Dental insurance: Finding the right code for periodontal scaling
Recently I had a patient who had mild periodontitis on several posterior teeth. All of his anterior teeth were fine.
By DIANNE GLASSCOE WATTERSON, RDH, BS, MBA
Recently I had a patient who had mild periodontitis on several posterior teeth. All of his anterior teeth were fine. Specifically, I found 5 mm pocketing on at least one site on teeth Nos. 2, 3, 15, 18, 19, 30, and 31. There was no recession, but there was a moderate amount of bleeding. When I recommended periodontal scaling for the patient, the front desk assistant informed me that he did not qualify for periodontal scaling due to not having enough teeth that were periodontally involved. She suggested I just do a prophy. I disagreed, which only made her angry with me. I’m not the best with codes, but I do believe this patient needs more than a prophy. Can you help me explain this to my stubborn front desk assistant? By the way, I should mention that I am new to the practice, and I graduated from dental hygiene school last year.
Your situation is a woeful example of a front desk assistant who is (1) incorrect with her assessment, (2) unaware of the correct codes for this situation, and (3) not qualified to make treatment recommendations. Ignorance of correct treatment codes costs the practice money. But worse, not treating a known disease entity could lead to allegations of malpractice for the doctor. A prophy is fine for teeth with no symptoms of disease. For those teeth with evidence of bone loss, definitive periodontal scaling is appropriate. You have identified several teeth in need of more definitive treatment than a prophy. If you do not treat those early pockets now, what happens to them? They continue to deepen over time, making conservative treatment more difficult. “Just do a prophy” is the path of least resistance in the mind of the business assistant. But it is a path of long-term destruction for the patient and the practice.
Fortunately, the ADA gave us a code to use — D4342 — for periodontal situations with three or fewer teeth in a quadrant that require definitive periodontal treatment. Typically, third-party payers will not reimburse periodontal treatment under the code D4341 if there are not at least four teeth in the quadrant that are periodontally involved. The definition for code D4342 is:
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. Some soft tissue removal occurs. This procedure may be used as a definitive treatment in some stages of periodontal disease and/or as a part of presurgical procedures in others. (Excerpted from CDT© 2010 of the American Dental Association)
According to Dr. Charles Blair’s book titled “Coding With Confidence,” the presence of bleeding on probing, calculus, 4 mm to 5 mm pocket depth, and some radiographic evidence of bone loss will generally satisfy third-party payer requirements for reimbursement of this code. Further, it is typically reimbursed at 50% to 60% of the D4341 fee. You should be sure to specify exactly which teeth received definitive periodontal care on the claim form.
Let’s say a patient has two teeth in a quadrant that require periodontal scaling, whereas all the other teeth are periodontally healthy. It might be advantageous for the patient to receive both D4342 and D1110 on the same date to save the patient an additional visit. However, many third-party payers will not reimburse both procedures performed on the same date unless there was extended time used (which you would spell out in a narrative). This is highly variable among payers. So if the patient is insurance-dependent, the business assistant should find out if reimbursement requires two separate visits.
For the patient described in your post, I recommend that you perform the D1110 prophylaxis first. A second visit would be scheduled for periodontal scaling of all periodontally involved teeth on the right side of the mouth, and a third visit for the left side of the mouth. If you start with periodontal scaling first, there could be a 90-day waiting period required before reimbursement of either D1110 or D4910.
Your conversation with the patient would go like this: “In the assessment today, I’ve discovered some areas around a few of your teeth that show early-stage periodontal infection. Thankfully, we discovered this before it progressed into a much more difficult problem, and we get very good results with our treatment as a rule. We will need separate appointments for that treatment, which will require you to be anesthetized. I’ll be treating the problem areas on the right first, and then we’ll treat the left side afterward. Let me show you where I found some problems.”
You should show the patient with your intraoral camera where the problems lie using your probe and radiographs. Then you should inform the patient of the consequences of nontreatment. “This is a chronic infection which, over time, causes destruction of the bone and ligaments around the affected teeth. It can also spread to other teeth. So it’s best to clear this up now.”
Given the fact that you are relatively young to the dental hygiene profession, I’m impressed with your desire to treat the disease in the appropriate way, even when the appropriate treatment goes against the traditional protocol of the practice. Far too many hygienists would have just said, “Oh, well, whatever,” and not rocked the boat. Worse yet is when there is evidence of disease in its early stages, and the plan is to “watch” it. Watch it do what? Get worse? Is there some magic point at which we say, “OK, I believe this infection is bad enough to treat now”? Do we wait until 5 mm pockets become 6 mm deep before we pull the treatment trigger? Surely we all understand that there is a higher success rate of pocket resolution in treating a periodontal problem in its early stages.
I believe a real problem exists in practices where hygienists are not allotted enough time to perform thorough periodontal probing/charting, there’s no automated technology available for hygiene use, or there’s no one available to help with getting the numbers recorded. In these situations, it is clear that a lot of early periodontal problems are missed. The doctor goes on vacation and, in the doctor’s absence, the patient breaks a tooth. The patient sees the dentist down the street for the dental emergency, but this dentist discovers a significant pocket on the broken tooth and informs the patient that she will have to see a periodontist first. This could be a patient who has been a regular six-month patient in the original office, but no one discovered the periodontal problem. This could be a lawsuit waiting to happen.
The practice where you work is blessed to have you, because it is clear you understand that periodontal problems require definitive, therapeutic care, and that is different from a prophy. I also recommend that your office purchase a copy of Dr. Charles Blair’s book mentioned earlier, as it sounds like your business assistant needs help with proper coding. You may purchase the book through Dr. Blair’s website at practicebooster.com. RDH
All the best, Dianne
DIANNE GLASSCOE WATTERSON, RDH, BS, MBA, is a professional speaker, writer, and consultant to dental practices across the United States. Dianne’s new book, “The Consummate Dental Hygienist: Solutions for Challenging Workplace Issues,” is now available on her website. To contact her for speaking or consulting, call (301) 874-5240 or email dglass coe@ northstate.net. Visit her website at www.professionaldentalmgmt. com.
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