When performing site specific scaling and root planing, which choice do you make?
BY Kathy S. Forbes, RDH, BS
Site specific scaling and root planing - To do or not to do? That is the question. Or, maybe it is one of many questions. Maybe it should be done only as an initial therapy procedure, or maybe as an ongoing therapeutic procedure, or maybe combined with something else. Then there's the question about how many "sites" are involved. What is a "site?" After all, there are two CDT procedure codes which address site specific scaling and root planing. What, you ask? Two codes?
Treatment planning of dental hygiene/periodontal procedures continues to seem complicated as clinical staff struggle to accurately diagnose and create treatment plans for periodontal diseases and select the appropriate procedure codes for billing purposes. At the same time, business staffs are under pressure to help patients understand that insurance carriers are continuing to limit benefits for periodontal procedures, and the out-of-pocket portion may be higher than the patient expects to pay.
There is no better time for both clinical staff and business staff to understand the specific definitions for the procedures they are recommending as well as billing. There is no code more confusing than "site specific scaling and root planing."
The American Dental Association's CDT 2014 Dental Procedure Codes manual defines these two codes related to site specific scaling and root planing on pp. 36-37. The most recognized code for isolated scaling and root planing is: "D4342 - Periodontal Scaling and Root Planing - one to three teeth per quadrant. This procedure involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. It is indicated for patients with periodontal disease and is therapeutic, not prophylactic, in nature. Root planing is the definitive procedure designed for the removal of cementum and dentin that is rough, and/or permeated by calculus or contaminated with toxins or microorganisms. (partial definition)"
Typically, this is the procedure recommended when a patient has active periodontal disease that includes evidence of bleeding on probing, inflammation of gingival tissues, clinical attachment/bone loss of 4mm or greater, gingival recession, and significant subgingival calculus deposits. There may also be evidence of beginning furcation involvement, tooth mobility and radiographic evidence of bone loss. The limiting factor is that, with this code, only one to three teeth in a quadrant would benefit from this procedure. (If more than three teeth in a quadrant, the appropriate code would be D4341.)
The other procedure code is one many hygienists use on a routine basis, but are unaware of the entire definition of what procedures are to be performed during this appointment. "D4910 - Periodontal Maintenance. 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. 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. (partial definition)"
Periodontal maintenance appointments are typically scheduled at three- or four-month intervals in order to manage the bacterial assault in periodontal pockets that the patient cannot clean, as well as the host response to that assault. Recognizing that periodontal infections can occur on an episodic basis in isolated pockets, site specific scaling and root planing, where indicated, is meant to be included during this procedure to ensure that those isolated areas are treated during this appointment.
So back to the question: To do or not to do? That is probably the easy question. The more specific question becomes "When do I provide site specific scaling and root planing - either during the D4910 or as a separate appointment as D4342? More importantly, what clinical criteria/rationale am I considering and documenting in the patient's clinical chart to support my treatment selection?"
A scenario for choosing treatment
A 54-year-old male patient has a history of scaling and root planing and has been returning for periodontal maintenance appointments on a regular or close to regular basis every three to four months for the past eight years. He occasionally has certain pockets (one to two specific sites) that "flare up" and need some definitive debridement/root planing (but anesthetic is not necessary). His periodontal condition is considered stable.
He arrives for his three-month periodontal maintenance appointment. All gingival tissues/pocket depths are stable with very isolated bleeding. The exceptions are No. 10M and No. 12M (both probe 5 mm), and they present with slight to moderate bleeding upon probing and light amounts of subgingival calculus and/or root roughness.
Based on the CDT definitions, what would you do?
• Provide a D4910 periodontal maintenance and consider the SRP of No. 10M and No. 12M as part of the "site specific scaling and root planing, where indicated?"
• Provide a D4910 periodontal maintenance and reschedule No. 10M and No. 12M for a separate appointment of D4342?
Feedback from dental hygienists
I surveyed a number of hygienists and found the results interesting. Here are some of the responses:
• I would provide a periodontal maintenance (following initial SRP) when the patient's mouth is generally healthy and pocket depths are stable. If there are localized areas which would benefit from definitive SRP, I reappoint for D4342.
• My answer depends on the number of sites involved and the extent of inflammation. If there were only one site involved, then a periodontal maintenance would be used. If the site were two to three teeth or more, then I would schedule a separate appointment and use the D4342 or D4341 code, especially if local anesthetic is necessary.
• If an area is not responding to the regular maintenance therapies and/or the patient has had a change in their systemic health that could change their prognosis, then it may be this patient requires undergoing therapeutic SRP again to get these areas back to a maintenance phase. The key is "unresponsiveness" and the fact that D4910 is to maintain the health of the patient, not provide therapy.
• If his periodontal condition is stable and one or two sites need definitive treatment that can be completed within the scheduled time, I would bill the periodontal maintenance only. After all, it seems like the intent of the procedure definition was to allow for those isolated areas to be treated during the scheduled appointment time.
• I would need a bit more info such as (1) General health status. Any changes? New meds? Stresses? (2) Calculus/stain building rate. How is the rest of the mouth? Am I going to be spending a lot of time chasing calculus and not have the time to spend subgingivally like I want? (3) Patient management. Is patient a "time sucker," fearful, talkative, etc. After all these years, I have learned that it is not worth my stress level trying to incorporate very much SRP into the PM appointment. I would rather reappoint and be thorough and not rushed to address the patient's needs. If it is just a single site, probably not, but if multiple sites, absolutely!
• If this patient is well maintained, I would continue to complete a D4910 and provide localized SRP during that time. I would revisit D4342/D4341 as needed for a quad/area requiring extra special attention after the initial couple of years on a PM program. Sometimes a patient will present with a "problem area/quad" that would benefit from starting over in order to get a handle on the progression of the disease.
• I usually rely on the parameters of the D4910 definition so that is what I would probably do for this patient. Occasionally, however, I have had patients who are experiencing a more generalized "break-down" with increased bleeding and inflammation, sometimes with several areas of increased pocket depth (not always) but certainly exhibiting changes in their usual clinical picture. There may have been changes in a patient's overall health status, stress levels, or habits (resuming or increased smoking or oral hygiene routine, occlusal changes, new meds, depression). Sometimes, it seems that routine maintenance over time is not managing things as well as I would like to see or expect. The usual methods of control - shortening the maintenance interval, increasing oral hygiene efforts, prescribing therapeutic rinses, etc. - simply do not seem to be effective. That is the point when I think it is appropriate for a quadrant approach and using D4342 in order to try to reverse and stabilize things.
So now that we have considered a range of professional responses to the proposed scenario, I offer my personal approach as to how I would treat this patient based on the information provided. The short answer is I would complete a D4910 periodontal maintenance procedure and include the two sites in need of active periodontal therapy (SRP) as part of that procedure. With light amounts of subgingival calculus and/or root roughness (and no anesthetic needed) and slight-moderate bleeding, I can complete the procedure in the scheduled time. I rely on the definition of the current CDT edition when it comes to determining and selecting appropriate procedure codes for the treatment I provide.
When the definition of periodontal maintenance was modified in CDT-4 (2003-2004), there were two significant changes to previous descriptions from CDT-2 and CDT-3 and those changes are still in effect with our current edition:
• "... maintenance starts after completion of active (surgical or nonsurgical) periodontal therapy and continues at varying intervals ... for the life of the dentition."
• "It includes ... site specific scaling and root planing where indicated ..."
What is even more interesting is that in CDT-1 (1990-1995), the definition did include "scaling and root planing where indicated" but was excluded in CDT-2 and CDT-3. For whatever reason, the American Dental Association, with input from other dental professionals and professional organizations, determined that it must be included again and considered it an integral part of the therapeutic treatment. And anyone who has observed the process of procedure code development knows that the ADA does not amend, edit, delete, or create codes without very specific criteria and long debates.
As long as the ADA reviews all of the procedure codes on an annual basis (yes, the manual is now revised yearly instead of every two years), it is up to dental hygienists to be aware of the procedures we provide and the codes that align with them. Related to these two codes for site specific scaling and root planing, the best we can hope for is to understand the definitions and be ready to document the rationale for the procedure/code selected. After all, the clinical notes for our patients must back up the treatment we provide, and the treatment we provide must match the CDT definition of the procedure code we are billing. RDH
Kathy S. Forbes, RDH, BS, has been a dental hygienist, educator, speaker, and author for over 30 years. She speaks frequently about the correct classification, documentation, treatment planning, procedure code selection, and long-term case management for patients with periodontal disease. She is a regular contributing author for the Insurance Solutions Newsletter, a national publication for Dr. Charles Blair and Associates, where she addresses issues related to dental hygiene procedures and proper billing practices. Kathy is also owner of Professional Dental Seminars, Inc., a continuing education provider. She can be reached at 253-670-3704 or [email protected].