Hygienists may believe that they do not have any responsibility for talking with patients about their insurance. However, most patients would agree that any help they receive when it comes to paying bills is appreciated. As hygienists, we may spend more time on a regular basis with our patients than does the dentist. Opportunities for enhanced trust and confidence often occur. For example, many patients ask their hygienists if “they really need” restorations or other treatment as recommended by the dentist.
Another common question is, “My insurance covers this, right?” While we may refer the patient to the treatment coordinator for the final word on payment, it is helpful to have some knowledge of common insurance limitations and the corresponding language skills for communicating with our patients.
It is a mistake for patients to decide on treatment based solely on cost and insurance benefits. We can help them understand why. Even so, we are misinformed if we imagine that “money doesn’t matter.”
The fact is that patients often believe that their dental benefits will cover most of their treatment. Unfortunately, dental benefits were never designed to cover everything. Helping patients make decisions based on treatment needs, while not ignoring their payment concerns, makes a practice productive. By helping our patients, we help the practice stay productive, and help support our future careers.
While individual dental plans may vary considerably, what follows are common payment guidelines many patients have to work with. Remember, though, that it is the office’s responsibility to recommend what is best for the patient, regardless of insurance benefits.
■ Evaluations - The office may use any code or perform any evaluation desired. However, most dental plans allow payment for two “recall” examinations per year (Code D0120), and one comprehensive evaluation (Code D0150, D0180) every three years. Any other exams are typically the patient’s responsibility.
■ “Cleanings” - Most plans will pay toward two so-called “cleanings” annually. (A “cleaning” is typically considered a D1110-Prophylaxis, Adult.) Many plans have a six-month time period requirement between prophies as well.
Some plans, such as Delta, may only pay toward “two prophylaxis and/or fluoride treatments” annually. This means that if the patient requires a fluoride treatment as well as a prophy, only the fluoride or the prophy may be covered, but not both. Patients who require additional prophy appointments or debridement services will usually have to pay for these themselves.
■ “Difficult prophies” - So called “difficult prophies” are also difficult to code. Patients who have excessive deposits but no bone loss, who have not had a prophy in many years, who have gingivitis, or who are simply a challenge to care for are not “standard” adult prophies. However, there are few codes at our disposal. Here are some choices:
- The hygienist may decide to use two visits to care for a patient; coding this as a double appointment prophy or D1110 x 2. The insurance carrier may pay for two appointments now, with no benefit available for the rest of the year; or may pay for one appointment now with the second appointment the patient’s responsibility and the next prophy in six months still covered.
- The hygienist may use an extended time prophy, coding this as a D1110, with a higher than “normal” fee. When this is done, a narrative placed directly on the ADA Dental Claim Form (written or computer generated in the No. 35 “Remarks” section) indicating time spent, heavy deposits, or whatever other issues are pertinent, is important. For example, “Heavy, tenacious calculus on maxillary facial surfaces and heavy stain on all lingual surfaces. An extended time appointment (90 minutes) was required.” Typical indemnity plans will pay what is allowed with the patient paying the balance.
- For offices where the dentist is a contract network provider for a plan, such as many Delta plans, an extended time fee may be “disallowed” meaning not payable by the plan and not chargeable to the patient. In these cases it may be possible to code the difficult prophy as D1110 along with D4999. D4999 (Unspecified Periodontal Procedure by Report) requires that a narrative, similar to the one described above, be included. The plan will likely pay what it allows for the D1110 and possibly an additional amount toward the D4999. If the plan denies the amount charged for the D4999, the patient is responsible. (The fee is not “disallowed.”)
It is important to note that when any of the “99” codes are used, a consultant will usually review the claim. This often somewhat delays payment.
- D4355 (Full Mouth Debridement to Enable Comprehensive Evaluation and Diagnosis) may be appropriate if an exam is not possible due to excessive deposits. While the code is not strictly defined as a “difficult prophy,” it may be the most correct description for some patients under certain conditions. It is usually not paid on the same date as any evaluation code and may or may not be a benefit of many plans. If a payment is allowed, it is typically after the deductible, rather than before the deductible as are many “preventive” codes.
A subsequent prophy (D1110) or perio services may be needed following D4355. The definition states that it is a preliminary service that does not preclude other services. The “other services” may or may not be the patient’s financial responsibility.
■ Periodontal maintenance - Most carriers will pay toward two D4910 (Periodontal Maintenance) appointments annually. A typical requirement is that the patient has previously received “active therapy” (root planing or surgery) and that at least three months have passed since the active therapy was completed.
Common record keeping and information submission requirements are: full mouth probing depths, bleeding points, furcations, mobility, and recession. This information can be included on an attachment or chart form (you can see a sample on my Web site at www.steppingstonestosuccess.com “Comprehensive Periodontal Examination”) or submitted electronically. Many of the Delta plans are no longer requiring routine radiographs for D4910 or D4341(Periodontal Scaling and Root Planing) payment.
Alternating D4910 and D1110 every few months is not appropriate (even though some carriers advise this!). It may be possible to enter D4910 as the proper code on the claim form, with a written or computer generated request in the remarks section, “If no benefit, please pay what is allowed for D1110.”
■ Sealants - Code D1351(Sealant per Tooth) is covered by many plans. Common restrictions are:
- Payment allowed for erupted first and second molars which have no caries or existing restorations.
- Coverage for first molars up to age 9 and second molars up to age 14.
- Payment only once every three years. If a standard restoration for a previously sealed tooth during that time period is needed, coverage may also be denied during that same three-year period.
■ Periodontal probing and charting - There is currently not a separate ADA code or typical benefit for probing and charting. Probing is considered to be an integral part of any evaluation procedure. If your office brings patients in for recurrent probing, polishing, or other services not covered by insurance, it is usually best to provide an estimate of fees before beginning treatment that features a total amount that the patient will be billed. Insurance may be billed for what is covered, with the patient owing for the balance.
A discussion of treatment recommendations, charges, and ultimate health benefits in advance of billing is vital. Patients need to understand the limited payment that may be provided by their insurance. It is important to remember that if some services are “disallowed” due to a contract that the dentist has signed, then no payment can be demanded of the patient. The hygienist, dentist, and front office staff need to be clear on what their obligations are.
(Dentists who wish to avoid “disallowances” under some plans, may still provide services by becoming “non-participating in-network” or “non-contract” providers. Patients usually are required to pay more of their own charges in these circumstances, but the dentist is under no obligation to accept restrictions.)
■ Irrigants - Many hygienists use medicaments as irrigants during hygiene procedures. Most carriers consider irrigants to be an integral part of hygiene services and do not provide a separate benefit. This may be based, in part, on examples in dental resource material, or other sources of their own. For example, according to the American Academy of Periodontology’s “Parameters of Care Supplement” (Journal of Periodontology May 2000, page 850), periodontal maintenance includes the use of “antimicrobial agents as necessary.”
Confusingly, the CDT-2005 does not list antimicrobials in its definition of D4910. Again, it is possible to use D4999 (Unspecified Periodontal Procedure, by Report) or D9999 (Unspecified Adjunctive Procedure, by Report) with the fee the office has decided on. If the carrier does not cover the procedure, the patient will need to pay, unless, as previously mentioned, the dentist is a contract provider with restrictions on charges.
■ Crevicular or “pocket” medicaments - Code D4381 (Localized Delivery of Antimicrobial Agents via a Controlled Release Vehicle into Diseased Crevicular Tissue, per Tooth, by Report) is described in the ADA CDT as “FDA approved subgingival delivery devices containing antimicrobial medications are inserted into periodontal pockets to suppress the pathogenic microbiota. These devices slowly release the pharmacological agents so they can remain at the intended site of action in a therapeutic concentration for a sufficient length of time.”
Carriers who cover D4381 typically do so only for refractory sites limited to two or three teeth per quadrant. Previous perio surgery or scaling and root planing is commonly required. A few carriers cover D4381 on the same date as D4341 or D4342 (scaling and root planing). Those that do usually require a diagnosis of a Case Type III, or the newer designation of Localized or Generalized Chronic Periodontitis with Clinical Attachment Loss-Severe (greater than 5mm clinical attachment loss) as described in the “Classification of Periodontal Diseases and Conditions” (Annals of Periodontology, Volume 4, Number 1, December 1999). In addition, a maximum of two teeth, regardless of how many sites per tooth are treated, per quadrant are usually considered.
Denial of payment by carriers due to contract restrictions in no way means that treatment is not recommended or required. However, treatment discussions with patients, before denials are received, help patients understand the limited nature of dental benefits and minimizes the problems that can arise from financial misunderstandings. To read two brochures that may help, see my Web site at www.steppingstonestosuccess.com. Future articles will cover coding for scaling and root planing, and possible payments for new CDT-2007 codes. RDH
Carol Tekavec, CDA, RDH, is the author of the Dental Insurance Coding Handbook, the designer of a patient chart and an informed consent booklet, and the author of several patient brochures, including,”What is the Difference Between a ‘Regular’ Cleaning, Root Planing, and Periodontal Maintenance?” She has appeared at all major dental meetings and is a presenter for the ADA Seminar Series. Contact her by phone, (800) 548-2164, or visit her Web site at www.steppingstonestosuccess.com.
