New ADA codes for prophys

Carol Tekavec, RDH

The new ADA CDT-4, effective Jan. 1, 2003, gives a revised definition for D1110-Prophylaxis, Adult. While this procedure is frequently performed, there has long been confusion about when this code is actually appropriate. Unfortunately, changes in the CDT-4 are expected to increase the confusion for many offices.

The revised description for D1110 states, "A dental prophylaxis performed on transitional or permanent dentition that includes scaling and/or polishing procedures to remove coronal plaque, calculus, and stains." The previous definition (CDT-3) stated, "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."

D1110 is believed to describe a scaling and polishing procedure for adult patients in a healthy oral state, as well as in any condition other than actual periodontal disease with bone loss. The description specifically states that deposits are coronal only. The definition also has added the words and/or concerning polishing.

This definition perpetuates a serious problem for many dentists and hygienists, because most adult prophys are performed on patients who present with supra- and subgingival plaque, calculus, and stains on coronal and root surfaces. These patients also frequently have a certain amount of gingivitis. Code D1110 does not cover these conditions. (At its February meeting, the Code Revision Committee "clarified the original intent" of the D1110 description. They did not want to imply that a pumice cup prophy qualifies. The CDT-5 in 2005 will likely reflect this clarification.)

In the CDT-1 (1990-1995) the ADA designated a code for prophylaxis for healthy patients, 01110, and a code for patients presenting with gingival inflammation and subgingival deposits, 04345. It is thought that pressure from the insurance industry led to the deletion of 04345-Periodontal Scaling Performed in the Presence of Gingival Inflammation because insurers thought the code was "overutilized" by dentists. It is unknown what issues continue to prevent an accurate description for an adult prophy today.

What should offices do? Even though that is not what the code description says, it is believed that the ADA intends for code D1110 to apply in all cases not involving periodontal disease, and expects offices simply to take more time and increase the fee as needed. Third-party payers commonly interpret a D1110 as a "cleaning" for patients over age 14, sometimes interpreted as any patient who has erupted second molars. Most carriers limit payment for D1110 to twice per year, with some paying only once in a six-month period. (The latter means that a full six months must pass between each D1110 procedure for a benefit to apply.) If more than one appointment is needed (double prophy or D1110 x 2), the insurance carrier may pay for two appointments now, with no benefit available for the rest of the year, or may pay for one appointment now with the second appointment being the patient's responsibility. For a double prophy, use D1110 for each of the visits, with a brief narrative written or typed directly on the claim form stating heavy deposits, heavy stain, or whatever other issues are pertinent. Document with radiographs and an intraoral photo. If an extended-time prophy is needed, use D1110 with a brief narrative indicating time spent, heavy deposits, or whatever other issues are pertinent.

It would be beneficial in the future to have access to an expanded variety of codes to describe "cleanings." Having no codes between the D1110-Adult Prophy and D4341-Periodontal Scaling and Root Planing or D4355 Full Mouth Debridement makes accurate treatment reporting difficult.

Carol Tekavec, RDH, is the author of the Dental Insurance Coding Handbook Update CDT-4, co-designer of a dental chart and an informed consent booklet, and a national lecturer. Contact her at (800) 548-2164 or visit her Web site at www.steppingstonestosuccess.com.

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