7.2.10 Issue #434 Forward This Newsletter To A Colleague

Carol Tekavec, RDH
Hygiene Consultant
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Hygiene Services-Controlled Release Antimicrobials and Fluoride
By Carol Tekavec, RDH

Hygiene services are often mistakenly thought of as simply consisting of “BWs” and prophys.  While “professional cleanings” and bitewings are staples of treatment, there are obviously many more services that hygienists perform every day. In fact, practices where hygienists are not performing interceptive periodontal treatment or providing other adjunctive services are typically practices where the hygiene department is low in production. Let’s look at two treatments that hygienists can provide to help patients become healthy, while also adding to the practice’s bottom line.

Controlled Release Antimicrobials
D4381-Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report. FDA approved subgingival delivery devices containing antimicrobial medications are inserted into periodontal pockets to suppress the pathogenic microbiota. These devices slowly release the pharmacological agents so they can remain at the intended site of action in a therapeutic concentration for a sufficient length of time.

ADA Current Dental Terminology codes are not product specific. Therefore, although a code may apply to a particular product, it was not designed to refer to that product. With this in mind, the use of several agents currently on the market might be described by this code. These include but are not limited to:

  • Perio Chip-Chlorhexidine wafer
  • Actisite-Tetracycline fiber
  • Arestin-1 mg Minocycline delivered in a syringe
  • Atridox-Doxycycline mixed in a syringe
  • Perio-Protect - which is a custom fabricated tray used with an agent determined by the dentist - might also be described by this code

Antimicrobials can be useful adjuncts to scaling and root planing to help patients return to, or maintain their periodontal health. Despite this, insurance carriers vary in their contract language as far as benefits for D4381 are concerned.  While a few may cover these services at the time of SRP's, many carriers will cover D4381 only for “refractory pockets” with a one month to one year waiting period following scaling and root planing. These carriers also may look for a diagnosis of at least Chronic Periodontitis, Moderate or Severe, with 5mm or deeper pockets on the teeth being treated, plus bleeding on probing. They may also limit their coverage to two teeth per quadrant.

It is important to note that “irrigation” is not considered to be accurately reported with D4381. The primary reason appears to be that irrigation is not considered to be “controlled release.” In fact, “irrigation” does not have any attached code.  How to code irrigants? Here are some considerations:

  • The Current Dental Terminology definition of Periodontal Maintenance-D4910 does not mention irrigation, therefore the ADA Code Revision Committee does not appear to think it is a “part” of the procedure.
  • Conversely, the American Academy of Periodontology in their “Parameters of Care” for periodontal maintenance, state that it includes “antimicrobials as necessary.”
  • Because the CDT codes are the designated code set for dentistry, and despite the AAP parameter, it appears that D4999-Unspecified Periodontal Procedure, by Report, may be appropriately used for irrigation.
  • It is unlikely that any carriers will cover the procedure when reported separately, regardless of the code used.
  • Network dentists may not be able to charge separately for irrigation under their contracts.
  • Offices may opt to include the fee for irrigation into the larger service being performed rather than trying to find a way to charge separately.
  • The use of irrigants can be an important difference between D1110-Prophylaxis-Adult, and D4910-Periodontal Maintenance.

Coding and insurance payment issues aside, if an office has determined that the delivery of antimicrobials is in the patient’s best interest, these medicaments can be included in the treatment mix. Fees for D4381 often run at around $150 per tooth. If a hygienist identifies only one patient per month who needs two teeth treated; 12 months  x $300= $3,600 additional practice income for the year.

The concept that office fluoride application is “just for kids” has fallen by the wayside. The ADA Report of the Council on Scientific Affairs, May 2006, Evidence Based Clinical Recommendations: Professionally Applied Topical Fluoride, set guidelines for the appropriate use of fluorides for various age groups and associated risk factors. Among their recommendations:

  • Fluoride is appropriate for persons with moderate caries risk, described as over age 6 with 1-2 incipient or cavitated carious lesions in the last 3 years, or other risk factors such as poor oral hygiene, poor family dental health, etc.  For persons under age 6, fluoride may be appropriate even if there are currently no caries, but other risk factors apply.
  • Fluoride is appropriate for persons with high caries risk, described as over age 6 with incipient or cavitated carious lesions in the last 3 years and multiple factors increasing risk, such as poor oral hygiene, suboptimal previous exposure to fluoride, presence of exposed root surfaces, etc.

Insurance carriers frequently cover fluoride treatments, but may have age specifications in place.  A common restriction is that fluoride will be covered for persons up to, not through, age 14, two times per year. Older persons may also be covered when fluoride is reported on the same claim form as restorations, or when a brief report of patient issues is included in section #35 of the claim form. With this in mind, many patients can benefit from professionally applied topical fluoride on a regular basis, and many of their insurance plans may pay toward this service!

Offices may develop a Preventive Fluoride Policy to set a format for when fluoride will be applied, according to the dentist’s philosophy. 

For example:

  • Low-risk patients of any age - fluoride varnish annually
  • Moderate risk children and adults - fluoride varnish every six months
  • High-risk patients of any age - fluoride varnish every 4 months

Before instituting any changes in what an office has previously been providing, a staff meeting should be held to go over what the changes are going to be, why they are being instituted, and how they are going to be explained to patients. It is important that all staff members understand and are able to verbalize the benefits of any new treatments or increased frequency of treatments. Fees for D1206-Fluoride Varnish often run at around $40. If a hygienist identifies only two adult patients a week who could benefit from fluoride; 48 weeks x $80 = $3,840 additional practice income.

Carol Tekavec CDA RDH is the Director of Hygiene for McKenzie Management. Carol can improve your hygiene department in just one day of training “in your office.” Interested in knowing more about how to improve your hygiene department? Email hygiene@mckenziemgmt.com

Carol is also a speaker on dental records, insurance coding and billing, patient communication and hygiene efficiency for McKenzie Management.  Interested in having Carol speak to your dental society or study club?  Click here

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