The large majority of the questions I receive on a consistent basis are about billing for a prophy after scaling and root planing has been completed. Like it or not, the majority of offices accept PPO assignments. Even if your office is not a provider of a PPO, you most likely offer to submit for payment to your patients’ insurance company. Today I will write about some strategies for treatment and billing for the periodontal patient. At the end of this blog, you can opt-in to get more tools to get everyone on your team “on the same page.” You can read this article and then grab the tools to implement immediately. (Click on the picture to the left and you will be able to view the video that goes along with this blog)
1. When do we submit for periodontal maintenance?
2. Can we alternate a prophy with periodontal maintenance?
These questions are very common and they can also be very confusing but the employees who bill for payment and the dental hygienists who are providing treatment. This can also be hazardous to legal and ethical reasons as well as being confusing. First let’s look at the definitions set by the American Dental Association for these services. Prophylaxis D1110 is one of the most misinterpreted codes in dentistry.
The CDT Procedures book describes a prophylaxis as a preventive procedure NOT a therapeutic procedure. You may not ask “What does this mean for the hygienist treating patients?” and/or “What does this mean for billing the patient and/or insurance company?”
What this means is that if a patient has bleeding with 4 and 5 mm pockets (or greater), radiographic bone loss, even slight mobility, furcation involvement, muco-gingival involvement and/or recession, it means that this patient is not treated as a prophylaxis patient.
Know that the above paragraph describes a periodontal patient. This means that you will complete scaling and root planing. If the patient has only 1-3 teeth in any quadrant you will bill D4342 and if there are more than 3 teeth involved in a quadrant you will bill D4341. Four to six weeks after scaling and root planing is completed you will have the patient return for a post-op (re-evaluation) visit. This visit is billed as the first of a life-time of Periodontal Maintenance appointments. (The Periodonta Patient will return approximately every ninety days and if billing insurance, the CDT code will be D4910) Think of this very similar to a patient with Diabetes and they will return to their physician or a lab to have a HbA1c blood test. If a patient has high cholesterol they will routinely see their physician for blood work to check their cholesterol levels.
It’s the same thing when a patient is diagnosed with periodontal disease. You will treat with scaling and root planing, then re-evaluate. This re-evaluation is the first of future periodontal maintenance appointments.
Now let’s review the most recent definition of the Periodontal Code D4910:
Following periodontal therapy is periodontal maintenance and this continues at varying intervals determined by the clinical evaluation of the dentist and hygienist for the life of the dentition or any implant replacements. Periodontal maintenance includes removal of the bacterial plaque and calculus from supragingival and subgingival regions, site specific scaling, and root planing where indicated, and polishing the teeth. If new or recurring periodontal disease appears, additional diagnostic and treatment procedures must be considered. The definition of Periodontal Maintenance states that this procedure should continue for the life of the dentition.
There is no mention in the definition to only providing this service for a specific period of time after initial therapy.
I am consistently asked: Do we ever revert back to billing D1110?
It’s very important to note that treatment should always be based on diagnosis. If periodontal infection exists, it needs to be maintained to minimize recurring infection (meaning that if active disease returns you will complete D4341 or D4342 as necessary) and destruction of the periodontal support system and bone. If periodontal maintenance is needed, this is what should be completed regardless of insurance limitations.