I’m
Glad You Asked...
by Kathy S. Forbes, RDH, BS
Q.
Is bone loss a requirement for D4341 and D4342?
We have a young man who has 4-5 mm pockets over his
entire mouth with severe bleeding and subgingival
calculus but not much bone loss. His insurance doesn’t
want to pay for root planing and scaling.
A.
Yes, bone loss is a requirement for
billing D4341 and D4342 – hence the term “scaling
and root planing.” The reason the insurance
carrier may be denying payment of these codes is because
it cannot determine if there is any bone loss from
the pocket readings. Many periodontal chartings are
submitted with only the pocket depth readings. This
alone does not give an accurate picture of bone loss.
I have seen patients whose sulcus measurements were
4-5 mm in the posterior, but this was due to severe
gingivitis (inflammation). No bone loss was involved.
It is critical to submit complete periodontal chartings
in order to show evidence of bone loss. This would
include not only pocket measurements but also areas
of recession, mobilities, furcation involvements,
bleeding areas, documentation of minimal or no attached
gingiva, the American Academy of Periodontology (AAP)
classification, etc.
The CDT code used for a patient with moderate to
heavy calculus and moderate to severe gingivitis,
possibly requiring two appointments (perhaps with
anesthetic), is D1110, adult prophylaxis. This is
newly defined in CDT-2005 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.” The
American Dental Association (by virtue of HIPAA) owns
the dental procedure codes and has stated that a patient
such as the one you described should be coded using
D1110 as many times as is needed to complete the case.
Here is one example of how you might explain the situation
to the patient in order to help him better understand
his insurance benefits (or lack of them!): “John,
I am glad you came in today. The good news is that
in spite of the serious gum infection you have in
your mouth, there has been no loss of bone support
around your teeth. The bad news is that we will need
more than one appointment to get your mouth healthy
again.
Were you aware that most patients’ dental plans
only pay for two “cleanings” (or adult
prophylaxis as we call them), each year? Sometimes
they pay for two within a twelve month period and
sometimes they pay one every six months. Do you know
how your plan plans? If you don’t mind, I will
ask our insurance coordinator about your plan? What
do you want to do about this infection if your plan
only pays twice a year and you need to see us four
times a year?” You do want to get this infection
under control, don’t you?
Most patients understand this since they know they
“grew” the calculus and probably did not
do a thorough job of homecare. Encourage the patient
that you will do your best to maximize the benefits
available under his dental plan...but not at the expense
of his oral health.
WHAT CODE DO WE USE
TO BILL FLUORIDE VARNISH?
Daily, we are reminded that there are new staff members
submitting dental claims and/or fielding patients’
insurance questions with little training or support.
Reviewing the fundamentals of coding and dental plan
design may be helpful for newer staff members.
Q.
We billed D9910, fluoride varnish, on a prophy
patient. When checking eligibility and benefits, online
we were told that either fluoride or varnish is covered
twice each benefit period (with no age limit). However,
the claim was denied, and when I spoke to the customer
service representative she said D9910 is not covered
on any of their plans. She suggested that I reprocess
using D1204, adult fluoride. Can I legally do that?
I know that we have a legal responsibility to bill
what we do. We painted on fluoride varnish. We did
not use fluoride gel trays.
A.
You are wise to ask. Dental plan phone representatives
often instruct dental offices to rebill using codes
that will be covered by the patient’s plan--not
realizing that it is illegal for a dental office to
simply change a code to obtain payment.
According to CDT 2005, when fluoride varnish is used
for caries prevention, it is reported using the topical
fluoride codes (D1201, D1203, D1204, or D1205). When
fluoride varnish is used to desensitize a tooth, however,
D9910 is the appropriate code (application of desensitizing
medicament). That being said, it is important to remind
clinical staff to always document their reason for
using.
