Demystifying hard-to-code scenarios

Dental hygienists are bound by the law to use an accurate CDT code for each procedure. Sometimes choosing a code is easy—and sometime it's not. Here's what to consider when it's not.

Content Dam Diq Online Articles 2019 03 Demystifying Codes Whiteley Diqthumb

As dental hygienists, we need a basic understanding of the CDT codes that fall under the scope of our practice. The CDT codes are procedural codes set by the American Dental Association, not by insurance companies. Understanding the nomenclature helps us to more clearly and consistently document and report the treatment we performed. The code is part of our record of treatment. Accuracy, along with proper documentation, is part of our job. Also, we are bound by the law and HIPAA requirements to code for what we actually did. Hopefully, the review of common hygiene CDT codes discussed in my previous article provided a reference for those providers who might not have been proficient in the area of coding.

There are many times we can clearly choose the appropriate code to fit the situation. What about those times when it isn’t so easy or straightforward? The focus of this article is to discuss some of those harder-to-code cases along with considerations for handling them.

The difficult prophy

This is the case when patients seem to fit only into the prophy (D1110) code. They do not have the attachment loss and active disease state of a scaling and root planing case, and they do not have the generalized moderate to severe inflammation to warrant the gingivitis code. Further, the deposits present do not inhibit a proper comprehensive evaluation, making debridement an inappropriate code for this case.

I had a patient just like this. He came in twice a year with heavy stain. He wasn’t willing to change his habits or follow the home-care recommendations and recare interval suggested. This wasn’t a straightforward prophy as it took a lot of extra time beyond what was typically scheduled.

A suggestion in this case may be to see the patient over two separate visits, and bill a prophy (D1110) on each occasion. If the patient uses insurance benefits, the additional visit may not be covered, based on limits of the plan. The upfront dialogue between you and the patient is important. “We are unable to remove the deposits on your teeth during the time allocated for a typical cleaning. We’ve recommended some alternatives to try to help you with this, and at this point, we are not able to complete your care over one visit.”

I have also had this conversation with patients who have not been in for regular care in quite some time. I may say something like, “During the three years that you did not receive care, you missed a minimum of six hygiene appointments. We can’t catch up in one visit.” Photos can add to the value of this conversation. Further, it may be necessary to review with the patient that dental insurance is a benefit to help with dental expenses, and is neither all-encompassing nor focused on their individual needs. It is important to also have the dialogue with your business staff so they can work with the patient to determine what (if any) out-of-pocket costs will be incurred.

The maintained perio patient

This is the patient who has a history of scaling and root planing, or flap or osseous surgery, but is now maintained. The periodontal maintenance (D4910) code is one for which the patient may remain for the life of the dentition. We all know that once someone has clinical attachment loss/bone loss, it is not reversible.

In rare instances, the dentist may determine that the patient can be maintained with routine prophylaxis and can go back to the prophy (D1110) code. We know the disease is episodic/cyclical in nature. The issue with changing the patient back to a prophy is that, if the patient later presents with the need for site-specific scaling and root planing (as the periodontal maintenance code allows), you will need to start the process of scaling and root planing over again.

In these cases, if the patient has stayed maintained for a prolonged period, continue to code them as a periodontal maintenance patient, but extend the recare interval. If there are signs of negative changes, adjust the recare so it is more frequent.

The “unmaintained” perio maintenance patient

When your periodontal maintenance patient presents with new or progressing disease, or the disease is failing to stay controlled, additional diagnostics and possibly a re-treat of scaling and root planing and/or additional periodontal procedures may need to be performed. The patient may also benefit from a referral in this case.

Alternating perio maintenance and prophy

I’ve seen this in some cases when the patient alternates recare between the general office and the perio office. I’ve also seen offices resort to alternating the codes when the patient’s insurance plan does not reimburse for periodontal maintenance or does not cover the number of recare visits per year that the patient needs. However, you are bound to code for what you actually did, and it can be very hard—if not impossible—to justify how the patient flip-flops between two different diagnoses every three or four months. When I am performing periodontal maintenance in these cases, I use the D4910 code, as it accurately reflects what I did. I submit it along with a narrative stating that if periodontal maintenance is denied, we request that the alternative benefit of the D1110 (prophy) be paid.

New-patient considerations

Consider the new patient who presents with a history of periodontal disease as evidenced by attachment loss, but the disease is currently not active. If the patient has had a history of scaling and root planing, or osseous or flap surgery, periodontal maintenance (D4910) is appropriate. I would recommend submitting with a narrative that details when the scaling and root planing or surgery was performed, the name of the practice that performed the services, and submit with your current perio chart and x-rays. Depending upon the contractual limits of the individual plan, it may not be paid or it may be remapped to a prophy.

Another alternative, particularly if there is no documented history that you or your business team can find regarding a history of periodontal treatment, is to submit it as a prophy (D1110) with the narrative that you performed a prophy on a reduced periodontium.

This article covers some ideas on how to code in those areas that can be harder to figure out. It is based on my own experience. There are wonderful articles, books, and courses to help you and your team navigate this area. It is important to note that, although coding is not insurance based, insurance companies use the codes to determine reimbursement. The limits are based on contractual limits of the patient’s plan and should not dictate how we code. We code based on what we did related to our patient’s needs.

The bottom line is that sometimes patients have to pay for treatment. Consider the analogy of going in for an oil change on your car only to find you have more extensive repairs beyond the simple maintenance you were planning for. You need to take care of your car to keep it in working order. We do, however, have to have good practices in place for consistent communication of information among staff members and ensure that patients are informed of potential costs before services are rendered. Taking the time to educate the patient and creating value for them based on their individual risk factors, diagnoses, and goals are the first steps in getting out of the insurance trap that we can sometimes fall into.


Julie Whiteley, BS, RDH, is certified in human resources. She holds degrees in business administration and dental hygiene and has worked extensively in both fields. She is on the faculty of Massachusetts College of Pharmacy and Health Sciences University in Boston. Julie bridges her knowledge and experience from business, clinical hygiene, and teaching to deliver information and programs that enhance dental practices. Contact her at juliec.whiteley@gmail.com.

More in Student Hygiene