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Thursday Troubleshooter: How can this practice avoid fraud when using dental code D1110?

Jan. 3, 2019
The staff members of this dental practice are still confused about dental code D1110. They aren't alone.
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QUESTION: What is a D1110 cleaning? If a patient has moderate to heavy calculus and heavy bleeding, and some 4 mm to 5 mm of pocketing, can our office still bill it as D1110 and not be fraudulent or unethical?

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

This is a great question! Though the answer seems obvious, this is the crux of a lot of confusion, miscoding, and probably a significant level of fraud in many dental offices. I bet you didn’t expect that to start my response! Let me explain.

The problem begins with using the word “cleaning” in regard to D1110. Toilets, sinks, and floors get cleaned; teeth do not.

D1110 prophylaxis-adult is, has been, and continues to be a confusing code. We’re approaching the second birthday for D4346, scaling in the presence of generalized moderate to severe inflammation-full mouth after oral evaluation.For many of us, that has led to even more confusion.

The answer to using the correct code comes down to one word—diagnosis. What are we treating?

Note in the D4346 code, the words after oral evaluation are part of the name of the code. What this means is the exam/evaluation must come before care. It’s traditional in many practices for the dentist to check the patient after care is completed.

That makes no sense. How can care be performed and the diagnosis made afterward? This is like someone with a diabetic gangrenous foot having it removed, and then after the surgery is complete and the foot is gone, the doctor makes a diagnosis. We can all see that is nonsense, yet it has long been considered normal in dentistry.

To get coding correct, all data should be gathered and the diagnosis should be made before any treatment. Once the information is gathered, here is the magic equation:

In the absence of periodontitis:
• Inflammation is less than 30% of teeth = D1110
• Inflammation is greater than 30% of teeth = D4346

Back to your question, you have a patient with moderate to heavy calculus and heavy bleeding, and some 4 mm to 5 mm pocketing. It sounds like this not only does not qualify for D1110, it also does not qualify for D4346. This patient is clearly in need of more definitive care.

It is the duty of the practice staff to use the code that most accurately describes the treatment provided. To use a code for the purpose of increasing payment can be considered fraud. Though it might not be the specific purpose, do you have a desire to use D1110 because it is a covered procedure, whereas other procedures may not be covered? Fraud by accident, ignorance, or “we have been doing it this way for a long time and have never gotten caught” it still fraud.

There needs to be greater clarity in the CDT codes about all of these terms. In March 2019, the Code Maintenance Committee will have the opportunity to make any needed changes. Be watching for them!

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