Are you missing with 4910?

by Annette Ashley Linder, BS, RDH

During a recent office onsultation, I observed the hygienist greeting and seating a perio maintenance (Code 4910) patient. She had been seeing this patient at appropriate three-month intervals following periodontal treatment - i.e., quadrants scaling and root-planing (Code 4341) - eight years earlier. When she asked the patient how life was treating her, the patient replied that:

• she was overwhelmed at work,
• her physician had recently diagnosed her with irritable bowel syndrome,
• since her twin sister had been diagnosed with Type II diabetes, she had scheduled an appointment for diabetes testing for herself, and
• she was exhausted.

As I assisted the hygienist with recording the periodontal examination, it became clear that the patient was no longer a 4910 patient. She had 36, 4 to 6 mm bleeding sites, with generalized bleeding and inflamed tissues in all quadrants. This patient was presenting with active periodontal infection and the treatment required was more than periodontal maintenance.

Periodontal maintenance (4910) is appropriate treatment following active periodontal therapy (4341). It is not a three-month prophy appointment. Rather, it is a mini-perio appointment and includes a periodontal evaluation and retreatment of sites with scaling and root-planing. However, there is a tipping point when, as in this case, the patient presents with increased risk factors, poor compliance, generalized active infection, and is going downhill. This is especially true in light of the research correlating systemic health and periodontal health.

Consider the following key points as you update your office protocols for periodontal maintenance:

1 Most carriers do not define Code 4341 as a once-in-a-lifetime procedure. Remembering that periodontal diseases are a chronic infection - incurable but controllable (most of the time) - it is not extraordinary to have to retreat with quadrant/s of mechanical and chemical therapy. Many insurance carriers will pay for 4341 again if it has been more than 36 months since the last 4341 treatment. Some contracts are written to cover 4341 again after 24 months.

(FYI: I have been told by office insurance coordinators that some insurance companies will cover 4910 for up to two years following active treatment, and then require a new periodontal charting and explanation. It always depends on how the contract was written, and we have no control over that.)

2 Update the medical history at every dental hygiene appointment. This should include the physical condition, medications, vitamins, and any over-the-counter drugs the patient may be taking. Increasingly, patients are presenting with various levels of drug-induced xerostomia. The reduced salivary flow impacts soft-tissue health and also creates increased risk for caries.3 Update the personal history and risk assessment. In the above situation, even before the clinical examination was begun, my red flags were up because I heard the patient report her stress, her health, her genetics, and her predisposition to diabetes. It is important to listen to the patient as he or she responds to your “relationship” and “how are you and the family” questions.4The patient has to own his or her disease and understand and actively participate in the ongoing therapeutic process. Patients that enter treatment simply because “you said they must” often become noncompliant and complain about having to come every three or four months because the “insurance isn’t paying for it.”5 The periodic oral evaluation, Code 0120, and localized delivery of antibiotics, Code 4381, are charged separately.6 Documenting and claims submission: It appears to be beneficial to include a narrative with the 4910 claim. A sample narrative includes patient-completed active periodontal therapy on date of 4341 and noting the patient is now receiving periodic and ongoing periodontal care as described in the research. Many offices also are including a copy of the health history and risk assessment, and intraoral photos of bleeding, swollen, and inflamed tissue with the periodontal chart. Consider asking these patients to call their insurance company (they are the customers, after all) and find out why they are not paying a benefit. Provide patients with educational materials and information at each appointment. A well-informed patient is a compliant patient - compliant in self-care, keeping appointments, and paying for services rendered.