March’s Tip of the Month provided guidance on reimbursement for surgical extractions. Proper coding for non-surgical periodontics is another area that often leads to uncertainty. We’ll briefly review these codes and define the evidence Delta Dental of Virginia looks for in making claims determinations.
Periodontal Scaling and Root Planing – 4 or more teeth per quadrant (D4341) is a therapeutic procedure for patients with diagnosed periodontal disease, designed to remove cementum or dentin that is diseased or roughened by calculus, either as definitive treatment and/or pre-surgical care.
Claims submissions need to demonstrate documentation of bone and clinical attachment loss; pockets should be greater than 4mm. Where fewer than four teeth in a quadrant meet the criteria, the procedure may be alternative benefited to D4342, Periodontal Scaling and Root Planing – 1-3 teeth per quadrant. Scaling and root planing should not be billed at the same time as other non-surgical services and would be considered integral to periodontal surgery billed on the same date of service.
In the absence of any evidence of bone loss or attachment loss, the submission may receive an alternative benefit of D4346, Scaling in the presence of generalized or severe gingival inflammation – full mouth after oral evaluation. This procedure is designed to manage moderate to severe gingival inflammation in the absence of diagnosed periodontitis and should not be reported in conjunction with prophylaxis, scaling and root planning, or debridement procedures.
Full mouth debridement (D4355), in contrast, references the initial removal of plaque and calculus that interferes with the dentist’s ability to perform an exam. Because the implication of the procedure is that without it, an examination cannot be completed, the procedure cannot be performed on the same date of service as a D0150, D0160 or D0180.
Finally, Periodontal Maintenance (D4910) is done after the completion of definitive periodontal therapy and includes evaluation, removal of supra- and sub-gingival plaque and calculus, site-specific root planing and polishing. Periodontal maintenance cannot be billed on the same date of service as a prophylaxis or D4346, and counts toward the frequency limits for those procedures.
For all periodontal procedures, providing complete information will help to ensure reimbursement, including X-rays that are of diagnostic quality, periodontal probing depths, and evidence of loss of attachment, which helps avoid the possibility that the procedure will be benefited at a lesser level.
To avoid denials or an alternative benefit for a non-surgical periodontal procedure, it is important to be aware of the criteria before submitting a claim. If you do get a denial and wish to appeal the decision, be sure to provide additional detail in the form of radiographs, additional charting, photos and/or a narrative.
Michael D Weitzner, DMD, MS
Dental Director, Delta Dental of Virginia
