Carol Tekavec, RDH
The new ADA Current Dental Terminology CDT-3 lists a revised description and a new code number for perio scaling. D4341-Periodontal Scaling and Root-Planing, per quadrant, is described as involving "instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. It is indicated for patients with periodontal disease and is therapeutic, not prophylactic, in nature.
"Root-planing is the definitive procedure designed for the removal of cementum and dentin that is rough and/or permeated by calculus or contaminated with toxins or micro-organisms. Some soft-tissue removal occurs. This procedure may be used as a definitive treatment in some stages of periodontal disease and/or as a part of presurgical procedures in others."
The description revision involves the words "and/or" in the last sentence. In the CDT-2, the word used was simply "and." While the revision is not considerable, it does highlight the dual nature of perio scaling and root-planing. "Perio scaling and root-planing" are both a final treatment and a pretreatment, depending on the condition of each patient and his or her acceptance of referral care.
More and more dentists and hygienists are using periodontal scaling and root-planing as treatments to help patients control their periodontal disease. Unfortunately, many offices also run into insurance-benefit problems. While most indemnity carriers cover D4341, restrictions and requirements for payment are abundant. Some of these are:
* Many carriers have a "minimum-tooth" eligibility for full-quadrant benefits to apply. Most require at least five involved teeth per quadrant. (If fewer than five teeth need root-planing, the quadrant can be reported as a fraction. For example; 4/5 of a quadrant for four teeth, 3/5 of a quadrant for three teeth, etc.)
* Most carriers want to have an American Academy of Periodontology case Type written on the claim form. Procedures falling under Case Type III-Moderate Periodontitis through Case Type V-Refractory Periodontitis, usually are considered for benefits.
* Detailed, progressive charting of probing depths, recession, bleeding, mobility, and furcations are important. When an office can document several visits where probing depths have deepened and/or other conditions have worsened, the insurance carrier can verify a current disease condition. One probing appointment can reveal that periodontal disease has occurred. Carriers increasingly want documentation of an existing and ongoing disease process.
* Probing depths should be combined with information showing "loss of attachment." For example, this means that a tooth demonstrating 2mm of recession and 4mm pockets actually has a 6mm "loss of attachment." Most carriers will not pay a benefit for teeth with pocket depths or loss of attachment of less than 5mm.
* Payment for D4341 usually is based on four separate quadrants, once every two years. Some carriers increase the time requirement to four quadrants only once every 36 months.
* "Time spent" may be a requirement. Many carriers will pay a better benefit for a one- - or, at the most - a two-quadrant procedure performed at one appointment. A lower benefit is paid toward a full-mouth or four-quadrant procedure accomplished in one day. If a patient requires a full-mouth, four-quadrant treatment for whatever reason, the office should provide a written narrative indicating the amount of time spent on each quadrant. (Insurance carriers usually expect a minimum of 45-50 minutes per quadrant.)
* Currently, "gross scaling" in advance of D4341 is not believed to be routinely appropriate. Gross scaling is an incomplete scaling. Some healing and resolution of tissues is likely over incompletely removed deposits, but adequate resolution is not possible. Subsequent manipulation of the tissues for "fine scaling" may cause pain, lacerations of the sulcus, and possible disruption of the attachment apparatus. Code D4355-Full Mouth Debridement to Enable Comprehensive Periodontal Evaluation and Diagnosis, prior to D4341, may be appropriate in certain isolated cases. However, it is not considered to be a viable, routine, "standard-of-care" treatment modality. Current thinking indicates that D4341-Periodontal Scaling and Root-Planing should be utilized as a first treatment, rather than a second or "final" scaling treatment.
Carol Tekavec, RDH, is the author of a new insurance-coding manual, co-designer of a dental chart, and a national lecturer with the ADA Seminar Series. Contact her at (800) 548-2164 or at www.steppingstonetosuccess.com.