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Problem codes and services-prophys, perio, and evaluations.

Although I have covered these codes and explanations in past articles and blogs, they continue to pose problems for dentists and staff. In fact, I receive at least one call pertaining to these services every day. What are these problem codes and services? D1110-Adult Prophylaxis, D0120-Periodic Oral Evaluation, D0150-Comprehensive Oral Evaluation, D0180-Comprehensive Periodontal Evaluation, D4910-Periodontal Maintenance, and D4341-Periodontal Scaling and Root Planing.

First, let’s address the number one question I receive: How do I explain the differences among a “regular” cleaning, a root planing, and periodontal maintenance to my patients?

This comes up so often that I have published a patient education brochure that staff can utilize to find the “words” to use themselves, and to give to patients to support staff explanations. (See and read this brochure on my website at www.steppingstonestosuccess.com). If patients do not understand what is happening during these types of appointments, they may decide that they are receiving “prophys” all of the time, but are being charged for root planing! State dental boards list this as one of the top complaints currently lodged against dentists. So, how can we help our patients understand what’s going on?

1. Be sure that there are distinct and separate procedures provided during these appointments. Don’t expect your patients to understand what is happening if you are not or have not explained their treatment to them. Obviously, if the treatment seems the same to patients, they will be unhappy with higher fees.
2. Therefore, before beginning any periodontal services, including root planing, be sure that your patient understands what periodontal disease actually is, and what you are going to do for them. This typically means that a treatment conference and written fee estimate should be provided for patients before starting any clinical care. Patients should not be sent to the hygienist for their first root planing appointment asking, “What are we doing today??”
3. Be clear on what diagnostic parameters apply for each procedure. For example, an adult prophy is recommended for persons who do not have any bone loss, periodontal disease, or infection around their teeth. In other words, the mouth is healthy, with no gum or bone problems. A root planing is scaling all the way down to where the root, gingiva and bone meet. It is recommended for persons who have suffered some periodontal disease and bone loss. (For insurance carriers to cover root planing, they typically require at least a 5mm loss of attachment (perio pockets plus recession) for a benefit to apply. Does this mean that patients with 4mm pockets should not receive root planing? Of course not. But it does mean that patients with less than 5mm pockets may not receive an insurance benefit. (All the more reason to be sure they understand their treatment and fees.) Periodontal maintenance is required to keep the periodontal disease process under control. According to the American Academy of Periodontology it entails, but is not limited to, full mouth probing, scaling and root planing as needed, polishing of the teeth as needed, and pocket irrigation as needed. (To read the entire AAP recommendation, refer to AAP Parameters of Care, Supplement to Volume 71, Number 5, May 2000.)
4. Understand that most insurance carriers will cover two D1110-Adult Prophy services per year, or two D4910-Periodontal Maintenance services per year, and four quadrants (with at least 4 involved teeth per quadrant) -D4341-Periodontal Scaling and Root Planing, every three years.
5. Know that despite what some carriers may tell you, it is not appropriate to alternate between D1110 and D4910 to allow patients to receive payment toward four services each year. Obviously a standard prophy is not periodontal maintenance! It does not make sense and is not accurate. If carriers or patients request that you alternate between D1110 and D4910 (for patients who require four perio maintenance procedures per year), try this instead: List D4910 as the service but print or generate a short narrative (section #35 on the ADA Claim form) stating, “If no benefit, please pay what is allowed for D1110”. You will be reporting the service accurately, but requesting the alternate payment for a prophy to help patients get at least some benefit.

For evaluations, or examinations, questions seem to focus on when it is “right” to use D0120-Periodic Oral Evaluation, D0150-Comprehensive Oral Evaluation, and D0180-Comprehensive Periodontal Evaluation. The short answer is that any of the codes may be used any time the dentist decides it is appropriate. But, there is a difference with insurance coverage. Most carriers will allow a benefit for D0120-Periodic Oral Evaluation twice per year, and D0150-Comprehensive Oral Evaluation or D0180-Comprehensive Periodontal Evaluation once every 3 to 5 years. Most carriers reimburse the same amount for D0150 and D0180 and consider them somewhat interchangeable; with a few providing a slightly higher benefit for D0180. So, if a dentist reports D0180 once per year, it is likely that the patient’s carrier will cover one D0180, and then pay what they allow toward a D0120-Periodic Oral Evaluation, for the rest. This usually also applies for the dentist’s exam when it is performed along with D4910-Periodontal Maintenance. The dentist may decide to report his/her exam as D0180-Comprehensive Periodontal Evaluation, but the carrier may change the code and provide payment toward D0120-Periodic Oral Evaluation. When carriers change our codes it does not mean we “should” have provided the changed code service, it simply means that the patient’s plan won’t cover the coded service we reported. An “alternate benefit” allows the plan to pay toward another service, so the patient’s treatment is not just denied outright. (If your office is a network provider for a plan, you may or may not be able to balance bill the patient for amounts not covered. Non-network providers may typically balance bill as they like.)

Another common question—how long is it appropriate for patients to stay on periodontal maintenance therapy? The short answer is that it is up to the dentist to decide when or if periodontal maintenance can be replaced with adult prophylaxis. The CDT-2009-2010 states that D4910-Periodontal Maintenance “is instituted following periodontal therapy and continues at varying intervals, determined by the clinical evaluation of the dentist, for the life of the dentition or any implant replacements”. This implies that once on perio maintenance, always on perio maintenance; but the dentist’s clinical judgement remains the key. (see Dental Insurance Coding Handbook 2005-2010).

Bio: Carol Tekavec CDA RDH is the author of the Dental Insurance Coding Handbook 2005-2010 and was the columnist on insurance for Dental Economics magazine for eleven years. She is also the developer of a dental chart, informed consent forms, and a patient brochure series. Contact her at www.steppingstonestosuccess.com, call 800-548-2164 or email:carol@steppingstonestosuccess.com

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Comment by Thornhill Dentist on September 19, 2010 at 5:22pm
The dentist richmond hill may decide to report his/her exam as D0180-Comprehensive Periodontal Evaluation, but the carrier may change the code and provide payment toward D0120-Periodic Oral Evaluation.
Comment by Mary Jane RDH BS on December 11, 2009 at 10:03am
When I provide a "service" to my patient's it is referred to a a prophylaxis. Until we get away from the term "cleaning" there will always remain a confusion about what a hygienist does do. For POH, I tell my patient's what they are doing is a mini debridement daily; they by their home care, are destroying the juvenile pathogens before they can be destructive and like little ants replenishing their ant hills, they have to restructure their biofilm unless the patient debrides it again. It is in their power to stop that from happening.
Comment by Carol Tekavec on December 11, 2009 at 9:51am
Thanks for your comments. The main reason it is a problem is that when patients are billed for services that are not covered by their dental plans, they get mad at the dentist, hygienist and staff. If patients and staff are on the same page, and patients understand what treatment they are receiving and why-issues are reduced. Even though the experience of a so-called "cleaning" and perio maintenance are very different, if patients don't perceive and understand that difference; they also get mad.
Comment by Mary Jane RDH BS on December 11, 2009 at 8:25am
I really don't understand why this is such a problem. We as providers are the ones that know what services we are providing and what codes to use. The problem is at the front desk that do not understand and are continually questioning what is really a straightforward sequence of events. Perio maintenance in our office doesn't change. I don't do RP on pseudo pockets and a six millimeter pocket without surgery is not going to change to the degree that it is not going to need to be maintained at every two to three month interval.
Comment by Darrell Pruitt on November 17, 2009 at 7:31pm
Every time payment is complicated for any reason, payers win unearned profit.

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