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D4346 Advanced Prophy Difficult?

July 2016

Over the better part of the last 50 years, I have learned quite a bit about the art, science, and business of dentistry. So much has changed with the profession that in many ways it no longer resembles any of its earlier predecessors.

Old time dentistryRemember the smocks with the buttons running down the collar, shoulder, and sleeves? How about the matching bonnet style caps, capes, dresses, and shoes of the “dental nurse”? Yes, those were the days before we knew anything about social media, branding, and that evil concept of dental insurance.

In all my years of teaching, consulting, and testifying, I can honestly say that I have never encountered a dentist or dental practice that had problems with the patients’ insurance. The problem was always later confirmed to be somewhere else but the symptoms manifested themselves within the observable workings and administration of the patients’ insurance.

And if you think that more redefined, potentially new procedure codes are going to make life in the dental office any easier or more profitable – you have got to be dating the tooth fairy. Come on – many offices can’t even use the existing coding sequence accurately!
How is changing a bunch of definitions going to simplify and streamline the overall reimbursement process?
Answer – it won’t.
We have got to understand that insurance companies and third party administrators pay, by contract, toward the overall costs for completed procedures.

A symptom of a greater problem?

Now why is the reincarnation of D4346 merely a symptom of a greater problem? Let’s look at the actual sub components of its ancestors and see if the solution does not automatically appear. The Code on Dental Procedure and Nomenclature references the following:

“Prophylaxis is the removal of plaque, calculus, and stain from the tooth structure in the permanent and transitional dentition. It is intended to control local irritational factors.”

Now how does one remove plaque, calculus, and stain from the tooth structure? The answer is by scaling and polishing.

Scaling is the technique of meticulous removal of accretions and debris from the surface of the tooth, either subgingival or supragingival.

Polishing is the removal of mucinous film, superficial stain, or deposits to provide a smooth surface that will be more resistant to future accumulation of foreign substances.

Now what about initial therapy for periodontal disease? Doesn’t everything start with periodontal scaling and root planing? We already know about scaling but what is up with:

Root planing is the definitive procedure designed for the removal of cementum and dentin that is rough, and/or permeated by calculus or contaminated with toxins or microorganisms.

It seems relatively simple. We have only three distinct identifiable sub components. They are root planing, scaling, and polishing. As a matter of fact, it is simple. All we have to do is bill for exactly what was done. And what was done is exactly what is, and was, documented in the patients’ treatment ledger. Transparency is a good thing.

If the patient has been diagnosed with periodontitis because the root surfaces of the teeth are in need of being planed away (not merely scaled), then we have D4341 or D4342 based upon the number of teeth root planed as it’s expected that the scaling will be global to the affected as well as treated area.

If the patient does not have periodontitis because they have been properly diagnosed with no loss of clinical attachment as well as no radiographic confirmable loss of alveolar bone, then all that clinically can be done for this patient is scaling and polishing.

The real root of the problem

Are you beginning to see the real root of the problem? You see, it’s in the documented diagnosis – or lack there of.

Everyone wants to be paid for his or her time. Me included. But the hygiene team is screaming that they want and need more time to do the new patient cleaning. And where does the time fit in? Do you want to charge the patient more because it took longer than anticipated to do the procedure? If you want to charge more, feel free to do so. As long as the patient is willing to pay you the additional fee, we can all celebrate that capitalism is a wonderful thing.

But wait. The patient has insurance and some think the solution is with additional procedure codes whereby more can be charged. Add to that failed concept the idea that insurance companies should be prohibited from disallowing certain technique sensitive components from being individually charged to patients above and beyond the limitations of their plan. Do you now see the real intent behind all this non-covered service legislation? The problem is slapping the profession right in the face.

Too many patients are being treated based upon the strengths and weaknesses of their benefit plan.

Ever wonder why the patient says they only want the procedures if it’s paid for by their insurance? It’s unfortunately too true. Who brought up the subject of the patients’ insurance — you or them? Is the patient driven by their plan? You know they are because they see the importance of the plan in helping to offset their overall cost of care.

All too often treatment plans are established based upon the results of an hour-long phone call to the plan determining what procedures are currently payable as well as what was already charged out by some other doctor. What do you think the plan is determining about your office when they tell you an FMX was done last year and now your new patient comprehensive evaluation is billed out with only bitewings? Are you treating the plan or comprehensively diagnosing the patient?

Now let’s solve the problem by addressing first things first.

Treat the patient and not the plan.

The patient has to come first. The diagnosis has to come first. The examination findings by the doctor will tell you what radiographs the patient needs. Now that the diagnosis and treatment plan are soundly established, let the patient know what treatment needs are to be done first.

And as for D4346… It’s not first until after the doctors’ evaluation.

Let me help you change the life of your practice by joining me on August 5th in Atlanta.

See you there.

Tom Limoli

Tom Limoli

“The Nation’s Leading Reimbursement Expert”

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