Creative Coding

Dear Dianne, I work in an office with two other hygienists. I came to work here six months ago, and the other two hygienists have been here more than 10 years.

Dear Dianne,
I work in an office with two other hygienists. I came to work here six months ago, and the other two hygienists have been here more than 10 years.

The reason I am writing is because I am concerned about some of the protocol we use in our office. For example, when we get a new patient, the protocol has been to first use the D4355 code, even if the patient does not have periodontal disease. It is called an “exploratory” scaling. Have you ever heard of this before?

Another thing they do is take four bitewings and a panoramic film and code it as a D0210, full-mouth series. I always thought an FMX was 14 periapical films and four BWs.

I have also been instructed to use the code D4342 on gingivitis patients. My understanding is that this code is for patients who need limited periodontal scaling. Can it be used for gingivitis patients too?

Since I’m still a relative newcomer to the practice, the last thing I want to do is make waves about how they do things, but it seems to me that some codes are being used inappropriately. Can you shed some light on this for me?
Wilma from Washington

Dear Wilma,

In my experience, I have found that the D4355 code is one of the most misused codes in the book. Let’s look at the CDT7 definition for that code.

“The gross removal of plaque and calculus that interfere with the ability of the dentist to perform a comprehensive oral evaluation. This preliminary procedure does not preclude the need for additional procedures.”

The wording is clear. This code is to be used on those individuals who have so much calculus that the clinician cannot perform a comprehensive oral examination. There is no indication that this code is to be used for an “exploratory” scaling, whatever that is!

It reminds me of the old protocol that existed when I finished hygiene school back in the 1970s, where we did a “gross scale/fine scale” for those patients who required more than one appointment because of heavy debris.

Most patients who have large quantities of “vintage” subgingival calculus will need periodontal debridement under anesthesia anyway, so what is gained by doing a “drive-by” scaling to simply remove the outer layers? Further, many third-party payers do not recognize D4355 and will downcode it to a D1110 prophylaxis. For that reason, I do not recommend using that code, except in limited situations that fit the definition.

As for the radiographic coding, the code D0210 is for “intraoral complete series (including bitewings).” The last time I checked, panoramic films are extraoral. So the use of D0210 to report a panoramic film with bitewings is a misuse of the code. The ADA is clear in its guidelines that providers must use correct coding and bill for what they do.

However, insurance companies sometimes “remap” or “downcode” a submitted code to another code for payment purposes when the contract allows that action, and it is not considered illegal or improper. According to Dr. Charles Blair’s book, Coding With Confidence (www.drcharlesblair.com), it is routine for payors to convert separately coded extraoral panoramic film and intraoral bitewing films to the lower, complete-series fee. The typical adult full-mouth series involves 14 periapical films and four bitewings.

The code D4342 (periodontal scaling and root planing - one to three teeth per quadrant) is explained like this:

“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.”

The key word periodontal is actually in the code descriptor. We really need to go no further when deciding if this code is appropriate for gingivitis patients. It is clear that the use of this code for a gingivitis patient is improper. Most payors require radiographic evidence of bone loss for consideration of payment, and a true gingivitis case will not have bone loss. This code should be used to report scaling and root planing on one to three diseased teeth in a given quadrant. My experience has been that this code is typically reimbursed at 50 to 60 percent of the D4341 fee.

There is some confusion among clinicians as to which code, D4910 or D1110, is appropriate after using D4342. The periodontal maintenance code D4910 is appropriate after full or partial quadrant scaling. However, if only a few isolated teeth are involved, some payors will not reimburse D4910 after a single or dual D4342 visit. This is highly variable among payors. The wording states that the dentist should exercise clinical judgment in deciding whether the patient can be maintained with a prophy or will need ongoing periodontal maintenance.

I recommend that if a patient needs D1110 and D4342, consider doing the prophy first and the periodontal scaling on a second visit. If an office submits both D4342 and D1110 on the same day, the prophy may not be reimbursed. However, if you include a narrative about extra time used, D1110 may be reimbursed as well. Again, this is variable among payors.

Since we do not have any specific codes for gingivitis, most offices use the D4999 code with a narrative if multiple appointments are needed. Here is a sample narrative:

“Patient has had no care for ___ years. Heavy calculus and debris but no pocketing evident. Scaled right side of mouth this visit. Will need additional appointment to complete.”

I understand your concern about not making “waves” in the practice. However, misuse of codes is a serious matter, and anyone who uses codes incorrectly can face stiff penalties if the coding violations are ever discovered. There was a recent case involving a hygienist who was billing for periodontal procedures but actually performing prophylaxis procedures. She faced five years in jail but instead got a one-year active sentence. Do you know anyone who would be willing to risk spending time in jail just to gain better reimbursement amounts for the practice?

My advice is to talk with the doctor privately about these matters and start using the proper codes. Otherwise, trouble is just ahead!
Best wishes, Dianne

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