Protocol for gingivitis patients: Due to a lack of insurance codes, are we taking shortcuts with gingivitis?

Aug. 20, 2015
Let’s establish the criteria for gingivitis. Gingivitis is characterized by redness, inflammation, and bleeding. It can range from mild to severe and is most commonly caused by poor oral hygiene.

Dear Dianne,

I work in a rural community, and many of our patients are insurance-dependent. We understand that paying for needed care is difficult for some people, so we want to help them maximize their benefits. The problem we’re having in our office is how to properly treatment plan and code patients with gingivitis.

Since there are no codes for gingivitis, it seems that we have very few options. Do you have any tips for dealing with gingivitis patients and proper coding?

Kimberly, RDH

Dear Kimberly,

You are correct in stating that there are no specific codes for gingivitis. Personally, I wish the ADA Code Committee would develop some gingivitis codes. It has been requested many times, but the committee continues to say no.

Let’s establish the criteria for gingivitis. Gingivitis is characterized by redness, inflammation, and bleeding. It can range from mild to severe and is most commonly caused by poor oral hygiene. All gingivitis does not progress into periodontitis, but all periodontitis begins with gingivitis. Gingivitis can be chronic for years without affecting other periodontal tissues, and it is seldom painful. There is no bone loss associated with gingivitis.

One form of gingivitis—acute necrotizing ulcerative gingivitis (ANUG)—is seen mainly in young adults. This severe form of gingivitis is characterized by painful bleeding gums and necrosis of the interdental papillae. We believe it is caused by stress, malnutrition, fatigue, and poor oral hygiene.


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Since we know there is no bone loss associated with gingivitis, traditional root debridement is not possible or appropriate. After all, how can you scale roots that are covered with bone? Unfortunately, more than a few clinicians have tried to pass off gingivitis as periodontitis in order to upcode for a higher fee. Probing of 4 mm or even 5 mm in some cases results from swelling, not bone loss. That’s the reason most insurance companies deny coverage for root planing if there is no radiographic evidence of bone loss.

If you have a situation where the bone loss is real but not supported by radiographic evidence (such as facial or lingual), insert your probe into the pocket and take a picture with the intraoral camera. Submit the picture with the claim or preauthorization to help the reviewer see the situation clearly.

Here’s a patient scenario. Mr. Allen has not had any dental care for four years and is scheduled for a hygiene visit. He has lots of debris (soft and hard) and stain, but the bone looks good radiographically. Your probings reveal several 4 mm pockets, and the color and texture of his tissue points to gingivitis. You know you cannot perform thorough care in one visit due to time limits. It is easy to use up half or more of your available time doing all the preliminary tasks that help you determine what level of care this patient needs, i.e., medical history review, radiographs, periodontal probing, visual assessment, and oral cancer screening.

My recommendation for such a patient is to perform the preliminary tasks and then use the remaining time to perform debridement on half of the mouth only. The reason I recommend this protocol is because if you perform a full-mouth debridement on the first visit, the patient may not feel the need to return. You will better ensure the patient will return if only half the mouth has been treated.

Homecare instructions are very important for gingivitis patients, as we know the primary reason for gingivitis is poor oral hygiene. Unfortunately, when hygienists are pressed for time, they shave time in two primary areas—periodontal probing and home care. Every practicing hygienist knows I’m being truthful. We tend to omit two of the most important aspects of high-quality hygiene care when we’re in “run and gun” mode. How can we tell if pockets are present or deepening if we don’t probe? Further, what good have we done if we clean patients’ teeth but we don’t teach them how to take care of themselves at home? Teaching home care takes time and effort, but hygienists tend to prioritize scaling over teaching homecare. After all, didn’t we get points taken off our grade in school if we left one little speck of debris? Therefore, scaling becomes the mindset. Scaling is important, but so are probing and home care instructions.

So, if you concentrate your efforts on half of the mouth only on the first appointment, you will have time to perform a thorough debridement and reinforce homecare at the succeeding appointment. But, how can you code a gingivitis patient who needs two appointments to complete?

There are two options. One would be to code both visits as D1110. That’s the way the ADA Coding Committee would recommend you code a gingivitis patient who needs two visits to complete. If you have to expend both of the patient’s preventive care benefits to give him the care he needs, then so be it. The second option would be to use the code D4999 on the first visit with a narrative. Our patient, Mr. Allen, would have this narrative: “Patient has had no dental care for four years. Heavy staining and debris. Will need additional visit to complete.” Then use D1110 for visit two. That way, the patient will have an additional preventive benefit to use six months later.

Some offices use the code D4355 to perform a full-mouth gross debridement, but my experience is that many insurance companies do not compensate this code. Also, this code is supposed to be reserved for patients who have so much calculus that a thorough exam cannot be performed. Most offices do not see that many people in this category unless the practice services a large indigent population.

One of the problems with hygienists is that we think we need to finish gingivitis patients in one visit. However, most patients in this category need two visits in order to perform thorough debridement and still have time to allow the patient ramp up home care.

My husband was referred to a periodontist for a site-specific periodontal problem. After his comprehensive exam, he was scheduled for a one-hour visit with the hygienist. This visit was devoted 100% to homecare, including proper use of a WaterPik, interdental brush turned vertically to access the pocketed areas, and using various antimicrobials. His customized routine did not include flossing. (I know some of you are gasping right now.) The fee for this appointment was $130, and in my opinion this was money well spent. The point is that homecare instruction was given a high priority in his treatment plan.

Maybe someday the ADA Code Committee will see the need to develop some gingivitis codes. Until then, we will have to use the only options we have, neither of which is ideal. The most important task is developing an appropriate treatment plan and delivering high-quality care with the goal of helping patients get better and maintain good oral health. RDH

All the best,

Dianne Glasscoe Watterson, RDH, BS, MBA, is an awards winning speaker, author, and consultant. She has published hundreds of articles, numerous textbook chapters, an instructional video on instrument sharpening, and two books. For information about upcoming speaking engagements or products, visit her website Dianne may be contacted at (336) 472-3515 or by email [email protected].