By Karen Davis
Between the ideal environment of pristine tissue and diseased periodontium exist patients who just have "a little bit of disease." How exactly do we manage their immediate and long-term care, and how do we tap into maximum insurance reimbursement to treat their condition? Good questions.
First of all, even though many of us in dentistry fall into the trap of verbally minimizing our messages to our patients by referring to conditions as "a little bit of bleeding" or a "little bit of decay," I'd like to suggest that we all strive to eliminate the "little bit of" reference to any type of condition that is less than the ideal when communicating to patients. While it is true that not all conditions are urgent or put a patient's teeth or periodontal support at immediate risk, early diagnosis of all disease in the mouth is valuable and warrants action to prevent "a little bit of" from becoming "a lot of."
Next, it is important not to overlook management of risk factors even though the disease presentation is localized. Here is an example. Your Monday morning patient presents with two to three teeth in each quadrant having 4-5 mm pockets and moderate localized bleeding, yet everything else appears healthy. The diagnosis of localized chronic periodontitis is made, and the patient is advised to return for a one-hour visit in which all eight teeth will receive definitive periodontal debridement to treat the condition.
Sounds reasonable that 60 minutes would be adequate time to complete this nonsurgical procedure on an existing patient. However, ask yourself if one 60-minute appointment seems reasonable considering the following risk factors for that patient:
- She is 37 and has been trying to get pregnant for two years.
- She has high blood pressure and is currently taking two medications to help manage hypertension.
- She is working full-time as a CPA and typically her workdays are 10 hours long.
- She is overweight and relies mostly on grabbing something fast for lunch each day.
- She consumes one or two Cokes daily and has a habit of using Altoids throughout the day to freshen her breath.
- She doesn't sleep well and has gotten into the habit of taking Benadryl each night.
- Her parents both have had periodontal disease and her mother is a Type II diabetic while her father had a triple bypass this year to treat his cardiovascular disease.
Adequate time for education and risk reduction should direct treatment planning as much as consideration of pocket depth and local factors.
Dental hygienists are in an ideal position to coach patients toward behavior modifications when adequate time is allotted to do so. Additionally, many third-party insurers will reimburse at a higher rate if the localized quadrants needing treatment are provided in two appointments, rather than lumped into one visit.
Essentially, the patient could benefit from both preventive prophylaxis on healthy sites and therapeutic treatment on diseased sites. A word of clarification here: There is nothing in the definition of ADA codes that states both prophylaxis and localized periodontal therapy cannot be performed on the same patient. The only issue is whether or not the patient's insurance benefits will provide reimbursement for both. Benefits generally coincide with premiums. The higher the premiums paid, the greater the benefit, and-likewise-lower-cost premiums generally yield fewer benefits. This point is imperative for clinicians and patients alike to understand in order to maintain realistic expectations of insurance benefits.
In general, for patients who present with localized disease warranting periodontal debridement on one to three teeth per quadrant without prior periodontal therapy, there are a couple of options. The best option would be to make a diagnosis of localized periodontal disease during the prophylaxis appointment and provide prophylaxis on healthy sites, billing accordingly. The patient would return for localized periodontal debridement, individualized education, and management of risk factors. Insurance claims would reflect the use of ADA codes D4342 per quadrant for each therapeutic treatment. The patient would then be seen for periodontal maintenance at customized intervals.
Another option would be to provide the first appointment of localized periodontal debridement instead of prophylaxis, followed by a second appointment of localized periodontal debridement, and bill accordingly. The patient would then be seen for periodontal maintenance at customized intervals.
Both of these examples show patients being seen for periodontal maintenance following localized periodontal therapy, but is it ever appropriate to follow localized periodontal debridement with prophylaxis instead of periodontal maintenance? Perhaps. The American Dental Association (ADA) and the Academy of Periodontology (APA) are clear that periodontal maintenance follows active therapy for the lifetime of the dentition, so that scenario will be appropriate for the vast majority of periodontal patients irrespective of whether the disease is localized or generalized.
However, the ADA Current Dental Terminology 2016 addresses the question of possible prophylaxis following active therapy in its Q & A section by basically reiterating that D4910 follows active therapy, but also concedes that in some cases the dentist may determine prophylaxis is an appropriate treatment following active therapy based upon the patient's current diagnosis. In practical terms, this is likely describing a patient who had a diagnosis of localized chronic periodontitis with little or no additional risk factors, responded well to periodontal therapy, subsequent periodontal maintenance, and currently presents with no evidence of bleeding upon probing, bleeding upon scaling, and no probing depths deeper than normal levels. Clinical notes would basically reflect a new diagnosis for the patient and prophylaxis would be provided.
Never should clinicians bill for prophylaxis following active therapy unless a new diagnosis has been established on the patient reflecting no active disease, and never should clinicians bill for prophylaxis while essentially providing periodontal maintenance, just to increase reimbursement opportunities for the patient. So, bottom line: Base treatment upon diagnosis, and bill insurance accordingly. RDH
Action point take-aways
1. When patients present with localized periodontal disease, consider providing prophylaxis on healthy sites first; then reschedule for active therapy.
2. Consider time for education and management of risk factors when developing treatment plans for treating localized disease.
3. Periodontal maintenance will follow localized periodontal therapy the majority of time, but there are clinical "exceptions to the rule" in which prophylaxis would be appropriate based upon diagnosis.
Karen Davis, RDH, BSDH, is the founder of Cutting Edge Concepts, an international continuing education company, and practices dental hygiene in Dallas, Texas. She is an independent consultant to the Philips Corp., Periosciences, and Hu-Friedy/EMS. She can be reached at [email protected].