Alternating Insurance Codes
Understanding how the puzzle fits together
Understanding how the puzzle fits together
Can you alternate the D1110 or D4910 codes? Who knows? Who cares? It makes you crazy just to think about it. The office manager says you must. The insurance carrier says you can. The dentist doesn’t want to get involved any more than you do. The CDT-5 book says it’s a matter of clinical judgment. It really doesn’t make that much difference anyway, does it? Actually, you can commit fraud by “accident” or “ignorance.” The decisions made by others can put your license at risk. This is the second article on why the RDH needs to care about insurance. It will tackle the sticky issue of alternating codes.
Whether you like it or not, or want to be involved or not, your practice accepts insurance assignment or is enrolled in PPOs/HMOs, so as a clinician you are affected by the dental benefits industry. Dental insurance is a marketplace reality, yet many hygienists take a complete hands-off attitude to something that affects much of what they do. Insurance carriers are often inappropriately blamed. Before any discussion of how insurance affects hygiene, it is necessary to remind practitioners that we treat patients, not insurance policies. The treatment plan should be developed according to professional standards, not according to the provisions of the contract.
Taking apart the pieces
To understand the answer to the alternating codes question, we must take apart the pieces of the confusing puzzle. Look first at the evaluation/exam process. We now use the fifth and latest version of the Common Dental Terminology book - CDT-5. CDT-5 is divided logically into sections, and the first section is I. The diagnostic codes are numbered D0100 to D0999, with the first subsection called Clinical Oral Evaluations.
There are six evaluation codes:
• D0120 Periodic
• D0140 Problem focused-limited
• D0150 Comprehensive
• D0160 Detailed extensive-problem focused
• D0170 Re-evaluation-limited, problem focused
• D0180 Comprehensive periodontal evaluation
These are listed as evaluation codes, not exam codes. The difference is that an evaluation includes a diagnosis and treatment plan. It is important to understand this distinction. When these codes are used, it means a specific diagnosis has been made. Sounds simple, yet how often do we truly have a specific diagnosis? More often, we just do stuff. Dental professionals often think in terms of procedures, not diagnoses. The CDT process facilitates this thinking because there are no diagnosis codes, only procedure codes. This is not the case in medicine. There is a well-defined set of diagnosis as well as procedure codes. Diagnosis is important here because it is the key to answering many coding questions.
Can a hygienist make a diagnosis? Those words strike fear in the hearts of some hygienists, who have been told over and over and over that an RDH cannot diagnose. Repetition works, repetition works, repetition works. Yet saying something over and over does not necessarily make it true. In June 2005, ADHA, the largest organization representing the interests of the more than 120,000 dental hygiene professionals, published the ADHA: Dental Hygiene Diagnosis Position Paper. This important document states:
“The position of ADHA is that dental hygienists, by virtue of graduation from an accredited dental hygiene program, are educationally prepared to conduct a dental hygiene diagnosis, and that the formulation of a dental hygiene diagnosis is the responsibility of the dental hygienist in the delivery of quality oral health care.”
This is not a stand-alone statement. This position is well thought out and supported by evidence. Licensed dental hygiene professionals can benefit by reading, understanding and embracing this document found at www.adha.org/downloads/DHDx_position_paper.pdf.
What is D1110/D1120 prophylaxis?
As CDT has evolved from its first version in 1991 to CDT-5, there is one code that has been defined and redefined numerous times. But rather than clarifying this code, these revisions have confused the issue even more. It is the belief of this author that further redefinition would only make it worse. The codes D1110/D1120 should be eliminated. The word prophylaxis should also be eliminated, because as long as we use the same words and codes, no matter the redefinition, the issue is still confusing. The codes available for the care most often provided by hygienists are woefully inadequate, and much is based on 1950s thinking. (See “Why Should an RDH Care About Insurance?” RDH May 2006.)
Until these changes occur, clinicians need to work within the system. The CDT-5 definitions of a D1110 and D1120 are:
• D1110 - “Removal of plaque, calculus, and stains from the tooth structures in the permanent and transitional dentition. It is intended to control local irritational factors.”
• D1120 - “Removal of plaque, calculus, and stains from the tooth structures in the primary and transitional dentition. It is intended to control local irritational factors.”
These are the latest redefinitions. As differentiated from earlier versions of CDT, these new definitions do not include parameters and descriptors that discuss pocket depth. These definitions identify local irritational factors for localized gingivitis. There is no longer language on scaling or polishing as part of the procedure. The scaling and polishing language was an issue when CDT-4 was issued. The CDT-4 definition changed one word from the CDT-3 version - scaling and polishing to scaling and/or polishing. Sometimes a little change can make a big difference. Adding or to the CDT-4 edition meant that polishing could equal a prophylaxis. It was through the immediate efforts of the ADHA that the definition changed back to scaling and polishing. There are those who do not want a description of the procedures included at all. In the current CDT-5 edition, language on scaling and polishing was removed altogether.
Another issue that needs clarification is determining the age of a child and an adult. In the Q&A section of CDT-5, age is answered by pointing to the definition in the code that states the difference as dentition-specific vs. age-specific. The Q&A states that third parties may have age restrictions through their policy-making process. Though dental professionals like to blame the carriers, selection of a policy and the limitations therein are not the fault of the carriers. The responsible party is the party purchasing the policy, generally an employer.
The American Dental Association (ADA) House of Delegates created a resolution to clarify the age of a child:
➜ “Age of child (1991:635)
• Resolved, that when dental plans differentiate coverage based on clinical development of the patient’s dentition, and be it further
• Resolved, that where administration constraints of a dental plan preclude the use of clinical development so that chronological age must be used to determine child or adult status, the plan defines a patient as an adult beginning at age 12 with the exclusion of treatment of orthodontics and sealants.”
Clear as mud? It says if an insurance plan doesn’t allow dentition-specific determination, then the age of an adult is 12. What do you do if a policy states the age as above 16? This becomes an ethical question. It is necessary to remind practitioners that we are treating the patient, not the insurance policy. The treatment plan should be developed according to professional standards, not according to the provisions of the contract.
Gingival and periodontal disease lack of diagnosis
Whether D1110 prophylaxis is the appropriate procedure is based on the diagnosis. The factor most often used to determine the difference between gingival disease and periodontal disease is bone loss. The measurement from the healthy, normal alveolar crest to CEJ is 1.5 to 2 mm, yet that number is not well known to many beyond educators, students, and new grads. Most practices don’t have a system for measuring and documenting bone height. This lack of a systematic approach is another factor that leads to just doing stuff without a diagnosis.
Diagnoses are often made using ADA Treatment Categories Type I to V. These treatment categories were created by the ADA in the 1980s and have been superseded by the 1999 American Academy of Periodontology Classification System for Periodontal Diseases and Conditions (www.perio.org). In the ADA system, Type I is for gingivitis. The AAP classification system recognizes that not all gingival disease is gingivitis. Treatment should be based on diagnosis. The ADA system is overly simplistic for our current understanding of periodontal breakdown. The Host-Bacterial Interaction Theory defines breakdown as the result of how the immune system responds to acquired, genetic, and environmental challenges. Research has well supported this theory for more than 20 years. As we recognize that periodontal disease is a risk factor in heart disease, diabetes, low birth weight, premature infants, and much more, the issue of proper diagnosis and treatment becomes even more important.
Pretend that a real diagnosis using appropriate disease classifications has been made, periodontal therapy has been completed, and the patient has returned for a second three-month maintenance appointment. The presenting condition shows the disease process has been stabilized. Does this mean the D1110 code should be used? With the current system, we must assume the major parameter of bone loss was evidenced to make a periodontal disease diagnosis. Did the bone grow back with therapy? It has not been the experience of this author that we have the technology for that.
Trisha O’Hehir, long-time columnist on perio for this magazine, said, “Alternating codes is not acceptable since it’s not accurate. Actually, it’s considered insurance fraud. Once a patient is diagnosed with periodontal disease and receives treatment, you will always use the D4910 code for maintenance on that patient - it has nothing to do with pocket-depth readings at maintenance visits. Hopefully, periodontal treatment was complete and successful and at maintenance visits these patients won’t have any pockets. Your maintenance visits will keep them healthy and free from disease. If they have bleeding pockets at maintenance visits, they need treatment, not maintenance.” O’Hehir made this statement in 2003, before the CDT-5 release.
The Q&A section of CDT-5 states that using D1110 after periodontal therapy is a matter of clinical judgment. Appropriately it should be reported as D4910. If the treating dentist determines that the condition can be treated with routine prophylaxis, delivery of this service and reporting with code D1110 may be appropriate.
Phone conversations with several professionals have clarified this issue. In January 2006, a dentist from the ADA Dental Benefits office said, “D1110 and D4910 are not interchangeable and should not be alternated. The dentist must make the diagnosis, but then the proper code for the procedure provided needs to be used. A D1110 can be coded for every three-month visit for someone who comes in that frequently but has not had their periodontal disease treated, or it could be used to indicate those patients who have had their disease treated, have great tissue resolution, and continue to come in for the three-to-four-month care to control or maintain their periodontal status following some type of periodontal therapy or surgery. It does appear that you could choose one code or the other, based on the diagnosis, but it would never be appropriate to alternate them.”
Is this enough to convince those in your practice? Here is more: Mark Rubin, legal counsel for ADA, was asked, “Have any dentists been sued for fraud for alternating these codes?” He responded, “ADA does not track this information; however, knowingly alternating the D1110 and D4910 to maximize insurance benefits would constitute fraud. We must code for the procedure being performed. By doing otherwise, the Attorney General could make a convincing case for prosecution.”
Bottom line - if office managers tell you to alternate, or they alternate in your name, it is wrong. If carriers tell you to alternate, again, it is wrong. If the dentist doesn’t want to get involved, that’s wrong too.
RDHs can make a difference
With the connection between oral and total health becoming more widely understood, dental benefit policies based on 1950s procedures are not appropriate. Molecular-based dentistry will soon replace restorative-based dentistry. This approach focuses more on prevention, which is the heart of dental hygiene. Research evidence is proving this to insurers and policy makers. The number of hygienists is increasing, while the number of dentists is decreasing. Hygienists can position themselves as the future leaders of oral health, but not by committing fraud or allowing others to do so in their names. Ethics are involved in this confusing situation.
Hygienists need to step up, take the time to understand the coding process, and actively work to create a brave, new world. If we don’t, others will continue to mandate the dental world for us. We can make a difference.
The author would like to thank fellow hygienists Trisha O’Hehir, Kathleen Johnson, and Pam Mecagni for their assistance with this article.