Coding for Hygiene Services
Last time we talked about the hygienist as a production and profit center for a practice. Now we will cover several ADA codes associated with hygiene services and see how they might be used. ADA Current Dental Terminology (CDT) codes are essential for reporting services on insurance claims. However, they also provide “shorthand” for offices when it comes to record keeping, treatment planning, and fee development. While it is well known that insurance benefits are limited when it comes to many preventive, periodontal and even diagnostic services, using accurate coding can streamline office communication while ensuring that patients are receiving the benefits for which they are entitled.
It goes without saying that treatment should always be based on patient’s needs, not their insurance contract. However, when we help our patients plan for their procedures by providing information about possible insurance benefits, they are more likely to go ahead with a proper and complete treatment plan. Here are a few “hygiene codes” and common insurance considerations. Keep in mind that there will always be exceptions to any general guidelines.
The code name indicates that the procedure is appropriate for an adult, however the definition mentions “permanent and transitional dentition.” Therefore, this code can be accurately applied to individuals of various ages. Insurance contract guidelines may designate age restrictions, such as for patients over the age of 14 or 16, but that should not be the rule for the dental office. If the service provided is the equivalent of an adult prophy, then age should not be a deciding factor. Despite this, patients and their parents should be advised that a carrier may only pay toward the “child” procedure D1120-Prophylaxis-Child, based on their contracts language. Most carriers cover D1110 twice per year, sometimes with a 6-month interval requirement.
D4341 and D4342-Periodontal Scaling and Root Planing
Many carriers will cover D4342 at a rate of 60-70% of what they allow toward a D4341. It is a good idea to decide on one fee for the code, regardless of whether one, two or three teeth in the quadrant need treatment. In other words, if #3 and #4 are in need of root planing, submit D4342 with whatever fee the office uses. Don’t reduce it by 1/3 because only two teeth are involved. Many carriers are paying toward D4341 and D4342 once every two-three years. Patients who have undergone these services may then receive D4910-Periodontal Maintenance for the “life of the dentition or any implant replacements.” Most dentists also consider that they, and their hygienists, have the prerogative to decide when and if a patient has returned to health.
Next time: Hygiene Scheduling - Never Enough Time?
Carol Tekavec CDA RDH is a speaker on dental records, insurance coding and billing, and patient communication for McKenzie Management. Interested in having Carol speak to your dental society or study club? Click here
Interested in knowing more about how to improve your hygiene department? Email email@example.com.
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