The sequence is the secret!

Jan. 1, 1998
One very common office-scheduling problem is dealing with new patients or patients of record who have not been in for several years and who need to have more than just a standard prophy. These patients typically want to be seen for an exam and a "cleaning" on the same day.

Carol Tekavec, RDH

One very common office-scheduling problem is dealing with new patients or patients of record who have not been in for several years and who need to have more than just a standard prophy. These patients typically want to be seen for an exam and a "cleaning" on the same day.

If a standard cleaning is not sufficient and further appointments are necessary, the result can be an unhappy patient.

For new patients, problems are compounded because many misunderstandings ensue when a patient has not had a chance to develop a relationship with an office and is not convinced that what he is being told is actually true. (Shades of Reader`s Digest!)

For patients of record who have been away for extended periods, perceptions of what treatment they have had in the past color what they expect for the future. If they generally had good dental health in the past, they are upset if they are told that they need to have more extensive periodontal therapy, such as root-planing or a double prophy.

How can we treat new or re-established patients to offer them the most appropriate services with the highest degree of understanding?

Rule No. 1

Do not set up an appointment for a new-patient exam and a prophy at the same time. When new patients call to schedule an initial appointment, everything about the way that they are handled is important. New patients are forming their first opinions of the office. We want these opinions to be positive. For this reason, new patients should be scheduled initially with the dentist and chairside assistant only.

If a hygienist is scheduled first, it means that he or she will have to explain to the patient what radiographs are necessary; expose, develop and mount these X-rays; perform a periodontal probing or screening and perform the cleaning, all during a typical hour-or-less appointment.

If it turns out that a standard prophy is not what the patient needs, further time is taken by explanations of what the patient actually does require. Local anesthesia, if needed, must be administered and detailed home care must be reviewed. Patients who are not prepared for a double prophy, extended-time prophy or root-planing may be startled and distrustful.

Rule No. 2

Patients who require an extended or double prophy and/or root-planing need to have a written estimate. Patients deserve to be told what their treatment entails and what it will cost. If insurance is involved, discuss what the office will or will not do to help the patient obtain benefits. A very common mistake offices make is neglecting to provide estimates for double prophys or root-planing. Patients with or without insurance, well-off or just getting by, expect to know what treatment they will be having and at what fee.

Rule No. 3

Fees for hygiene procedures must reflect time needed, skill required and supplies used. One formula that might be used is:

- Code 01110 - Adult Prophy = X

- Code 04355 - Full-Mouth Debri-dement or Code 04910 - Perio Main-tenance = 2X

- Code 04341 - Periodontal Scaling and Root-Planing Per Quadrant = 3X

Sequencing is the secret

Insurance coding and the sequence to use for extended or difficult prophys pose a challenge. The new code, 04355-Full-Mouth Debridement To Enable Comprehensive Periodontal Evaluation and Diagnosis, is defined by the ADA as "the removal of subgingival and/or supragingival plaque and calculus that obstructs the ability to perform an oral evaluation." The code is appropriate for a difficult prophy, but it is erratically paid by third-part carriers and only is payable after the deductible.

Sequence and Coding for New Patient - Difficult Prophy

Initial Visit:

- Patient meets staff, tours office, has oral-cam visual and dentist orders radiographs.

- Dentist begins initial hard- and soft-tissue data collection, and performs a periodontal screening. Excessive deposits obscure exam.

- A treatment conference and estimate for the double or extended-time prophy is completed.

- The double prophy or extended prophy is scheduled.


- Code 00210 - Intraoral Radio-graphs-Complete Series Including Bitewings. Code 04355 will be used at the patient`s next visit. It cannot be used appropriately following an exam. (No exam is coded or charged for this visit.)

Second Visit:

- First of two prophys performed by hygienist.

- Oral hygiene instructions given.


- Code 04355 - Full-Mouth De-bridement To Enable Comprehen-sive Exam (may be paid by insurance 1X per three-five years or downcoded to Code 01110)

- Code 01330 - Oral Hygiene In-structions (Paid 1X/year by some carriers. No exam is coded or charged for this visit. Code 04355 is not paid by third parties when filed on the same date as an exam code.)

Third Visit

- Second of two prophys performed by hygienist.

- The dentist and hygienist perform a complete, comprehensive oral evaluation, including periodontal probing.

- The dentist maps out a complete treatment schedule (treatment plan) for the entire patient case. A treatment conference for the rest of the treatment is accomplished.


- Code 01110 - Adult prophy.

- Code 00150 - Comprehensive Oral Evaluation.

- Code 01330 - Oral Hygiene In-structions.

Detailed systems for working with new patients are essential to practice growth. Appropriate treatment, combined with good communication and proper sequencing, can ensure positive experiences for our patients and patient referrals for our office.

Carol 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 or at

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