There is some confusion in our office about how to bill the appointment following scaling/root planing (SRP). A course I attended said to bill out a prophy (D1110), but I was under the impression that following SRP, the patient should be on periodontal maintenance (D4910).
We have noticed that some insurances will not pay for the maintenance if it is scheduled before the three-month point after the last SRP. Have you seen that before?
Another question we have is this: Is it ever appropriate to go back to a standard prophy after SRP? It makes me feel bad to charge a patient the full periodontal maintenance fee when the patient is doing great and the disease seems to be under control.
Insurance Confusion in Indiana
Dear Insurance Confusion:
These are all good questions, and I will try to address each concern separately.
First, there seems to be some general confusion about the word prophy.
Some doctors consider it just a polishing procedure, as evidenced by a number of offices that schedule child patients with dental assistants (in states that allow for coronal polishing by assistants) to come in for a “prophy” (polish) and doctor exam, and then charge it out to an insurance company as a child prophylaxis (D1120) and periodic exam (D0120). In those situations, the doctor is obligated to remove any calculus or soft debris remaining. When you say “prophy” after SRP, I’m assuming the appointment is for polishing. However, why can’t polishing be accomplished along the way? Why does there have to be a separate appointment for that procedure? If you read the CDT-5 definition of the prophylaxis procedure (D1110), I think you will agree that this is not meant for post-SRP treatment, nor is it appropriate for nonhygienists to perform.
Here is the code D1110 definition: “Removal of plaque, calculus, and stains from the tooth structures in the permanent and transitional dentition. It is intended to control local irritational factors.” It does not mention scaling or polishing, but is intended to control local irritational factors, which suggests gingivitis. In the case of active periodontal disease, which indicates loss of bone and/or attachment, the patient would be maintained with periodontal maintenance procedures, which is D4910. I think the sticking point for you is that someone told you somewhere that the patient should have a prophy after active periodontal therapy is completed. That is simply someone’s opinion, and there is nothing in the literature to support that line of thinking. The ADA is adamant that you must bill what you do, and the consensus among insurance gurus is that it is not appropriate to bill D1110 after SRP. Additionally, it is not appropriate to bill D1110 and D4910 alternately. That would suggest the patient is alternating between disease and health, which is neither feasible nor probable.
All that being said, the code revision committee wrote a statement in the CDT-5 that allows practices to move a patient from D4910 maintenance back to D1110 after a period of time following active periodontal treatment.
Here is the quote from the CDT-5 concerning coding for a prophylaxis after periodontal therapy.
“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.”
The point is that some patients do very well after nonsurgical/surgical treatment and actually get to a point where they have no signs of active disease. In my opinion, the best protocol is to keep the patient on a strict three-month cycle for the first year, and then evaluate carefully to see if the recare interval can be lengthened. Give the patient hope that at some future date, it may be possible to stretch the time interval between visits. It is impossible to predict how any patient will fare long term - some will get control of their disease, and some will not. Just keep in mind that if you move a patient back to a regular six-month prophylaxis protocol and signs of disease crop back up, the appropriate treatment would be SRP again.
Clear as mud, right?
If you consider what you do (prophy) simply polishing, this can be accomplished all along the way during each successive SRP visit. Additionally, you should revisit all the previously scaled areas at each new SRP visit with your power scaler to deplaque and debride those areas while waiting on the new area to become numb.
Personally, I think three months is too long to wait to do a maintenance procedure after completion of active periodontal treatment. According to the literature, pathogens build up to original numbers in nine to 11 weeks. I like to see the first maintenance visit at about six weeks out. And yes, some insurance companies balk at paying that soon. That’s not your problem, and your patient will have to pay alternately anyway.
Best wishes, Dianne