Coach's Corner for Dental Coding: Alternating D1110 and D4910

March 12, 2013
Alternating the two codes could mean fraudulent billing.

Q: I’m in a new office and they alternate D1110 and D4910 after periodontal treatment. I know this is wrong, so how do I make the case to my doctor to change this bad habit? - Anonymous

A: This comes up in my presentations so often that I’ve built a discussion point around it. Unfortunately there is so much bad information out there regarding how to bill these two procedures. D1110 is a prophylaxis (in the absence of gum disease) and D4910 is a periodontal maintenance procedure (in the presence of a disease state – active or maintained). Managers have told me that they have been told to alternate the codes by:

· Referral offices that believe they should bill D4910 and the general dentistry office should bill D1110 when sharing care of a periodontal patient.
· Insurance company representatives.
· Doctors/coworkers who have never taken a coding course.

You are correct in that it is wrong to alternate between the codes. D1110 is meant for healthy tissue. D4910 is meant to be used after periodontal treatment such as scaling/root planing or osseous surgery. It is meant to describe a more in-depth procedure than a prophylaxis in the presence of a disease state. Hopefully this disease state is not progressing because you are monitoring it, but it certainly is different than normal healthy tissue found in persons with no gum disease.

Simply put, to alternate the codes means you are stating that the patient is healthy, diseased, healthy, diseased, etc. I also want to be clear that this is fraudulent billing. If you are alternating codes because you believe that better reimbursement will follow, then you are committing fraud. Your codes should always reflect the service you provided, not the reimbursement you expect.

When presenting periodontal treatment to a patient, be sure to disclose that D4910 is what he or she will undergo in lieu of the traditional prophylaxis. Explain why (their mouth is not as healthy as it used to be), and be clear about the financial impact. Insurance plans sometimes cover D4910 up to four times a year at the basic level after deductible. Some plans will cover D4910 at the preventive level with no deductible up to three or four times a year. Be sure to check the patient’s benefits before you quote them a copayment amount. Remember to stress that this is a long-term change to their dental care.

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Teresa Duncan, MS, FADIA, FAADOM, is an international speaker who addresses topics such as insurance coding, office manager training, and revenue growth. Her company, Odyssey Management, Inc., provides virtual, customized training in these areas. She can be reached at [email protected].

Editor's Note: The dental procedures codes ("Code") are owned and published by the American Dental Association ("ADA") in its reference manual Current Dental Terminology ("CDT"). The ADA is the exclusive owner and copyright holder of the CDT, including the Code, as well as of the ADA claim form.