral health.