Carol Tekavec, RDH
Filing a dental claim for a "cleaning" appointment for the average adult patient shouldn`t be a difficult process. It is likely one of the most common procedures performed in a modern dental office. Unfortunately, the ADA code and description for a standard "cleaning" leaves plenty of room for questions and disagreements concerning the parameters of the procedure and what it actually entails.
The ADA description for a D1110-Prophylaxis-Adult is: "A dental prophylaxis performed on transitional or permanent dentition, which includes scaling and polishing procedures to remove coronal plaque, calculus, and stains. Some patients may require more than one appointment or one extended appointment to complete a prophylaxis. Document need for additional time or appointments."
The D1110 code is supposed to describe a scaling and polishing procedure for adult patients in a healthy oral state, as well as in any other condition. Two exceptions include those patients qualifying for D4355-Full Mouth Debridement to Enable Comprehensive Periodontal Evaluation and Diagnosis, or those that qualify for a D4341-Periodontal Scaling and Root-Planing, per Quadrant. The D1110 code description specifically states that deposits are "coronal" only - a situation that rarely exists.
Most adult prophys are performed on patients who present with supra- and subgingival plaque, calculus and stains on coronal and root surfaces, and who also frequently have a certain amount of gingivitis. Because of the ADA description of D1110-Prophylaxis-Adult, no ADA code accurately describes the preventive and therapeutic procedure performed by dentists and hygienists for the majority of their patients - i.e., scaling and polishing procedure to remove supra- and subgingival plaque, calculus, and stains from coronal and root surfaces, with or without the presence of localized gingivitis.
In the CDT-1 (1990-1995), the ADA designated a code for a prophylaxis for healthy patients (01110) and a code for patients presenting with gingival inflammation and presumably subgingival deposits (04345). Many feel pressure from the insurance industry - which claimed "overutilization" of 04345 by the dental profession - led the ADA to delete Code 04345 in the CDT-2 (1995-2000). For lack of a better code (since 1995), Code 01110 -changed now to D1110 - is the only code available to describe an adult prophy for healthy patients with supragingival or subgingival deposits, or those with gingivitis. (Surprisingly, some carriers continue to recognize and pay a benefit for the deleted code 04345.)
It is believed that the ADA intends for Code D1110 to apply to patients presenting with supra- and subgingival deposits - as well as gingival inflammation - even though this language is not in the code. The ADA appears to expect dental offices to simply take more time and increase the fee as needed with these patients.
Varying fees for each patient is complicated in today`s world of computerized claims and filed fee schedules, but it is an option. Another option might be for the office to select the fee that would be charged for the most "difficult" adult gingivitis prophy and apply that to all Code D1110 procedures. Still another method might be to use Code D4999-Unspecified Periodontal Procedure, by Report, to describe a subgingival scaling and polishing procedure for a patient with gingival inflammation. This normally will create a delay in processing a claim, but it might result in a benefit for your patient - as long as the treatment falls within the parameters of the patient`s contract.
Third-party payers commonly interpret D1110 as a "cleaning" for patients over 14 years of age. Most carriers limit payment for this procedure to twice per year, with some carriers paying only once in a six-month period. If more than one appointment is needed, a carrier may pay for two appointments now, with no benefit available for the rest of the year. Other carriers may pay for one appointment now, with the second appointment the patient`s responsibility, and the next prophy in six months a covered expense.
Because of the variety of restrictions applied to patients` dental plans, schedule new patients for exams only, rather than exams plus "cleanings." If patients need a more extensive and possibly "not covered" procedure beyond a "simple cleaning," it is difficult to convince them of that. Patients need a chance to develop a trust relationship with the dentist and staff before treatment is recommended.
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.