Carol Tekavec, RDH
Many dentists and hygienists are interested in designing a soft-tissue management program for patients with periodontal disease. The rationale behind these programs is that patient care is neglected with a "cleaning-twice-a-year" standard. Recognition and diagnosis of periodontal disease is a vital aspect of total treatment that can be of great importance to patient health.
However, there are problems that can arise with soft-tissue management programs:
• Patients may not understand why they are receiving expanded treatment and may react negatively.
• Patients may not perceive a difference between their previous, standard prophy appointments and what is being performed for them under the soft-tissue management program. In fact, complaints to state dental boards are on the rise in this area. Patients assert that they are receiving "cleanings," while being charged for root-planings and periodontal maintenance.
• Insurance patients may become upset when they realize that there are limited perio benefits under most dental contracts.
To help prevent these problems:
1 Design a treatment plan that you and your staff are comfortable with.Then present a written explanation of this plan to your patients before treatment begins. The written explanation should include details about why the treatment is needed and the total fee, regardless of possible insurance coverage. (Patients can be told that any insurance benefit received will be applied toward the total). This estimate and an informed-consent form should be signed by the patient. (Samples of an estimate form are available. Call 800-548-2164.) One copy of these forms should go home with the patient and one should remain with the patient's record.
2 Make sure the treatment the patient receives under the soft-tissue management program complies with American Academy of Periodontology's recommendations. For example, patients receiving root-planing and/or osseous surgery may be appointed for subsequent Periodontal Maintenance (D4910) at appropriate intervals until, or if, the patient returns to health. A "Parameters of Care" booklet (No. 5, May 2000, Pages 847-883), with detailed definitions and treatment recommendations for periodontal care, can be obtained from the AAP at (312) 787-5518.
3 Make sure the treatment the patient receives during a perio-maintenance appointment is radically different from the prophy experience — patients should be able to tell the difference! The maintenance appointment should include (at a minimum) assessment and recording of probing depths, bleeding, furcations, recession, and mobility, as well as removal of bacteria from pocket areas. Perform scaling and root-planing as needed. Insurance carriers usually will pay a benefit for two D4910 appointments per year. You must include documentation of the five assessments listed.
4 Typical perio-contract benefits for soft-tissue management include: D0150-Comprehensive Exam (one every three years), D0120-Periodic Oral Evaluation (one per year), D4341-Perio Scaling and Root-Planing (four quadrants every two years), and D4910-Perio Maintenance (two per year). A D1110-Adult Prophylaxis, performed at any point after scaling and root-planing, may or may not be covered. In addition, a few plans may cover a D4355-Full-Mouth Debridement at the beginning of treatment or the insurers may downcode payment to the benefit they allow for a D1110. Most plans do not cover D1110 and D4910, alternated at every other "recall," although there are notable exceptions. (The rationale is that once a patient is treated with a D1110, that patient has regained health.) D1204-Topical Application of Fluoride may be a benefit for patients with cervical decay or sensitivity. A narrative usually is required.
Additional appointments for D1330-Oral Hygiene Instructions, D9630-Subgingival Irrigation, D4381-Localized Delivery of Topical Agents, periodontal probing (which does not have a separate code), and polishing usually are not covered. Patients typically must pay the entire cost for these procedures themselves.
Carol Tekavec, RDH, is the author of the Dental Insurance Coding Handbook Update CDT-4, co-designer of a dental chart and an informed consent booklet, and a national lecturer. Contact her at (800) 548-2164 or visit her Web site at www.steppingstonestosuccess.com.