In my reference book, the “Dental Insurance Coding Handbook” - updated for the ADA CDT-2005 - a D4355-Full Mouth Debridement to Enable Comprehensive Evaluation and Diagnosis is described by the ADA as: “The gross removal of plaque and calculus that interfere with the ability of the dentist to perform a comprehensive oral evaluation. This preliminary procedure does not preclude the need for additional procedures.”
Dentists, staff, and patients typically have many questions regarding this code. When should this code be utilized and how do patient insurance contracts typically provide for payment? How do staff members explain to patients the difference between a “regular” cleaning (D1110-Adult Prophylaxis) and a Debridement (D4355)? What can staff say to patients who are upset about the costs associated with a debridement?
When should this code be utilized and how will insurance pay?
• Because the code title indicates the patient has presented with deposits so elaborate that a comprehensive examination and diagnosis are not possible, insurance carriers do not consider this code appropriate on the same date as an evaluation.
• This code may be used prior to (and on a different date than) a D4341-Perio Scaling and Root Planing/per Quad, D4342-Perio Scaling and Root Planing/One-Three Teeth, D1110-Prophy, and any evaluation code.
• The description implies that a D4355 might be thought of as a “gross scaling”; however, gross scaling is not currently believed to be routinely appropriate. Gross scaling is an “incomplete” scaling. Some healing and resolution of tissues are likely over incompletely removed deposits, but adequate resolution is not possible. Subsequent manipulation of the tissues for what used to be called “fine scaling” may cause pain, lacerations of the sulcus, and even disruptions of the attachment apparatus. Therefore, gross scaling is not considered to be a viable routine treatment modality. It is considered appropriate when an exam is impossible due to heavy deposits.
• While the description lends itself to the task of a “difficult” prophy, this is not believed to be what the ADA has in mind for the code. In addition, most carriers stipulate that a “difficult” prophy be coded D1110, and include a narrative indicating length of time and fee adjustment, as appropriate. Some patient contracts allow for a higher fee “once per lifetime,” or on a once per three-to-five-year basis for a “difficult” prophy. If not, then typically the amount provided for a “regular” prophy is paid, with the patient responsible for the balance. Very few plans cover the true fee of a debridement.
How can staff members explain a debridement to patients?
• Instructional videos or brochures can be used by staff members to support their verbal descriptions of what constitutes a debridement, as well as why insurance payment is likely to be modest. The most simple language possible should be used. For example: “A debridement is a procedure for removing thick or dense deposits of plaque and tartar from the teeth. A debridement is required when the deposits are too heavy to allow for an exam by the dentist.” To read a sample brochure, go to www.steppingstonestosuccess.com.
• Staff should be prepared to tactfully address the common statement, “I brush my teeth; why are my deposits so heavy?” An example of a response might be: “Most people try to brush their teeth and take care of their mouths. Sometimes, their efforts are not as effective as they could be. Brushing quickly and using a worn brush or an inappropriate technique might be to blame. Whatever the reason, a debridement can be the first step to getting you back to good oral health.”
What can staff say when patients are upset about the cost?
• It is usually best to address cost before beginning treatment. Misunderstandings can be reduced if patients understand why they need the debridement, that it will cost more than a regular cleaning, and that insurance benefits may not be as generous as the coverage for a regular cleaning. If these things are not explained prior to treatment, many patients will become angry.
• Staff may explain, “Most insurance plans pay a minimum for your treatment, regardless of what you might need. The good news is that with the help of dental benefits, the amount you have to pay is reduced.”
A debridement is a viable treatment for many patients. Pre-empting questions and concerns can make patient issues less of a problem.
Carol Tekavec, CDA, RDH, is the author of the “Dental Insurance Coding Handbook Update CDT-2005.” She is the designer of a dental chart, and is a lecturer with the ADA Seminar Series. Contact her by phone at (800) 548-2164, or visit her Web site at www.steppingstonestosuccess.com for more details about the new code handbook and her patient brochure, “What is a debridement?”.