Maintenance or a prophy?

There is some confusion in our office about which code to use after a patient has gone through periodontal scalings.

Nov 1st, 2005

Dear Dianne:

There is some confusion in our office about which code to use after a patient has gone through periodontal scalings. My present office says that after the patient goes through a series of D4341 (root planing and scaling) visits, all their subsequent preventive visits should be coded D4910, which is the periodontal maintenance code. However, another office I worked in alternated codes D1110 and D4910 so the patient would get benefits four times a year. My present office says that is not correct, that alternating those two codes could be considered fraud.

I do not know who is correct, but all I’m really interested in is helping my patient get better and stay better. Can you clear this up for us?

Carley in California

Dear Carley:

Your question prompted me to do some research on these particular codes. And while I can give you the strict definitions of these codes, there are often interpretation nuances that still leave us scratching our heads.

As it reads in CDT5, the definition for 1110 is: “Removal of plaque, calculus and stains from the tooth structures in the permanent and transitional dentition. It is intended to control local irritational factors.”

You will notice that this definition does not mention the words “scaling” or “coronal,” which were used in the previous definitions. This definition uses the phrase “tooth structures,” which (I believe) means supragingival and/or subgingival structures. Further, the phrase “irritational factors” sounds like gingivitis to me. However, to someone else it might mean supragingival and/or subgingival pathogens that are irritational. So, as you can see, this new definition also leaves us guessing about the intended use of this code.

The definition for 4910 is: “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 or any implant replacements. 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. If new or recurring periodontal disease appears, additional diagnostic and treatment procedures must be considered.”

As you can see, this code is to be used after periodontal therapy (either surgical or nonsurgical). The interval between appointments should be dictated by the patient’s own personal needs. Most periodontal patients will need three-month periodontal maintenance visits at least for the first year, and many beyond that. In fact, the research is clear that the patient’s long-term success in controlling their disease is dependent on controlling the bacterial populations that live and multiply in periodontal pockets. No level of supragingival plaque control is sufficient for controlling subgingival pathogens, so the subgingival debridement procedures you do are of utmost importance to the patient’s stability.

However, the “life of the dentition” phrase seems to indicate that after the patient has been treated for periodontal disease with periodontal therapy, that patient will always be subject to the periodontal maintenance category of care. Actually, that seems a little overboard to me. Over my many years of clinical experience, I have seen all kinds of patients across the successful outcome spectrum. Most of our patients were quite successful in their clinical outcomes, which made for my greatest professional gratification experiences. After a year or two of close three-month monitoring and maintenance, some of these patients exhibited no signs of active periodontal disease.

Some patients continued to exhibit signs and symptoms of periodontal disease no matter what we (or the periodontist) did, even after active periodontal scaling and/or surgery and being diligent in a three-month continuing care regimen. Many of the patients in this group were the ones who balked at coming every three months because their insurance would only pay twice a year. A few of these patients had identifiable systemic disorders that contributed to poor outcomes.

Evidently, the powers-that-be at the ADA have had some of the same questions as you about prophies after periodontal scaling. To quote from the CDT-5 concerning coding for a prophylaxis after periodontal therapy, here is their statement: “This is a matter of clinical judgment by the treating dentist. Follow-up patients who have received active periodontal therapy (surgical or nonsurgical) are appropriately reported using the periodontal maintenance code D4910. However, if the treating dentist determines that a patient’s oral condition can be treated with a routine prophylaxis, delivery of this service and reporting with code D1110 may be appropriate.”

Here is a possible scenario. Let’s say Mrs. Johnson goes through nonsurgical periodontal therapy in your office. She is placed on three-month disease control visits and shows continual improvement over time. After a couple of years, she displays no evidence of active periodontal disease. Her condition appears to be completely stable. Which maintenance code is appropriate for her? The more dogmatic among us would argue that “once a periodontal patient, always a periodontal patient,” and code all her preventive visits as D4910.

However, what if Mrs. Johnson decides to leave your office and go to another dental practice? When they see her as a new patient for her comprehensive examination, they do not find any signs of active disease. So what code will they use for her preventive care? Most likely, they would use the prophylaxis code, D1110.

This is a matter of concern for patients with third-party benefits, because D4910 is subject to the patient’s deductible. In other words, the patient’s deductible amount must be paid before the insurance will pay, whereas D1110 is not subject to the deductible in most cases. Patients prefer you use the D1110 code for that reason.

However, here is the most important point I wish to make. You must bill what you do. If the procedure you perform for your patient is periodontal maintenance, that is what you must bill. If the procedure you perform is a prophylaxis, that is what you must bill. There should be a distinct difference between the two procedures. You and your doctor should determine which procedure is most warranted for your patient.

Another thing to keep in mind is that sometimes our patients’ needs (appropriate treatment) do not fit neatly into any of the present “boxes” (codes) that we have at our disposal. In our attempt to help our patients get third-party benefits, we sometimes engage in a semantics game. In my opinion, we need more codes, especially for our gingivitis patients.

Further, just because the ADA develops a code for a certain procedure does not guarantee that an insurance company will cover it. I’ve noticed that benefit payers are sometimes slow about adopting new codes.

In summation, alternating codes D1110 and D4910 in an effort to obtain more benefits from the third-party payer is incorrect and could be considered fraudulent. Patients who require three-month preventive visits will have to pay out-of-pocket on alternating visits, unless their plan actually covers four preventive visits per year. However, your patient may reach a point where he or she shows no clinical signs or symptoms of active periodontal disease, and your doctor and you decide that the patient can be maintained with a prophylaxis.

Best wishes, Dianne

Dianne D. Glasscoe, RDH, BS, is a professional speaker, writer, and consultant to dental practices across the United States. She is CEO of Professional Dental Management, based in Frederick, Md. To contact Glasscoe for speaking or consulting, call (301) 874-5240 or email dglasscoe@northstate.net. Visit her Web site at www.pro fessionaldentalmgmt.com.

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