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Thursday Troubleshooter: Dental hygienist surprised by insurance rejection

Feb. 16, 2017
This dental hygienist has been scaling and root planing for over 10 years and recently encountered an insurance roadblock that blindsided her. What should she do?

Do you have a tough issue in your dental office that you would like addressed? Each week the experts on Team Troubleshooter will tackle those issues and provide you with answers. Send questions to [email protected].

QUESTION: I want to schedule a patient that I did three quads of SRP for a three-month perio maintenance program. I was informed that his insurance company would not cover perio maintenance unless all four quads are scaled. I’ve been a dental hygienist for 10 years and I’ve never heard of this. What are your thoughts?

ANSWER FROM PATTI DIGANGI, coauthor of DentalCodeology:
One common scenario that leads to denial of insurance coverage is skipping steps that are part of a standardized and accepted protocol. What was the diagnosis established before the three quadrants of non-surgical periodontal therapy was performed? How are you defining periodontitis?

The traditional parameters sought by carriers have been along the lines of:
Clinical attachment loss (CAL)
Radiographic evidence of crestal bone loss or changes in lamina dura
Radiographic evidence of root surface calculus

Let’s start with CAL. This is pocket depth plus the recession or bone loss. What is normal bone height? Measured from the alveolar crest to the CEJ, normal is 1.5 mm to 2 mm. This can only be determined with radiographic images. It is not pocket depth only. This is just the beginning of data needed to make the diagnosis.

The diagnosis is not Type I to Type IV, those are treatment types. A perio diagnosis might read, “Plaque-induced gingival disease modified by systemic factors, pregnancy and #14 and #15 aggressive periodontitis with 2 mm bone loss.” For this diagnosis, the treatment would be D4342 periodontal scaling and root planing, one to three teeth per quadrant, and D1110 prophylaxis. (Note: it may be different with new D4346 code.)

The bottom line is that what has been established is a periodontal diagnosis. When the patient returns in three months, the patient qualifies for D4910 from a coding perspective, based on the definition that states, “This procedure is instituted following periodontal therapy and continues at varying intervals, determined by the clinical evaluation of the dentist, for the life of the dentition or any implant replacements.”

There is no language that requires or defines how many areas were involved. Periodontal therapy was performed to treat the established diagnosis. Again, what was the diagnosis? Does the office documentation support that diagnosis?

From there, the question goes back to the carrier. Is there contract language requiring four quadrants of therapy to qualify for D4910 maintenance? Even if there is contractual language for this, the practice should not down-code. Why? Because dental practices are required to use the most accurate code to describe the care rendered. To use a different code for the purpose of payment can be considered dental fraud. An accurate code exists and therefore should be used. Avoiding fraud and proper coding is a team process. Without knowledge of the codes and how they are being applied, there is a likelihood of insurance fraud.

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Send your questions for the experts to answer. Responses will come from various consultants, many of whom are associated with Speaking Consulting Network, Academy of Dental Management Consultants, Dental Consultant Connection, and other expert dental support and human resources organizations. Their members take turns fielding your questions on DentistryIQ, because they are very familiar with addressing the tough issues. Hey, it's their job.

Send your questions to [email protected]. All inquiries will be answered anonymously every Thursday here on DIQ.

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