by Carol Tekavec, RDH
Last January, the American Dental Association provided the profession with an updated version of their treatment codes, the CDT-4. This updated version of the codes is also mandated by virtue of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. This means that all dentists and insurance carriers must use current ADA codes, now and in the future. (For 2003, dentists and insurers could request an extension until October.) Previously, the ADA scheduled revisions every five years. It is expected that revisions will occur more frequently from now on, possibly every two to three years.
As hygienists, we are intensely interested in several of the codes that we are required to use repeatedly. Plus, we are concerned with code descriptions that may or may not reflect the actual treatment that we perform.
D1110 Prophylaxis — Adult
The ADA 2003 revised description states, "A dental prophylaxis performed on transitional or permanent dentition that includes scaling and/or polishing procedures to remove coronal plaque, calculus and stains."
This code is believed to describe a scaling and polishing procedure for adult patients in a healthy oral state, as well as in any condition other than those presenting with deposits that hinder a comprehensive evaluation, or those requiring root planing. In those cases, the codes would be D4355 (Full Mouth Debridement to Enable Comprehensive Evaluation and Diagnosis), or, for those that qualify, a D4341 (Periodontal Scaling and Root Planing, Four or More Contiguous Teeth or Bounded Teeth Spaces, per Quadrant), or D4342 (Periodontal Scaling and Root Planing, One to Three Teeth, per Quadrant).
The description specifically states that deposits are "coronal" only, a situation that rarely exists. What is worse, the CDT-4 description also has now added the words and/or concerning polishing. With this definition, an adult prophylaxis can now simply be a "pumice cup prophy." (A pumice cup prophy, performed by dental assistants, is a legal service in many states.)
Patients with gingivitis or inflammation also present coding difficulties. In the CDT-1 (1990-1995), the ADA designated a code for prophylaxis for healthy patients, 01110, and a code for patients presenting with gingival inflammation and possible subgingival deposits, 04345. It is thought that pressure from the insurance industry — which claimed "overutilization" of 04345 by the dental profession — led the ADA to change the codes in the CDT-2 (1995-2000) to remove 04345. Since then, there has been no code to describe a "prophy for a patient with gingivitis."
It is unknown what pressures continue to prevent code designations and accurate descriptions for adult prophys or for services for patients with gingivitis. Each CDT revision has shown a consistent downgrade in technical difficulty description. There is no ADA code that accurately describes the preventive and therapeutic procedure performed by dentists and hygienists for the majority of their patients (i.e., scaling and polishing procedures to remove supra- and subgingival plaque, calculus, and stains from coronal and root surfaces, with or without the presence of localized gingivitis). For lack of a better code, D1110 is now the only code available to describe an adult prophy for healthy patients with supragingival deposits, healthy patients with subgingival deposits, patients with plaque only, or those with gingivitis and inflammation.
Even though that is not what the code description says, it is believed that the ADA intends for code D1110 to apply to all of these patients, and expects offices to simply take more time and increase the fee as needed. Varying fees for each patient is usually not a reasonable approach in today's world of computerized claims and filed fee schedules, but it is an option. Another option might be for the office to select the fee that would be charged for the most "difficult" adult "gingivitis" prophy and apply that to all code D1110 procedures. It may also be possible to use D4999 to describe a subgingival scaling and polishing procedure for a patient with gingival inflammation. Include a Case Type on the claim form (which should be Case Type I — Gingival Disease), a description of the patient's condition, a photo if possible, and radiographs showing deposits. Keep in mind that any payment provided will be delayed due to using a "99" code, which must be reviewed by a consultant, and will be initiated after applicable deductibles.
The American Academy of Periodontology revised its disease classification system in 1999 to the Classification of Periodontal Diseases and Conditions, a system different from the "Case Type" method. Despite this, most carriers will probably continue to use "Case Types" for some time in the future.
Third party payers commonly interpret D1110 as a "cleaning" for patients over 14 years of age — sometimes also interpreted as any patient who has erupted second molars. Most carriers limit payment for this procedure to twice per year, with some carriers paying only once in a six-month period. (Payment only once in a six-month time period means that a full six months must pass between each D1110 procedure for a benefit to apply.)
If more than one appointment is needed (double 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 the carrier may pay for one appointment now with the second appointment the patient's responsibility and the next prophy in six months still covered. For a double prophy, use D1110 for each of the visits with a brief narrative written or typed directly on the claim form stating heavy deposits, heavy stain, or whatever other issues are pertinent, and document with radiographs and an intraoral photo. If an extended time prophy is needed, use D1110 along with a brief narrative indicating time spent, heavy deposits or whatever other issues are pertinent as well.
D4910 Periodontal Maintenance
This code has also been revised for 2003. According to the ADA description: "This procedure is for patients who have previously been treated for periodontal disease. Typically, maintenance starts after completion of active (surgical or nonsurgical) periodontal therapy and continues at varying intervals, determined by the clinical diagnosis of the dentist, for the life of the dentition. It includes removal of supra and subgingival microbial flora and calculus, site specific scaling and root planing where indicated, and/or polishing teeth. When new or recurring periodontal disease appears, additional diagnostic and treatment procedures must be considered."
Although the CDT-4 definition states that intervals for the procedure are determined by the clinical diagnosis of a dentist, it eliminates the words, "periodontal evaluation," that were included in the CDT-3 definition. It also does not make any mention of examination or evaluation in any other context. Therefore, a D0120 (Periodic Oral Evaluation) may continue to be properly reported separately, although it will be inconsistently paid by insurance separately.
A few carriers are reported to be considering reducing the benefit amount for a D4910 by the amount they offer for a separate benefit for the D0120. Therefore, the payment for the D4910 would be less, but a payment would be made for the D0120 when reported at the same time (however, probably not more than two times a year). Most carriers will not provide a benefit for this code until three months following active therapy and thereafter may pay toward this twice a year (a few may pay four times a year). Some carriers are also requiring that the "active therapy" be surgery, not root planing. There are a few companies that will provide alternating benefits, D1110 two times a year and D4910 two times a year, despite the fact that this regimen lacks logic.
Periodontal probing and documentation of bleeding, furcations, recession, and mobility may continue to be delegated to a hygienist, if the state dental practice act approves these procedures. Whether this is "data collection" or "examination" remains debatable and is of limited consequence to carriers.
What can be done about a fee if a dentist's exam is performed at the same time as the D4910?
• The office may properly charge for an exam separately with the knowledge that it may or may not be paid by the patient's insurance. The patient will need to pay for the exam personally.
• The office may set a fee for D4910 that reflects all services provided. Insurance will pay what it will, with the patient responsible for the balance.
The clinical experience of the D4910 as compared to the D1110 should be quite different. Patients should easily be able to make the distinction. Complaints by confused and unhappy patients to state dental boards in regard to their "cleanings" are on the rise. Be sure that your procedures are clear and that sufficient time is taken with D4910 patients. The American Academy of Periodontology's Journal of Periodontology ("Parameters of Care" publication, Supplement to Volume 71, No. 5, May 2000, pages 849-850) gives detailed definitions and treatment recommendations for periodontal maintenance.
When submitting claims for payment, include the following information to speed benefits for your patients:
• Periodontal Case Type of at least Case Type III.
• Dates of root planing or surgery.
• Complete progressive periodontal probing depths, bleeding, recession, furcations, and mobility. (My Comprehensive Periodontal Examination C-103-R form provides sections for all of these indicators for six successive appointments; then the form can be photocopied and attached to the claim for quick and complete documentation. See my Web site, www.steppingstonestosuccess. com.)
• Home care effectiveness (poor, adequate, good).
• An update of the medical/dental history.
D4341 Periodontal Scaling and Root Planing, Four or More Contiguous Teeth or Bounded Teeth Spaces, per Quadrant
This code also has been revised for 2003. The words, four or more contiguous teeth or bounded teeth spaces, were added. The ADA description remains the same: "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. Root planing is the definitive procedure designed for the removal of cementum and dentin that is rough and/or permeated by calculus or contaminated with toxins or microorganisms. Some soft tissue removal occurs. This procedure may be used as a definitive treatment in some stages of periodontal disease and/or as a part of pre-surgical procedures in others."
This common procedure may result in benefit problems if data collection for the patient is not obtained and reported in a certain way. Most insurance carriers expect a Case Type Classification (Case Type III-V) on the claim as well as detailed documentation of progressive charting of probing depths (which must be 5mm or more), recession, bleeding, mobility, and furcations.
Although the ADA has modified this code to apply to four or more contiguous teeth or bounded tooth spaces per quadrant, many carriers have a minimum tooth eligibility of five periodontally involved (5mm pocket) teeth for full quadrant benefits to apply. This may be, however, changing, and it is also clear that no benefits are likely for root planing for tooth spaces.
With the addition of a new code for 2003, D4342 (Periodontal Scaling and Root Planing — One to Three Teeth per Quadrant), reporting a single tooth root planing will be easier. However, it is not known how carriers will pay benefits for this code.
Payment for D4341 usually is based on four separate quadrants once every two years. Some carriers stretch that time period to four quadrants once every 28 to 36 months. "Quadrants per visit" may also limit insurance payment. Most carriers allow a lesser benefit for a full-mouth, four quadrant D4341 performed on the same day than they do for a two quadrant per visit procedure. (There is no ADA code for a full-mouth periodontal scaling and root planing. Each quadrant must be listed separately under D4341.) Patients requiring full-mouth treatment for whatever reason may receive a better benefit when the office provides a written narrative including the amount of time spent on each quadrant. Carriers often look for a minimum of 45 to 50 minutes per quadrant.
As of January 1, 2003, there are still too few ADA codes to accurately describe common hygiene services. In addition, most benefit plans provide limited payment toward prophys and perio maintenance. Hygienists and dentists should provide patients with a pre-treatment explanation of what services are going to be performed as well as the fees involved. Patients who understand what to expect are less likely to be upset when their insurance pays very little toward their care. Patients need to know that having insurance is a help with dental bills, but was never intended to cover everything.
Carol Tekavec, CDA, RDH, is the author of the Dental Insurance Coding Handbook Fourth Edition, which contains updated information about new codes, insurance industry guidelines, and description explanations. She also wrote the patient brochure, "My Insurance Covers This ... Right?" The brochure explains the limited nature of dental insurance in laymen's terms. She is also the designer of a dental chart, an informed consent booklet, and a scheduling system, as well as a national lecturer. Still practicing as a clinical hygienist in a general practice office, she can be contacted at (800) 548-2164 or by visiting her Web site at www.steppingstonestosuc cess.com.