I have addressed the problems that surround reporting a so-called “difficult prophy” in previous columns; however, questions continue to trouble many offices. Dentists and staff who help their patients with insurance are frequently faced with the difficult task of explaining necessary services and insurance limitations to patients. While it is ultimately patients’ responsibility to understand their insurance, many rely on their dentists for help. There are several methods for coding so-called “difficult” prophies. All are discussed at length in my Dental Insurance Coding Handbook-CDT 2005.
1)Patients presenting with such elaborate deposits that a dental evaluation is not possible may have their treatment reported as D4355-Full Mouth Debridement to Enable Comprehensive Evaluation and Diagnosis. This code is described as “the gross removal of plaque and calculus that interfere with the ability of the dentist to perform a comprehensive oral evaluation. This preliminary procedure does not preclude the need for additional procedures.” Some considerations:
☛Because the code title indicates the patient has deposits that prevent an exam, insurers do not consider this code appropriate for payment on the same date as an evaluation.
☛This code may be used prior to and on a different date than root-planing and scaling (D4341 and D4342), or Prophylaxis-Adult (D1110).
☛The description implies that a D4355 might be thought of as a “gross scaling.” But according to the ADA, this should be used only as it applies to facilitating an adequate exam. In many circles, gross scaling is not believed to be routinely appropriate prior to D4341, D4342, or D1110. Gross scaling is an incomplete scaling. Some healing and resolution of tissues are likely over incompletely removed deposits, but adequate resolution is not possible. Subsequent manipulation of the tissues for what used to be called “fine scaling” may cause pain, lacerations of the sulcus, and even disruption of the attachment apparatus.
It is believed that the ADA considers the code to be applicable to any patient case where mouth debris, calculus, food, stain, or other contingencies make an exam impossible, while making no recommendations on “difficulty.”
☛Regardless of the description, most insurance carriers regard the code as intended only for extreme cases and do not typically provide a separate benefit. Many will just pay whatever benefit is allowed for a D1110. A few will pay D4355 as a once-per-lifetime benefit or a once-per-five-year benefit. When payment is applied, it is typically “after the deductible.”
2)If the dentist can perform an exam, he or she may recommend an “extended-time prophy” with an appropriately higher fee. In this case, D1110 - along with a brief narrative indicating time spent, heavy deposits, or whatever other issues are pertinent - may be used. For example, “Patient had heavy, tenacious calculus on maxillary facial surfaces and heavy deposits with stain on all lingual mandibular surfaces. An extended-time appointment (90 minutes) was required.” Keep in mind that all narratives should be patient- and treatment-specific, and that radiographs and/or intraoral photos may be helpful. Carriers may pay an additional amount due to the extended time required or pay the usual benefit. The patient pays the balance.
3)The dentist can perform an exam and decide if a two-appointment prophy is appropriate. In this case, use D1110 for each of the two necessary appointments. A narrative on the claim form can document heavy deposits, heavy stain, or whatever other issues are pertinent, in addition to the fact that two appointments (and time spent for each) are needed. Carriers will likely either pay for both D1110 fees now, with future D1110 fees being the patient’s responsibility, or they may pay for one D1110 fee now, with the second the patient’s responsibility.
4)Dentists who are “in-network providers” for certain plans have agreed to their fees for D1110 in their contracts. In these cases, charging more for a D1110 in the extended time case may not be possible. The dentist is limited to the agreed-upon fee he or she can charge for D1110, and the patient may not be charged an additional amount. Using D4999 with a narrative describing the additional time required may eliminate the “disallowment” for the extra charge, with the patient being required to pay for the additional time. However, the use of D4999 also may cause payment to be somewhat delayed due to the typical need for consultant review of “unspecified” codes.
To read my brochure regarding the differences among a “regular” prophy, a root-planing, and perio maintenance, go to www.steppingstonestosuccess.com.
Carol Tekavec, CDA, RDH, is the author of the “Dental Insurance Coding Handbook-CDT 2005.” 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?”
