The ADA coding system undergoes updating and revision periodically. The CDT-4 and the revision process is a function of the Code Revision Committee, which includes representatives of both the ADA and the insurance industry. HIPAA regulations require that both dentists and insurance carriers use the current version of the ADA CDT (Current Dental Terminology). Individuals may recommend code changes. Information about the process can be obtained at the ADA Web site, www.ada.org.
Basic periodontology codes ...
D4341–Periodontal Scaling and Root Planing– Four or More Contiguous Teeth or Bounded Teeth Spaces, per Quadrant (revised nomenclature) ...
For the first time, this code specifies the number of teeth per quadrant. For fewer teeth, Code D4342 is required. Include the following information on the claim form for quicker payment:
- Diagnosis (for example, Chronic Periodontitis).
- Case Type Classification (for example, Case Type IV–Advanced Periodontitis). Although the AAP has recently modified its diagnosis and disease classification system, carriers are still using case types.
- Periodontal probe measurements, which typically must be 5 mm or more in at least one area per tooth for any tooth to be considered for a benefit.
- Recession, bleeding, mobility, and furcation measurements.
Payment toward D4341 usually is based on four separate quadrants once every two years. Most carriers allow a lesser benefit for a full-mouth, four quadrant D4341 performed on the same day than they do for a two-quadrant-per-visit procedure. There is no code for a full-mouth perio scaling and root planing. Patients requiring a one-visit procedure, for whatever reason, may receive a better benefit when the office provides a written narrative including the amount of time spent on each quadrant, which should be a minimum of 45 minutes. As with all claims, the more information provided with the initial claim, the better the chance for a timely benefit payment.
D4342–Periodontal Scaling and Root Planing– One to Three Teeth, Per Quadrant ...
This new code addresses fewer than four teeth in each quadrant needing root planing. One method for reporting this is to list the D4342 with the tooth numbers involved on separate lines of the claim form. For example, D4342–#3, #4; D4342–#14; D4342–#19, #20; D4342–#30. Fees might be based on a per-tooth basis. For example, one tooth might be $45, two teeth $90, and so on depending on what the office decides. Many carriers are basing their fee allowance for D4342 on 60 percent of what they allow toward D4341, when the D4342 is three teeth and the D4341 is four teeth. A prorated amount per tooth is also likely.
D4910–Periodontal Maintenance ...
Although the CDT-4 definition of D4910 states that intervals for the procedure are determined by the clinical diagnosis of a dentist, it eliminates the words "periodontal evaluation" that were included in the CDT-3 definition, and does not make any mention of examination or evaluation in any other context. Therefore, a D0120–Periodic Oral Evaluation may continue to be properly reported separately. As new contracts are provided for your patients, you will probably see more carriers paying a benefit for both the D4910 and D0120 when performed on the same day. However, the previous benefit for the D4910 is likely to be reduced. Many carriers will cover only two D4910 procedures and two D0120 procedures per year, with any other visits being the patient's responsibility.
The clinical experience of the D4910, as compared to the D1110–Adult Prophylaxis, should be quite different. Patients should be able to make the distinction easily. Complaints by confused and unhappy patients to state dental boards in regard to their "cleanings" are on the rise. (A patient-friendly brochure detailing the difference between a standard "cleaning," "root planing," and "perio maintenance procedure" may be purchased from Stepping Stones to Success, www.steppingstonestosuccess. com.) Also, the American Academy of Periodontology provides guidance as to what should be included in perio maintenance in its "Parameters of Care" publication (updated periodically). Contact the AAP at (312) 787-5518.
One method for calculating fees in this area is to set your office's desired fee for a D1110 (x), double that fee for a D4910 (2x), and triple that fee for one quadrant of root planing D4341 (3x). Code D4342 might have a fee that reflects three-fourths of the fee charged for D4341. For example, if a dentist charges $60 for a D1110, she would charge $120 for a D4910, $135 per quad for a D4342, and $180 per quad for a D4341.
Codes D4381, D4355, and D1110 often provide problems with insurance benefits for patients ...
D4381–Localized Delivery of Chemotherapeutic Agents ...
This code is designed to describe any crevicular agent used to treat periodontal disease. Many carriers do not cover this procedure as a matter of contract. A few will pay a benefit when it is done in refractory areas following root planing and/or surgery. Typically a time lapse between the active therapy and the crevicular treatment is required, often at least four to six weeks. The claim form should include case type (usually at least Type III–Moderate Periodontitis), progressive periodontal probing, a narrative stating that the patient has previously undergone treatment and the dates of that treatment, and the pockets being treated.
D4355–Full-Mouth Debridement To Enable Comprehensive Evaluation and Diagnosis ...
The ADA description is, "The removal of subgingival and/or supragingival plaque and calculus. This procedure does not preclude the need for additional procedures."
Some considerations include the following:
- Because the code title indicates that the patient has presented with deposits so elaborate that a comprehensive examination and diagnosis are not possible, carriers do not consider this code appropriate on the same date as any evaluation.
- This code may be used prior to and on a different date than a D4341, D4342, D1110, and any evaluation code.
- The description implies that a D4355 might be thought of as a "gross scaling," but this should only be as it applies to facilitating an adequate exam. Gross scaling is not currently believed to be routinely appropriate. Some healing and resolution of tissues is likely over incompletely removed deposits, but adequate resolution is not possible.
- Code D4355 is not a replacement for 04345–perio scaling in the presence of gingival inflammation, which was deleted in 1995.
Regardless of the ADA description for D4355, most carriers regard it as a code intended only for extreme cases and do not typically provide a separate benefit. Most will simply pay what they allow toward a D1110.
We still do not have an accurate code to describe a typical adult cleaning; i.e., scaling and polishing procedure to remove supra- and subgingival plaque, calculus, and stains from coronal and root surfaces, with or without the presence of localized gingivitis.
The current description for this code is, "A dental prophylaxis performed on transitional or permanent dentition that includes scaling and/or polishing procedures to remove coronal plaque, calculus, and stains." The Code Revision Committee recently made a "clarification to the original intent" of D1110 and stated that the word "or" should be removed from the definition. This means that a simple polishing procedure should not be considered a D1110. This clarification is expected to appear in the next printed version of the Code, but should be considered in effect now. Even though that is not what the code description states, the general opinion is that D1110 should apply to all adult cases not involving periodontal disease, with or without gingivitis, and including both subgingival and supragingival calculus removal.
Correct coding can help patients receive their best benefit. Knowledge of common insurance limitations can help your team prepare patients for what their benefits might be. While dental insurance has never paid for all the treatment patients need, those with insurance see the dentist more frequently and have more comprehensive treatment completed.
Carol Tekavec, CDA, RDH
Ms. Tekavec is the author of the "Dental Insurance Coding Handbook Update CDT-4." She is a national lecturer on recordkeeping and insurance coding. You may contact her at (800) 548-2164, or visit her company Web site at www.steppingstonestosuccess.com.