Difficult prophys

Dealing with insurance issues for patients who present with oral conditions requiring more than a simple prophy, but less than root-planing and scaling, is difficult. Most insurance carriers will provide a benefit for a D1110-Prophylaxis-Adult twice per year, sometimes with a stipulation that the procedures be at least six months apart. Carriers also will typically provide a benefit for D4341-Periodontal Scaling and Root-Planing, per Quadrant, based on four separate quadrants once every two year

Carol Tekavec, RDH

Dealing with insurance issues for patients who present with oral conditions requiring more than a simple prophy, but less than root-planing and scaling, is difficult. Most insurance carriers will provide a benefit for a D1110-Prophylaxis-Adult twice per year, sometimes with a stipulation that the procedures be at least six months apart. Carriers also will typically provide a benefit for D4341-Periodontal Scaling and Root-Planing, per Quadrant, based on four separate quadrants once every two years.

The remaining related code is D4355-Full-Mouth Debridement To Enable Comprehensive Periodontal Evaluation and Diagnosis. In the ADA CDT-3 code revision, this is described as "The removal of subgingival and/or supragingival plaque and calculus. This is a preliminary procedure and does not preclude the need for other procedures. This D4355 procedure may be necessary more than once and may require multiple visits to complete."

Some considerations for D4355 include:

- Because the code title indicates that the patient has presented with deposits so elaborate that a comprehensive periodontal examination and diagnosis are not possible, insurance carriers do not consider this code payable on the same date as an evaluation.

- This code may properly be used prior to (and on a different date than) a D4341-Periodontal Scaling and Root-Planing, D1110-Prophylaxis-Adult, and any evaluation code.

- The description implies that a D4355 might be thought of as a "gross scaling," but this is the case only as it applies to facilitating an adequate exam. Gross scaling is not believed to be routinely appropriate prior to D4341 or D1110; it is considered an incomplete scaling. Some healing and resolution of tissues are likely over incompletely removed deposits, but adequate resolution is not possible.

- With the new ADA description, D4355 may conceivably apply to a "difficult prophy," "double prophy," or "extended time prophy."

- Code D4355 is not a replacement code for D4345-Periodontal Scaling Performed in the Presence of Gingival Inflammation. Code D4345 was deleted in 1995, but it still may be paid by certain insurance plans, despite the fact that it is not a current ADA code. Because insurance carriers are not required to use ADA codes, some patient claims may be returned with codes of the carrier`s own invention or outdated codes such as this one.

- Regardless of the ADA description of D4355, most insurance carriers regard it as a code intended only for extreme cases. They typically do not provide a separate benefit. Most will simply "downcode" or change the code to a D1110 and allow whatever benefit applies for that procedure. (Carriers frequently change claim codes from a code that a contract provides no benefit for to a code where some benefit may apply. This does not mean that the dentist is expected to perform the lesser-paid service. It means that the carrier will only pay a benefit based on the lesser-paid service.)

- A few insurers will pay D4355 as a once-per-lifetime benefit or a once-per-five-year benefit. When payments do apply, they are typically "after the deductible," because the 4000-series codes are not considered "preventive," "before the deductible" services. Whatever the case, the patient must pay the difference between what the carrier pays for and what the dentist charges for the procedure.

What is the best way to code a "difficult prophy"? Right now, utilizing D1110-Prophylaxis-Adult - with an increase in fee for an extended time period (be sure to note how long the appointment lasted on the claim form) - or charging out two times for a double appointment procedure seem to be the best ways to accurately report and elicit benefits for patients. Patients still may have to pay for the second of the two D1110 procedures or they may have to pay for subsequent D1110 procedures completed in the same year.

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 visit her Web site at www.steppingstonetosuccess.com.

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