Treatment Plan What You See
There is a new code available to use when submitting claims to insurance. According to “A Guide to Reporting D4346” written by the American Dental Association, the D4346 code can be used for “scaling in presence of generalized moderate or severe gingival inflammation-full mouth, after oral evaluation. The removal of plaque, calculus and stains from supra- and sub-gingival tooth surfaces when there is generalized moderate or severe gingival inflammation in the absence of periodontitis. It is indicated for patients who have swollen, inflamed gingiva, generalized suprabony pockets, and moderate to severe bleeding on probing. Should not be reported in conjunction with prophylaxis, scaling and root planing, or debridement procedures.”
Based on further reading, I can’t say I am overly excited about using this code. I have been practicing full time as a clinical hygienist for 29 years. This code has the description of what we are missing when it comes to codes, and it is supposed to fill the gap we have needed for years. However, the actual utilization and the way it may be paid might not be what we need.
In the question/answer portion of the D4346 guide, it says the procedure that goes with this code is “based on the diagnosis rather than intensity of treatment required. The procedure is expected to be completed on a single date of service, but patient comfort and acceptance may require delivery over more than one visit. Should more than one day be required, the date of completion is the date of service.”
Who knows if insurance companies are going to pay any more for this code than a D1110. They might only pay for it once in a lifetime, or not at all. They may even count it as one of the patient’s prophylaxis appointments. Even in the question/answer information, it states individual plans may have limitations and it may be best to pre-authorize. As many employers continue to cut employee benefits, it can often seem like we are going backwards regarding insurance. Pre-authorizing is old school in today’s society.
At this time, there is not a set waiting period between performing a D4346 and a D1110. However, this does not mean individual insurance plans will not set their own standards of payment. When you use the code, it is not followed by a periodontal maintenance. The patient will be considered a prophylaxis, unless root planing is later performed due to the patient’s gingival health continuing to deteriorate because of attachment loss.
When you have a patient with clickable calculus that is visible on the x-rays, no attachment loss but a lot of inflammation and bleeding upon probing, this may be a D4346. However, just because you need to get them numb and more time is required for treatment, it does not necessarily mean you will get paid more by insurance. The practice could always charge it out at a higher fee once the procedure is complete, but it still does not mean the insurance companies are going to pay anything more than the allotted amount for a prophylaxis, and count it towards one of the two prophylaxis that they allow.
Treatment planning patients’ gingival care is extremely important at every visit they have. It is also very important that the treatment plans be based on what your diagnosis is, and not what the insurance will or will not pay. When reviewing the treatment plan with patients, if there is no preauthorization you might want to tell them their insurance company may not pay at all, but you are happy to bill insurance and in the meantime they can utilize CareCredit if needed.
For many patients, as long as the probings are complete along with gingival recession, it would benefit them and the practice more to do scaling and root planing on any areas that specifically show loss of attachment. This code may be nothing more than a smoke screen that does not enable us as dental professionals to be paid for the amount of work being done. Time will tell.
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