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Thursday Troubleshooter: Confusion over new D4346 dental code

June 1, 2017
There is no doubt that the new D4346 has created confusion, and even fear. The good news is dental offices now have a code that identifies that care they have been routinely performing.

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If a patient visits the practice, has an exam, x-rays, and more, and the person is diagnosed with needing the new D4346 and requires an additional appointment for therapy, how exactly is this charged out? What is the initial visit if we cannot complete treatment? Do we charge out two D4346, one for each visit? What should the fee be for D4346? My fear is this: if we have patients that require more than one visit and we do not charge for the initial appointment, I worry those patients may “slip through the cracks” and not return. The office loses because nothing was completed, but there was also nothing collected for the service that was provided.

ANSWER FROM PATTI DIGANGI, RDH, BS, coauthor of the DentalCodeology," series of books:

There is no doubt that the new D4346 has created confusion, and even fear. The good news is we have a code that identifies the care we have been routinely performing. We can finally treat gingivitis after decades of merely dumping gingival inflammation into the same category as health. This new code can potentially close the loop and elevate our standard of care.

With increasing research pointing to the connection between oral disease and medical conditions, the timing is perfect. Early recognition ensures early intervention and disease prevention. There is nothing to fear. The challenge is we need to examine and rethink our traditional diagnostic and treatment processes. This code can boost the bottom line of the practice when we take the time to examine our systems. This code isn’t just a number; it’s a game changer. You are already on the right track looking for answers.

Let’s look into the pieces of your question:

Diagnosed with needing D4346—This is the key. What is being diagnosed? D4346 is a code, it is not something that’s diagnosed. Gingivitis associated with dental plaque only or gingival disease modified by systemic factors are diagnosis classifications that can be treated with D4346 care as long as specific criteria are met. In my book A Gingivitis Code Finally! I discuss the specific data that is needed to support this code. For example, one part of the D4346 descriptor says we need to determine the absence of periodontitis. This mean a full perio chart is needed, not a recording of just pockets and bleeding on probing (BOP). We need to know if there is clinical attachment loss (CAL). This can only be determined with a full perio chart and current radiographs.

This code is also not aged-based, which means it includes children. This is a huge change for many of us. Most of us are not accustomed to perio charting children. Also, we must have documented that there is greater than 30% inflammation Type 2‐3 on Loe and Silness Inflammation index. (See the ADA Guide on Reporting D4346.) What other factors medically or orally put a person at risk? The challenge is dentistry has fallen into thinking there are only two types of diagnosis—gingivitis and periodontitis. Treatment provided under D4346 isn’t limited to plaque-induced gingivitis. There are many types of gingival diseases.

What gets charged out?—The D4346 code requires an evaluation to be completed prior to care. The care charged would minimally be an evaluation and radiographs. Why wouldn’t there be time to perform this care? Again, we have been providing it all along. Most often the D4346 treatment can also be performed as well as other therapeutic and preventive care. The condition being treated is not different as much as we are finally recognizing and treating inflammation because it is not health. D4346 is not a code for partial care; it is for the full mouth. If care can’t be completed, my guess is the diagnosis might not have been correct.

Requires an additional appointment for therapy—If we saw someone who presented with an active inflammatory infection that we treated, I would expect that we should see them in 10 to 14 days to evaluate if healing has occurred. How do we evaluate it? Again, full perio chart with inflammation documented.

There are three ways this second visit might go:
· Complete healing, no further care is needed. An evaluation can and should be charged under D0171 re-evaluation, post-operative office visit.
· Some healing has occurred and there is less than 30% inflammation but not 100% healthy. We can perform a D1110 or D1120 prophylaxis.
· If greater than 30% inflammation again, that would be a second D4346 treatment. There is no limitation to using D4346 from a coding perspective.

Slip through the cracks—Dental practices can’t afford to leave money on the table. Yet we often get all mixed up in our thinking with codes, coverage, and fees. A practice can choose to charge the fees they want. Practice fees should be based on the cost of doing business plus a reasonable profit based on what the local market will bear. Routine analysis of cost helps to assure that your practice is functioning efficiently and effectively. How many “no charge” appointments can a practice afford? Not many. Whether a chair is empty or full, there are the costs of overhead, equipment, staffing, and more. Just because there is a body in a chair doesn’t necessarily cover the costs if nothing is charged. Our time, expertise, and so much more has value.

The first point to consider is there also doesn’t have to be a different fee because there is a new code. A code is not the same as a fee. With that being said, one way a practice might set fees for D4346 is to set the fee halfway between the prophy and one quad fee. The care is to treat gingival disease with a diagnosis that is between health and periodontitis. But that is a guess, not a good business practice.

My fear is—The fear here is fear of change, fear of not doing everything right, fear of losing money for the practice, fear of patient reactions to change, and much more. Fear gets a bad rap, but it isn’t necessarily bad. The fear here can become a springboard to success. By the very questioning and rethinking our traditional systems, you have already embraced what I see with this new code: lots of opportunity.

D4346 has the potential to:
• Give more reasons for patients to return besides just saying they are due
• Elevate standard of care
• Bridge the gap between oral and systemic health
• Ensure earlier intervention and disease prevention
• Boost the bottom line of a practice

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About the Author

Team Troubleshooter

This weekly column on DentistryIQ features questions from everyday people who work in dental practices, who have issues they would like addressed by the experts. Those who regularly take the time to answer questions include Rebecca Boartfield, Patti DiGangi, Dr. Chris Salierno, Laura Hatch, Karen Daw, Jill Townsend, Lisa Marie Spradley, Shelley Renee, Judy Kay Mausolf, Robin Morrison, Paul Edwards ... and the list is growing.

Send your question or issue for an expert to address to [email protected].. You'll be glad you did.