June 1, 2011
I have been told that insurance will usually pay for a full-mouth debridement onlyprior to a comprehensive exam and X-rays.

by Dianne Glasscoe Watterson, RDH, BS
[email protected]

Dear Dianne,

I have been told that insurance will usually pay for a full-mouth debridement onlyprior to a comprehensive exam and X-rays.While I understand that an FMD may be needed before the comprehensive exam, I believe that an FMX is needed first and foremost on all adult new patients.Also, if a new patient has 4 mm pockets and moderate to heavy supra calculusand possibly subgingival calculus as well, I feel an FMD is the best treatment followed by prophy four to six weeks later.My question is this: can the FMD be used as a "middle ground treatment" when there is obviously more calculus present than the definition of a prophy, but there is not active periodontal disease warranting SRP by quadrants?What are your recommendations for using the FMD 4355 code?

Thank you!

Cathy, RDH

Dear Cathy,

One of my least favorite codes is D4355.It hails back to the time when hygienists used to do the old "gross scale/fine scale" routine.I call these visits "drive-by scalings." You know the routine – you grab your big-gun power scaler and knock off all the gross deposits. It's actually fun in a macabre sort of way. But there are two downsides to this protocol: 1) It is not the best treatment, as removing only the gross calculus causes the tissue to tighten around the gingival margin, often making it more difficult to remove the underlying calculus later, and 2) some patients do not return for the definitive care they need.They feel better with the gross deposits removed, so they don't see the need to return. What have you really accomplished if there are copious subgingival deposits left behind? Before we understood periodontitis well, we used to do lots of "gross scaling" on patients with frank periodontitis, which is not really appropriate.

The CDT heading and descriptor for D4355 is: Full Mouth Debridement to Enable Comprehensive Evaluation and Diagnosis. The gross removal of plaque and calculus that interferes with the ability of the dentist to perform a comprehensive oral evaluation. This preliminary procedure does not preclude the need for additional procedures.

The code D4355 is supposed to be used only when there is so much calculus and debris that a comprehensive evaluation cannot be performed due to excessive deposits. We see a few patients like this, but certainly not many, and certainly not every new patient. It is meant to be a preliminary procedure to be followed by more definitive procedures later. Many third-party payers do not recognize this code. According to Charles Blair's insurance coding manual "Coding with Confidence," "D4355 is only reimbursed about 25% to 33% of the time." ( Another caveat with this code is that many payers will not reimburse for an examination if it is performed on the same day as D4355. Dr. Blair also suggests that a narrative may help an insurance consultant understand why the procedure was performed. "Patient has not seen dentist in three years. A full-mouth debridement is necessary for a subsequent comprehensive oral evaluation." The inclusion of intraoral photographs may also help confirm the need for a full mouth debridement.

I have seen this code misused many times.I was in an office that routinely used D4355 on all new patients as an "exploratory" scaling.I have seen other offices use this code as a type of "first prophy" scaling visit. Additionally, I have seen the code misused following definitive periodontal scaling and before beginning periodontal maintenance. According to the descriptor, such uses are inappropriate.

In my clinical experience, if a patient has THAT much calculus, he or she is going to need definitive periodontal treatment.It is more advisable to perform definitive scaling on a segment of teeth (even two or three teeth) rather than perform a "drive-by scaling"on the entire mouth.

Whether or not D4355 can be used appropriately depends on how much debris is present. Is there so much debris that a comprehensive examination is impossible? Or can an examination be performed, although the patient needs preventive and/or periodontal care? In my clinical experience, the average practice will have very few individuals who present with so much debris that a comprehensive exam is impossible until full-mouth debridement is performed.

Let's say a patient presents with so much calculus, plaque, and staining that it is impossible to perform an examination. (Again, these patients are rare.) The proper sequencing would be to perform a full-mouth debridement on the first visit. The second visit would be for the purpose of a comprehensive oral evaluation with the doctor, which would include radiographs and periodontal charting. The third visit would be to either do a prophylaxis or begin periodontal therapy if bone loss is present. Also, please note that if a patient is in pain and presents with excessive deposits that prohibit a thorough examination, palliative treatment (D9110) may be a viable code to use "under an acute and spontaneous discomfort scenario."

Sometimes we see patients who have not been in for three to five years who have heavy deposits but no periodontal disease. When patients have heavy calculus but no pocketing – gingivitis – it is preferable to do a right side/left side routine. The ADA would tell you to code both visits as D1110. I think it is appropriate to adjust the fee upward to reflect the difficulty, especially if extra time is taken. The other option is to use the D4999 code on the first visit, but you have to include a narrative.The narrative might read: "Patient has had no dental care for five years. Heavy debris and staining present, but no pocketing evident. Scaled right side only.Will need additional visit to complete." If you must use both preventive benefits that patients are allotted per year to bring a gingivitis patient back to good oral health, then you are doing what is necessary. Dental practices accept far too much responsibility when patients neglect to keep up with their preventive care. Unfortunately, too many people have abdicated their personal responsibility for dental care, choosing to rely entirely on third-party benefits. What patients often do not understand is that third-party benefits cover only routine procedures; the care they need sometimes exceeds what is considered routine. That is especially true when they neglect their dental health over an extended period of time.

I am in complete agreement about the need for an FMX on all new patients if they do not bring a recent (less than two years old) set with them. If the patient has a history of periodontal disease, the set should be one year old or less.

Dental hygienists are not given very many codes to use in patient care. Given the descriptor of D4355, very few patients qualify for treatment under that code. I urge you to proceed directly to definitive periodontal care for any patient with periodontal pocketing. One thing is sure – make sure you code correctly for what you do. To do otherwise is considered fraud.

Best wishes,

Dianne Glasscoe Watterson, RDH, BS, MBA, 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

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