Payment for perio maintenance
Periodontal maintenance - Code D4910 - is a common service provided by both general and specialty practices.
Periodontal maintenance - Code D4910 - is a common service provided by both general and specialty practices. The ADA code description and insurance reimbursement for this procedure have undergone changes in the past few years. The current description for D4910 is “a procedure instituted following periodontal therapy and continuing at varying intervals, determined by the clinical evaluation of the dentist, for the life of the dentition or any implant replacements. It includes removal of bacterial plaque and calculus from supragingival and subgingival regions, site-specific scaling and root planing where indicated, and polishing the teeth. If new or recurring periodontal disease appears, additional diagnostic and treatment procedures must be considered.”
•Although the definition states that intervals between the procedures are determined by the dentist, it does not mention an exam or diagnosis by the dentist. The dentist’s exam has not been listed in the definition since the CDT-1 (1990-95). Therefore, an exam - most typically a D0120, periodic oral evaluation - may still be properly reported separately from the D4910. Remember that any evaluation code the dentist deems appropriate may be reported. However, most carriers will only cover the fee for a D0120 in association with D4910, and then only twice annually.
•While many carriers deny payment for more than two evaluations per year, most do not “disallow” the fee. This means that evaluations performed, but not paid by insurance, may be charged to the patient. This is important for dentists who are network providers for plans such as Delta, which may have “disallowances” for certain procedures. “Disallowance” means Delta doesn’t pay and the dentist may not charge the patient. Such contract concessions on the part of dentists are usually accepted because estimates are that one out of every four insurance patients is covered by Delta. Dentists who do not want to accept contract concessions may provide services on a nonparticipating or non-network basis.
•Periodontal probing and documentation of bleeding, furcations, recession, and mobility may be delegated to a hygienist, if the state practice act approves of these procedures. However, diagnosis and any evaluation code must be associated with a dentist’s exam.
•Periodontal maintenance is usually not reimbursed unless it is performed at least three months after active therapy, which is either periodontal surgery or periodontal scaling and root planing (D4341). This does not mean that maintenance is not appropriate at any interval the dentist chooses. It does mean that most contracts observe a three-month delay after active treatment.
•The words “implant replacements” have been added to the description, which means that implants and natural teeth both might require the procedures performed during a D4910 for the life of the teeth and implants. A return to D1110, adult prophylaxis, is not appropriate.
•Claims for conditions less than a perio Case Type III (usually 5 to 7 mm pockets) typically are not covered. This does not mean that periodontal treatment and/or maintenance is not appropriate, but that most carriers will not reimburse for it. (The American Academy of Periodontology has developed a new method for classifying perio conditions called the “Classification of Periodontal Diseases and Conditions,” which can be read in its Annals of Periodontology, Vol. 4, No. 1, Dec. 1999, or in my “Dental Insurance Coding Handbook, CDT 2005-2007,” reprinted by AAP permission. A few carriers are requesting classifications based on these new parameters rather than on class type.)
•The D4910 patient clinical experience should be vastly different from a D1110 adult prophylaxis experience. If it isn’t, patients will be justifiably upset. A description of what should be included in D4910, taken from AAP Parameters of Care, can be read online in my brochure, “What Is the Difference Between a Regular Cleaning, Root Planing, and Periodontal Maintenance?”
Periodontal maintenance is an important aspect of patient care. Observing aspects of common insurance coverage and AAP recommendations can streamline the procedure and payment.
This column brings to a close my monthly contributions to Dental Economics®. However, I hope that you will look for other articles of mine in these pages in the future. Many thanks for your readership, and as always, feel free to contact me personally.
Carol Tekavec, CDA, RDH, is the author of the “Dental Insurance Coding Handbook, CDT 2005-2007.” 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, where you may also read her patient brochure, “My Insurance Covers This ... Right?”