Records, Risk and Reimbursement

That are some common parameters regarding third-party payment for periodontal treatment? In the case of standard indemnity insurance, restrictions as to frequency, maximums and esthetics are typical. Most plans feature a $50 deductible, and a maximum benefit amount per year (commonly $750-$1,000). Only two examinations of any type and two "cleanings" of any type are covered during the calendar year. Six months may be required between each of the two "cleanings," or they may be covered one after

Carol Tekavec

That are some common parameters regarding third-party payment for periodontal treatment? In the case of standard indemnity insurance, restrictions as to frequency, maximums and esthetics are typical. Most plans feature a $50 deductible, and a maximum benefit amount per year (commonly $750-$1,000). Only two examinations of any type and two "cleanings" of any type are covered during the calendar year. Six months may be required between each of the two "cleanings," or they may be covered one after the other. This means if a patient receives a Comprehensive Oral Evaluation (Code 00150) at the office of a general practitioner and is referred to a periodontist that same month, the periodontist`s submission of Code 00150 for his evaluation may or may not qualify for payment.

Some periodontists still are submitting the former American Academy of Periodontology code for a "new-patient" exam - Code 04110-Initial Periodontal Examination - and are receiving a benefit from some carriers. However, this is one of several codes rescinded by the AAP in 1995 in favor of the revised ADA Current Dental Terminology-CDT-2 codes.

If the periodontist`s evaluation is a benefit, under any code, then further exams might not be paid for by the insurance company for the remainder of that year. With this in mind, if a new patient "emergency" comes in, and the dentist uses Code 00410-Limited Oral Evaluation-Problem-Focused, the insurer might cancel out the patient`s benefit for a subsequent and recommended "New Patient" examination - i.e., Comprehensive Oral Evaluation-Code 00150 - in six months.

If a patient requires two visits over a two-week period for a thorough prophylaxis, both may be paid for, eliminating further payment that year, or only one may be covered. If the dentist uses the new code for Full Mouth Debridement (Code 04355), insurance may cover this at a slightly higher payment than a standard adult prophy, but pay it only once every three-five years or once per lifetime. The insurer also may decide to pay it at the same fee as a Code 01110, or it may not cover any portion at all. (If it is a benefit, Code 04355 is a "nonpreventive" code and is paid after the deductible is reached.)

Watch your dates

Code 04355 is defined as "the removal of subgingival and/or supragingival plaque and calculus that obstructs the ability to perform an oral evaluation. This is a preliminary procedure and does not preclude the need for other procedures." By definition, an exam cannot be done on the same date as Code 04355. In practice, however, a preliminary evaluation usually will be performed by the dentist on the same day as the Code 04355. This is done to determine the need for the procedure, with the actual exam Code 00150-Comprehensive Oral Evaluation, submitted on the patient`s second visit. The only "cleaning" codes, available for use on the second appointment of a two-visit "difficult" prophy are either another 04355 or the standard 01110-Adult Prophy. Neither is completely correct, and it is unlikely that a payment will be made for more than a standard prophy.

Periodontal scaling and root-planing

Patients requiring periodontal therapy can be appropriately scheduled for this immediately subsequent to a 04355-Full-Mouth Debridement. When Code 04341-Periodontal Scaling and Root-Planing, Per Quadrant - is utilized, most indemnity plans require charting, verifying several teeth with 5 mm or deeper pockets in each quadrant to be treated, as well as radiographs. Periodontal Scaling and Root-Planing usually will be paid as a benefit once every two years.

Three months after the last quadrant is completed, a Periodontal Maintenance Procedure-04910, will typically be paid for. If the patient needs a Code 04910 sooner, no benefit will apply. If the patient requires four 04910 visits each year, only two of these will be paid for after the deductible is reached. Patients needing Code 09910-Application of Desensitizing Medicaments for sensitive root areas; Code 01330-Oral Hygiene Instructions; Code 09630-Gingival Irrigation, under Other Drugs and Medicaments, By Report; or multiple reprobing and follow-up visits usually must pay for these procedures themselves. (Multiple perio follow-up visits or reprobing appointments do not fall under a current ADA code. The closest codes are 09430-Office Visit for Observation, or Code 09999-Unspecified Adjunctive Procedure, By Report.)

If a dentist is a DHMO contractor, payment required by the patient is much less. Under the terms of a typical DHMO, verification of pocket depths usually is not required. Four quadrants of root-planing (Code 04341) require payment by the patient at a specified, discounted fee (often 50-70 percent less than the dentist`s usual fee) at the time of service. Periodontal Maintenance-Code 04910 can be scheduled at any time after treatment and at any interval thereafter; again, at a specified, discounted fee. Patients requiring Desensitizing Medicaments-Code 9910, Oral Hygiene Instructions-Code 01330, Actisite-Code 04381, or multiple reprobing visits usually are eligible for these procedures at no charge. Under a typical DHMO contract, the dentist is required to absorb the total costs of these services.

Carol Tekavec, RDH, is the author of two insurance-coding manuals, co-designer of a dental chart, and a national lecturer. Contact her at (800) 548-2164 or at www.steppingstonetosuccess.com.

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