11.11.16 Issue #766 info@mckenziemgmt.com 1-877-777-6151 Forward This Newsletter

Carol Tekavec, RDH
Hygiene Consultant
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New Hygiene Codes for 2017
By Carol Tekavec RDH

As everyone in the profession knows, the ADA revises the codes that dentists and dental insurance carriers must use on an annual basis. Several codes have been added or deleted for the 2017 Code on Dental Procedures and Nomenclature (CDT) Manual. The existence of a code does not mean that any insurance plan will pay for it. However, services without specific codes are typically relegated to the “99” codes that are notoriously underpaid or simply denied (for example; D4999-Unspecified Periodontal Procedure, by report). Even so, the development of a code is the first step in recognition and possible future payment or inclusion for a procedure in an insurance plan.

In 1995 the ADA deleted a code that was very useful to dentists and hygienists after it was deemed “over-utilized” by insurance carriers paying on claims. The code was D4345-Periodontal Scaling Performed in the Presence of Gingival Inflammation. There were several keys to applying this former code to a dental service. Of importance was the use of the descriptor “periodontal scaling”, implying scaling into an actual periodontal pocket, as opposed to a pseudo, or inflamed supra-bony pocket.

Insurance carriers decided that the code was being inappropriately used for a so-called “difficult” prophy, or a prophy that requires extra time, but not necessarily a different service. It must be noted that a D1110-Adult Prophy is performed in a healthy mouth, removes plaque, calculus and stains, and is intended to control local irritational factors. If the service takes longer than average, it is assumed that extra time will be allotted and the fee will be adjusted, which is always problematic when insurance payment is requested.

Prior to 1995, the D4345 was used frequently because many of our patients are not just simple adult prophys, and no other code was available. Since its deletion, no code considering inflammation has existed, until now.

The new code for scaling in patients with inflammation is D4346-Scaling in the Presence of Generalized Moderate or Severe Gingival Inflammation-Full Mouth, after Oral Evaluation. It is described as: “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 supra-bony pockets, and moderate to severe bleeding on probing. It should not be reported in conjunction with prophylaxis, scaling and root planing, or debridement procedures.”

It is expected to be used after an exam (Code D0120, D0150, D0180) and in cases where inflammation involves soft tissue only, with no loss of attachment or bone loss. The ADA also cautions that the procedure is “based on the diagnosis rather than the intensity of treatment required.”  So yet again, this code does not apply to a “difficult prophy”. 

Code D4346 is also different from D4355-Full Mouth Debridement to Enable Comprehensive Evaluation and Diagnosis in that D4355 applies when an exam and diagnosis are not possible prior to the removal of the large deposits the patient is presenting. D4346 is a therapeutic service performed after an exam and a diagnosis of gingivitis. It is further thought the ADA intends that an exam and a D4346 may be appropriate on the same day, and therefore, on the same claim form.

Since a diagnosis of “generalized inflammation” is essential for use of the code, the American Academy of Periodontology provides some guidance.

• 30% or more of the patient’s teeth at one or more sites are involved.
• Moderate inflammation means redness, edema, glazing of tissues, and bleeding on probing.
• Severe inflammation means marked redness and edema, and ulcerations with a tendency to spontaneous bleeding.

These conditions should be noted on the insurance claim form and in the patient record. Pseudo pocket depths and bleeding on probing, as well as the inclusion of photo attachments if possible, are also important. If a patient has only localized inflammation, as opposed to generalized inflammation, D1110 is still appropriate.

Subsequent hygiene recall appointments will be for standard D1110 services, not D4910. D4910 is a procedure that is only appropriate after a patient has received periodontal scaling and root planing (D4341-Periodontal Scaling and Root Planing-Four or more Contiguous Teeth per Quadrant, or D4342-Periodontal Scaling and Root Planing-One to Three Teeth, Per Quadrant) or periodontal surgery.

Another new code is D6081-Scaling and Debridement in the Presence of Inflammation or Mucositis of a Single Implant, Including Cleaning of the Implant Surfaces, Without Flap. The description of this procedure states that it is not performed in conjunction with D1110 or D4910, so D6081 is a separate procedure which may be reported with the same date of service as either of these two other codes. It is also considered to be appropriate on the same date of service as D4346.

Payment for either of these two new codes will be paid as determined by a patient’s individual dental plan. Since these codes are new for 2017 there is no track record yet, however, it is likely that both will be followed closely by carriers to see how the utilization by dental offices unfolds. Until more is known, it will probably be advantageous to alert patients to the fact that the services may or may not be covered by their carriers, or they may be down coded to what is paid for a standard D1110.

Carol Tekavec 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.

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