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Insurance Coding for Non Surgical Periodontal Procedures


Through the years we have received many questions from general practices on submitting insurance claims for periodontal services. We have kept track of these questions and have often consulted outside sources to obtain the most up to date answers. We will review the most important ones. We sincerely hope that you will find this information helpful to your practice.

What are the basic requirements for a perio clam not to be rejected? There are two things that stand out as most important to include on any claim for services treating periodontitis. First, the claim should include the periodontal diagnosis and case type.

The ADA's diagnostic codes are : Gingivitis............................Case Type I........ADA 4500
Slight Periodontitis.............Case Type II........ADA 4600
Moderate Periodontitis.......Case Type III .... ADA 4700
Advanced Periodontitis.......Case Type IV......ADA 4800
Refractory or Rapidly Progressive Periodontitis
.....................................................Case Type V.... ADA 4900

If you include the case type on all of your claims, the dental consultant easily knows if the procedures submitted are justified based on the diagnostic category. ( ie., It would not be appropriate to list code 4260- Osseous Surgery for a Gingivitis case).

Secondly, include a copy of the full mouth periodontal charting. Many claims for root planing will be returned if a charting is not enclosed. If a charting is sent with each claim, the processing will not be delayed for this request. Additionally, you may experience fewer requests for radiographic documentation.

I usually spend an hour providing a comprehensive examination with a proportionately large amount of time due to the perio evaluation. How do we code for this evaluation ?
It is important to understand that there is no longer a separate procedure code for an initial periodontal examination. All of the ADA evaluation codes are intended to be used by general dentists and specialists alike. So, the initial evaluation should be coded as 00150, comprehensive oral evaluation. Periodontal charting is a component of the comprehensive oral evaluation, since charting should be completed for all new patients, whether the evaluation is performed by a general dentist or a periodontist.

What do we use in place of the old code 04345, scaling in the presence of inflammation?
It depends on the patient. If you are treating a patient who has such a heavy accumulation of calculus that you cannot pertorm an adequate oral evaluation, you should use code 04355, full mouth debridement to enable comprehensive periodontal evaluation and diagnosis. Keep in mind, however, that 04355 is not a comprehensive therapy--it is simply a means of coding for a gross scaling to enable a comprehensive evaluation and diagnosis. The evaluation should not be performed on the same date of service, since the swollen tissues resulting from the gross debridement may not allow for accurate periodontal probing depth measurements.

The situation changes for patients who have generalized gingivitis with minimal probing depths and who are in need of scaling. For these patients, it is appropriate to use code 01110, adult prophylaxis. The descriptor for this code has changed in CDT-2 so that it no longer refers only to dental patients in normal or good periodontal health. It is also appropriate to submit twice for 01110 if additional time is needed for completion of the prophylaxis, as long as you document the reason for the additional appointment with 01110.

Can you help me differentiate when to use code 01110 and 04910? The area of non-surgical periodontal procedures can be confusing. The definitions for the following codes are presented here to help differentiate between procedures.

01110 Adult Prophylaxis Scaling and polishing procedure performed on dental patients to remove coronal plaque, calculus, and stains to prevent caries and periodontal disease. Since pockets are absent in a completely normal periodontium, scaling and polishing are performed on the anatomic or clinical crown and into very shallow, sulci.

TIP: Code O1110 can be used for reporting a scaling procedure in a healthy or inflammed mouth. When more than a single appointment or an extended appointment is necessary to remove the hard and soft deposits from the teeth, a brief narrative should be used to explain the extra appointment and fee.

04910 Periodontal Maintenance Procedures Following Active Therapy This procedure follows active therapy to maintain periodontal health. Under the supervision of a dentist, 04910 includes:
Update of the medical and dental histories Review of radiographs Extraoral / intraoral soft tissue examination Review of the patient's plaque control Dental and periodontal examination Removal of bacterial flora from crevicular and pocket areas Scaling and root planing where indicated Polishing of the teeth

TIP: Code 04910 is used to report maintenance care following active periodontal therapy (quadrants of definitive scaling/root planing or periodontal surgical procedures). Since prior active therapy is necessary for patients to be reimbursed for maintenance procedures, third parties usually request documentation of active therapy.

TIP:Appropriate intervals for periodontal maintenance therapy are determined by the patient's attending dentist. Three months between appointments is an effective treatment schedule. Many plans pay for only two 04910 services a year. Sometimes a carrier will reimburse three or more treatment sessions a year if the need is documented by an narrative.

TIP:Code 04910 includes a periodontal examination. If you are submitting 04910, do not submit a separate code for a perio exam at the same appointment.

TIP: Do not alternate claims between 01110 and 04910 simply to get more benefits for the patient. If you provide four 0491O's in a year, submit four.

Why are deductibles applied to 04910 but not to 01110?
Insurance plans are structured to provide higher benefits for preventive services, thus encouraging preventive dental care. Code 01110 is categorized as a "preventive service." So, many insurance companies cover it at 100 percent and do not apply it towards the patient deductible. Code 04910 is categorized as a "periodontal procedure," not a "preventive service." Therefore, many insurance companies require a patient copayment and apply it towards the deductible.

What is the procedure code for for local drug delivery products like Arestin or Atridox?
Use the CDT-2 code 04381, localized delivery of chemotherapeutic agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report. It is helpful to indicate in vour report what types of therapy have alreadv been attempted prior to using tetracycline fiber therapy

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