4.23.10 Issue #424 Forward This Newsletter To A Colleague

Carol Tekavec, RDH
Hygiene Consultant
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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.

D1110-Adult Prophylaxis 
This code applies to a professional dental “cleaning.” It is defined as, “Removal of plaque, calculus and stains from the tooth structures in the permanent and transitional dentition. It is intended to control local irritational factors.” This code is believed to describe scaling and polishing for patients in a healthy oral state, as well as in any condition other than those presenting with deposits that hinder a comprehensive evaluation (D4355-Full Mouth Debridement to Enable Comprehensive Evaluation and Diagnosis), or those that qualify (4mm or deeper pockets and/or other issues such as bleeding, mobility, furcations, and recession) for a D4341-Periodontal Scaling and Root Planing, Four or More Teeth per Quadrant, or D4342-Periodontal Scaling and Root Planing, One to Three Teeth, per Quadrant. Most carriers also consider the code to apply to patients with gingivitis, due to the “local irritational factors” wording in the D1110 definition. An old code, D4345, which referred to scaling in the presence of gingival inflammation, was discarded many years ago.

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
These codes are described as D4341-Periodontal Scaling and Root Planing - Four or More Teeth per Quadrant, and D4342 - Periodontal Scaling and Root Planing - One to Three Teeth per QuadrantMost plans are now covering a portion of the fee for these codes when the patient presents with pockets, or clinical attachment loss (CAL) of 4mm or deeper. The previous stringent review by carriers of D4341 and D4342 has lessened somewhat in recent years. However, any office that submits these codes at a much higher rate than others in their geographic area may still find themselves under scrutiny. Documentation in the patient’s record of an appropriate diagnosis and treatment plan is important to support claims and defend against an “over-utilization review” and possible refund request.

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.

D4910-Periodontal Maintenance
No service seems to cause more trouble for offices than does periodontal maintenance. This appears to be because patients don’t seem to understand the procedure in general, or why they personally have a need for it. Add this to the fact that some patients think the only difference between a “regular cleaning” and a “periodontal maintenance procedure” is the cost, and you have a blueprint for blunders. What to do?

  • Be sure that when patients are receiving information about their need for root planing in the first place, that the necessity of maintaining their periodontal condition from now on is fully explained. Patients need to know that they are now on the “perio track” and that so-called standard cleanings are not appropriate for them anymore. A good analogy might be that of controlling high blood pressure. Once a person has been diagnosed with the problem, he must be vigilant in taking proper medication, controlling diet, reducing salt, or exercising from now on.
  • In advance of treatment, patients need to realize that their insurance will likely provide only partial payment toward what they require. It is not helpful to address insurance limits after a patient has already received an Explanation of Benefits refusing responsibility for much of their care. Discussion of fees is important and should not be avoided.
  • Make sure that you are providing the appropriate services during a periodontal maintenance procedure, and that the patient is aware of it. These services might include irrigation, use of the cavitron or other devices, root planing and scaling of individual teeth as needed and/or any other procedures not always associated with a D1110. For guidance, offices can use the American Academy of Periodontology Parameters of Care description for periodontal maintenance. In addition, the hygienist should explain what she is doing and why throughout the appointment.

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 hygiene@mckenziemgmt.com.

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