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Troubleshooter: What can this hygienist do about suspect coding?

Sept. 22, 2021
This dental hygienist believes her current office is basing diagnoses on insurance reimbursements instead of what patients actually need. What can dental pros in this position do?

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QUESTION: Every office I've worked in the last 10 years has agreed that if the patient is diagnosed for scaling and root planing, insurance will not pay if the patient has had a regular cleaning during the last six months. My new office does SRPs all day long. A new patient will come in and get an exam and x-rays. The doctor diagnoses a deep cleaning, then sits down and completes a regular cleaning. I was told the office bills for a full mouth debridement first. This doesn't seem right to me.

ANSWER FROM KATHY FORBES, director for the DentalCodeology Consortium:
You have described a very complex dilemma that many hygienists face. Every procedure an RDH performs must be based on a diagnosis, not a procedure or a procedure code. Once that diagnosis is determined (usually based on the American Academy of Periodontology Classifications of Periodontal and Peri-implant Diseases and Conditions), then an appropriate CDT procedure is selected. Too often in dentistry we select a CDT procedure code and claim that to be the diagnosis. Then we worry about whether insurance will cover the procedure.

As clinicians, we have the responsibility to select the CDT procedure code necessary to treat our patients. Are all the new patients in your office diagnosed with an AAP classification outlining the periodontal gingival health, gingival inflammation, staging and grading of periodontitis that would necessitate nonsurgical periodontal therapy (D4342, D4341)? If so, there is no rationale or evidence that “a regular cleaning” (D1110) is beneficial to the patient who required SRP. In fact, according to research dating back to the late 1980s, it could be harmful.  

When it comes to a full mouth debridement (D4355), clinicians need to be very cautious of overtreatment or overuse. Again, there is no rationale or evidence that debridement is therapeutically beneficial to the patient. When D4355 was first introduced to the ADA Code Maintenance Committee, the intent was to use it when we couldn’t find the teeth to determine what CDT procedure would be selected.

Patients are individuals and their treatment plans must be based on a clear AAP diagnosis with evidence-based decision-making used to select the appropriate procedure. How much an insurance carrier reimburses should be secondary to the appropriate care a patient deserves. I suggest a conversation with your employer about what rationale they’re using to determine the diagnosis of their patients and the treatment plans they recommend. The AAP has many position papers and other materials that outline the current treatment recommendations for patients with periodontal diseases and conditions.

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