Insurance Records, Risk and Reimbursement

Although many perio codes have been discussed in this column, coding for perio treatment continues to be a source of frustration for most offices. It is important to consider that employee dental contracts are seldom designed to cover much in the way of periodontal treatment. Even if treatment is medically necessary, recommended by the dentist and accepted by the patient, only procedures that are specifically delineated in the patient`s contract will be covered.

Carol Tekavec

Although many perio codes have been discussed in this column, coding for perio treatment continues to be a source of frustration for most offices. It is important to consider that employee dental contracts are seldom designed to cover much in the way of periodontal treatment. Even if treatment is medically necessary, recommended by the dentist and accepted by the patient, only procedures that are specifically delineated in the patient`s contract will be covered.

Four codes that routinely cause problems are: 04341-Periodontal Scaling and Root Planing, Per Quadrant; 04355-Full Mouth Debridement to Enable Comprehensive Periodontal Evaluation and Diagnosis, 04910-Periodontal Maintenance Procedure and 01110-Adult Prophylaxis. Most benefit plans will cover two "cleanings" per year per patient. Even with extensive documentation, many dentists find that the benefit offered for each of these four codes is what is allowed for the simplest procedure, 01110-Adult Prophylaxis.

What follows are some guidelines that may help your patients receive a better benefit, but only if the procedures described already are covered in the patient`s contract:

04341-Periodontal Scaling and Root Planing-Always include documentation of the patient`s original probing depths. A single chart form that allows for recording of six readings per tooth, in addition to bleeding points, mobility, recession and furcations should be attached to the claim form or preauthorization. Radiographs that document bone loss are very valuable as well and usually required for payment. Most carriers will not pay benefits for Code 04341 unless there are depths of at least 5 mm or more surrounding at least two teeth in each quadrant.

04355-Full Mouth Debridement-Radiographs and intraoral photographs can document excessive deposits. Be sure that an examination is not listed on the same claim form as the 04355. By definition, the 04355 is performed where there is excessive plaque and calculus, obstructing the ability to perform an oral evaluation. (This code is not well-accepted by insurance carriers. When coverage does apply, it often is limited to once in a lifetime, once in a three-to-five-year period or the claim is paid as Code 01110.)

04910-Periodontal Maintenance Procedure-This code only is appropriate following periodontal surgery or after Code 04341. It is not appropriate for a difficult prophy. Beginning in 1995, this ADA code description did not include an oral evaluation. Despite this, most carriers will not pay benefits for a "recall exam" performed at the same time as the 04910.

01110-Adult Prophylaxis-Third-party payers commonly interpret this code as a routine cleaning for patients over 14 years of age. (It sometimes is interpreted as applying to any patient who has erupted second molars). Most insurance carriers pay benefits for this service once in a six-month period or twice per year.

A good way to approach a patient`s periodontal benefits is to allow time for an initial treatment conference, even in advance of minor procedures. When patients understand the limited nature of their benefits, there is much less of a chance of problems when payment is required directly from them.

Carol D. 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.

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