I work in an office with three doctors and five other hygienists. We’ve been having problems lately in deciding how to properly code patients that have gingivitis.
The patient in question is sometimes a new patient. At other times, it is a patient who has not been in to see us for a long time. No periodontal pocketing is evident, but often there is thick calculus, plaque, and/or stain - so much so that it is impossible to remove all of the debris in one visit.
One problem our office has encountered is that many insurance companies will not pay on the 4355 code. They either disallow it or downcode it to 1110. As a result, when the patient returns, there is no insurance benefit for the additional visit. I’ve even seen patients get angry over this problem and storm out of the office.
Can you offer any advice on how to code these difficult gingivitis patients? It seems like what we are doing is not working.
One of the most often asked questions in my seminars is the same as your question. What is the right way to code gingivitis patients? A common scenario could be a patient who wanders back to your office after having taken an extended “leave of absence” from dentistry, possibly for several years. These “prodigal” patients often present with heavy deposits that are impossible to remove thoroughly from the entire mouth in a regular prophy appointment. Another scenario is a new patient who is seen in the hygiene department first and is expecting to get his teeth “cleaned.” Again, his history of previous dental care may have been irregular, and he presents with heavy deposits. The common denominator with both patients is that there is no pocketing. There may be marginal redness and swelling at specific sites, which is common with gingivitis, but bone levels appear to be normal.
The stress begins to build when you see how much debris is present. You know in your heart and mind that there is no way you can do a thorough job of debridement in the amount of scheduled time you have. The dilemma is that you know this is an insurance patient, and since he is not a bona fide periodontal patient, his insurance will not pay for multiple visits, which is exactly what he needs.
At this point, you have to make a choice. Your first option is to do what many hygienists do - seize the power scaler, crank the power up to “high,” and do a quick “once-over” to remove as much debris as possible. The mindset is that the top priority is to remove debris - period. Rarely is there time to check for thorough debris removal by drying the teeth with air and exploration for subgingival deposits.
There is no time for in-depth home-care education or helping the patient understand his disease, how to control it, or implications on overall health now and in the future. Just hurry up and get the bulk of deposits off and stop working when time is up. Home-care instructions amount to a 15-second tutorial about brushing and telling the patient he needs to floss. Additionally, there is no time for a thorough intra/extraoral exam, periodontal charting, or blood pressure screening.
The patient brings the hygienist a problem, the hygienist takes possession of the problem (which makes it the hygienist’s problem), and the patient leaves with the thought that the hygienist “solved” his problem.
But is the problem solved? Maybe we need to define the problem. The problem is where we place the priority. Granted, hygienists are supposed to remove debris thoroughly. But I submit that is not the most important thing a hygienist does. The true priority should be helping patients understand their disease. It is their problem. Then develop a plan to help patients get well and stay well. That involves more than flicking off calculus. Do we really do our patients justice when we omit so many important aspects of helping them get well and learning to maintain that state of wellness?
Time is the issue. We have established that, for many of our gingivitis patients, one visit is not enough. With regard to patients with third-party benefits, there are three possibilities for us to examine.
Option 1 - First visit is debridement (ultrasonics), Code 1110; second visit is prophylaxis and polish, Code 1110.
Most benefits programs allow enrollees two preventive appointments per year. A few still require a minimum of six months between visits, but most do not. If your patient needs two visits, you may code each of the visits like a regular prophy visit. The only problem is that six months later when it is time for the patient to return, there will be no third-party benefits because the patient has already used his or her allowable preventive benefits. So, the six-month recare appointment will have to be an out-of-pocket expense. (That’s not your problem. It is a benefits issue.)
One observation is that if the hygienist scales the full mouth in “gross debridement” fashion and removes the large deposits on the first visit, patients often do not return for the second visit to complete the scaling. My suggestion is to spend the first visit scaling only one side very thoroughly, because the patient is more likely to return to finish if he can feel the difference. The bottom line is that if you need more time to be thorough and you need the patient to return, the right side/left side scenario will be helpful.
I suggest a narrative: “Severe gingivitis with gross calculus/plaque deposits and bleeding, but pocketing not evident. Two visits are required to complete prophylaxis.”
Option 2 - First visit is full debridement (ultrasonics) to enable diagnosis, Code 4355; second visit is prophylaxis and polish, Code 1110.
The 4355 code (debridement to enable evaluation) is problematic in three ways and is probably one of the most misused codes in the book. First, it is a once-in-a-lifetime code. If your patient has had this code used in any other office, it will not be paid in your office. Another problem with 4355 is that some insurance carriers do not recognize it; so they downcode it to 1110. A third problem is the intent of the code, which is to do a “debridement” (or gross scaling) to allow the clinician to probe.
In my opinion, if the patient has deposits that are that heavy, the chances are great that this is going to be a full-blown periodontal patient. It doesn’t do the patient any good to just remove the heavy supragingival deposits and may even make the task of removing subgingival deposits on a later date more difficult because of tightening of the gingival margin. Generally, I do not recommend the use of this code unless your particular carriers have a proven track record of paying when it is used.
Option 3 - First visit is right side debridement, Code 4999; second visit is left side debridement, Code 1110.
All procedures coded 4999 (Unspecified periodontal procedure, by report) must have a detailed narrative and intraoral photo if possible. Here is a sample narrative: “Heavy, thick calculus deposits. Patient has received no care since (date). Inflammation evident, but no pocketing. Will require additional appointment.” If you find that the code is not honored on the first attempt, sometimes a second submission with an appeal to reconsider will bring results.
There are many different nuances with benefit plans, and it is quite common for patients to have little or no understanding of their benefits. It becomes a “semantics” game in some respects when we try to help patients receive dental benefits for care that we provide, especially when there are benefit limitations within their contract. It is a constant struggle between insurance companies trying to save (i.e., make) money and dental practices trying to get paid for providing dental care to their enrollees. In our current economic climate, the trend is for employers to scale back, even eliminate, dental benefits.
Dental insurance is a two-edged sword. On one hand, it has allowed people to receive dentistry that they normally would not receive. On the other hand, it has caused people to abdicate any financial responsibility for dental care. A basic tenet of human nature is this: People often do not appreciate things that cost them nothing.
The bottom line is do not let the patient’s problem become your problem. Give your patients the best care that you are capable of providing within the boundaries set by the patient and charge an appropriate and fair fee. If the amount the insurance actually pays makes the patient angry, again, it is not your problem. The patient needs to bear the burden of the insurance inquiry.
One last communication tip I will share is to be positive about the patient’s existing benefits. Never make disparaging remarks to the patient about his or her benefits. If the patient has only minimal coverage, see the glass half full instead of half empty.
Clinician: “Mr. Jones, I believe your insurance will cover about half the cost of your needed treatment.”
Mr. Jones: “Only half? I thought it paid 100 percent to get my teeth cleaned.”
Clinician: “The 100 percent you are referring to is for people with healthy gums. Unfortunately, yours are not healthy, and the treatment you need to get you healthy is not fully covered. But I’m so glad you have those benefits, even if it only covers ______. Many of our patients pay the full amount out of pocket.”
Gingivitis can come in many different “shades.” There can be mild gingivitis that responds quickly and easily to treatment, or there can be severe gingivitis with heavy bleeding, loss of stippling, and ulceration. Many, if not most, gingivitis patients warrant more than one visit to treat the disease and bring it under control.
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 [email protected]. Visit her Web site at www.pro fessionaldentalmgmt.com.