Thursday Troubleshooter: How to correctly charge for difficult patient requests?

This patient has the dental team baffled. She's stretching scaling and root planing into two visits, and has asked for local anesthesia for all hygiene visits. How can the office charge for this?

Jan 11th, 2018
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Nearly everyone has problems and concerns on the job, and sometimes you're just too close to a situation to solve something yourself. Share your concerns with Team Troubleshooter, and the experts will examine the issues and provide guidance. Send questions to megk@pennwell.com.

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QUESTION: I had a patient in for scaling and root planing for half the mouth, and she will return soon to complete the other half. She did great with local anesthesia for the right side and we will do the same during her next visit for the left side. I used Oraqix to complete perio charting and it did not help with the tenderness at all. She has requested to have local anesthesia for all hygiene visits because she has always been very nervous and she puts off dental appointments because she has such tender gums. She would like to do it the same as we’re doing now with two appointments, doing half the mouth each time. How would you charge out for the perio maintenance appointment that will need two visits to complete?

ANSWER FROM PATTI DIGANGI, coauthor of the “DentalCodeology" series of books:
Though your question sounds as if it is about fees, it appears to be about codes. A practice can choose to charge whatever fees they want. Practice fees should be based on the cost of doing business plus a reasonable profit with annual cost-of-living for inflation increases.

The code that should be used to properly document the administration of anesthetic, D9215 local anesthesia in conjunction with operative or surgical procedures,is an available code if you wish to report it separately. Benefit plan limitations may exclude separate reimbursement benefits for local anesthesia.

Predicting coverage is usually problematic, but not in this case. Coverage or non-coverage of care is generally determined by the clauses of the specific policy.

The D4910 code is in the D4000-D4999 V. Periodontics section of CDT. Under the title of that section is a statement for all the codes in that section that states, “Local anesthesia is usually considered to be part of periodontal procedures.” This means there will be no coverage for local anesthesia.

As far as charging out for two visit periodontal maintenance care, D4910 is a code for completed care. I will adapt the response in the CDT 2017 Companion book. “What code do I use for a difficult prophylaxis? There is no separate procedure code that reflects the degree of difficulty of a dental prophylaxis. The available prophylaxis codes are D1110 prophylaxis–adult, and D1120 prophylaxis–child.”

This case could be considered a difficult D4910. It is the patient’s choice for care to be completed in two visits. Just as with the difficult prophylaxis, there is only one code. Generally, there would be coverage once, not twice.

Can the office charge D4910 twice to the patient? Yes, unless the practice has an agreement with benefit carriers that prohibits it. Should the practice charge twice? What bears consideration is the cost of doing business. It costs the practice more for two visits. This brings us back to the first paragraph—Practice fees should be based on the cost of doing business plus a reasonable profit. That is a practice management issue that depends on the choices of the owner.

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