by Dianne Glasscoe-Watterson, RDH, BS, MBA
The business office where I work seems confused about how to code the patient with gingivitis or early periodontitis. Since insurance coding is not my “cup of tea,” can you provide some direction that will help them understand why it is not appropriate to use periodontal codes for gingivitis patients? Also, what treatment protocol do you suggest for the early periodontitis patient?
Tar Heel Hygienist
Dear Tar Heel,
It is unfortunate that the ADA Code Committee has not seen a need to provide any specific gingivitis codes. From experience, we know gingivitis can range from mild to quite severe. A patient who has not had professional care for an extended length of time is likely to present with some level of gingivitis and/or periodontitis. Many dental hygienists experience high stress when patients present with significant deposits, yet have insufficient time to complete the whole mouth in one visit.
Let's take Joe Blow, for instance. He has not been in for three years, but he is on your schedule today. The previous hygienist noted heavy deposits and staining — yes, he is a smoker. Your assessment and radiographs do not reveal any bone loss, but there is heavy calculus and staining. And you only have 40 minutes. After the assessments and radiographs, you're down to 20 minutes, and you know there is no way you can be thorough in one visit. Joe will need to be phased.
My suggestion is to concentrate your efforts on one side of the mouth only. Your patient is more likely to return if you refrain from doing a “drive-by scaling” and remove all the gross debris with your power scaler. There are three options for codes:
- D4355 — debridement to enable diagnosis. This is my least favorite code, as most insurance plans will not recognize it and typically deny it. However, some offices tell me they use it and get reimbursed.
- D1110 — prophylaxis. Outside of PPO/HMO dentistry, it is appropriate to adjust the fee upward to reflect the degree of severity.
- D4999 —unspecified periodontal procedure by report. This code requires a narrative such as: Patient has had no care for three years. Heavy debris/staining, gingivitis, but no pocketing evident. Will need additional visit to complete. Some insurance companies will pay on this code; some will not. It is variable. Submitting a picture taken with your intraoral camera might help.
The second visit to complete the gingivitis patient will be appropriately coded D1110. The advantage of using D4999 on the first visit is that the patient should still have benefits six months down the road, because most plans allow two preventive appointments per year. However, keep in mind that insurance companies have the option to remap the code to D1110 if they choose, which means the patient will have to pay out-of-pocket in six months if he returns for preventive care. Additionally, some companies require that there be a minimum of six months between preventive visits. If that is the case, the patient may have to pay out-of-pocket for one of the visits needed initially.
Look at the situation like this: No one forced the patient to abandon care or neglect his teeth for an extended time, which resulted in the need for an additional visit. Therefore, the business office assistant should have no problem relating the necessity for out-of-pocket payment for care. Why do we think we have to do whatever is necessary to ensure patients do not incur out-of-pocket expenses? Could it be that we are part of the problem of patients who have totally abdicated their responsibility for payment of dental services? I think so.
It is imperative that your business office NOT use periodontal codes for patients with no periodontal disease. This is called “upcoding” and is blatantly illegal. Another example of upcoding is charging for a surgical extraction when the extraction was simple. Unfortunately, there have been far too many dental professionals who thought they could fly under the radar and use inappropriate codes for procedures. When their fraud is discovered, the penalties can result in astronomical fines and/or license suspension or revocation and even jail time. Dentists and dental hygienists have been found guilty of insurance fraud in the past.
The patient with mild periodontitis presents a different treatment dilemma with regard to coding. Let's say a patient named John presents with pocketing that is 5 mm or more on two teeth in each arch. John does not qualify for quadrant scaling. He needs at least four teeth in the arch that are periodontally involved to qualify for D4341, quadrant scaling. However, he does qualify for D4342, root planing and scaling on one to three teeth. Your treatment sequence should be:
- 1st visit — prophylaxis for nonperiodontally involved teeth — Code 1110
- 2nd visit — UR/LR periodontal scaling (specify teeth) — Code 4342
- 3rd visit — UL/LL periodontal scaling (specify teeth) — Code 4342
Subsequent recare visits can be coded D4910, periodontal maintenance. Please note that for just a few isolated teeth with D4342, the patient may be maintained with prophylaxis in limited circumstances, in the clinical judgment of the dentist. Some insurance payors will not reimburse 4910 after a single or dual D4342 visit. It is highly variable among companies. Also, please note that some payors will allow D4342 on the same day as D1110, and some will not. Again, this is highly variable.
Allow me to recommend an excellent source of insurance coding information to assist your business assistants with insurance coding questions. Dr. Charles Blair publishes a coding manual called “Coding With Confidence: the ‘Go To' Dental Insurance Guide.” This resource can be ordered from www.drcharlesblair.com. This manual would be a wise investment for the practice.
The point I wish to make is this: Use the correct code for what you do. If the service you provide is a prophylaxis, then code the procedure D1110. If you provide periodontal therapy or maintenance, use the appropriate codes — D4341, D4342, or D4910. If all you perform is a debridement, then use D4355. Use code D4999 to delineate specific procedures that do not fit into the other categories.
If the patient qualifies for dental benefits, fine. If not, that is not your problem. All the same, the bill has to be paid if services are provided.
Using improper codes is illegal, immoral, and unethical. Don't do it!
Best wishes, Dianne
About the Author
Dianne Glasscoe-Watterson, 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-Watterson for speaking or consulting, call (301) 874-5240 or e-mail [email protected]. Visit her Web site at www.professionaldentalmgmt.com.