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
© 2011
Copyright. All rights reserved.