D4346 vs. 04345
Learn from the past or recreate the result
On May 17th of this year, the American Dental Association (ADA) released a 10-page publication entitled “A Guide to Reporting D4346 – A resource guide from the ADA developed to educate dentists and others in the dental community on the newly approved scaling code for CDT-2017 that will be effective Jan 1, 2017.”
Although well intended, the document lacks specificity if in fact, its intent was to guide the reader in the anticipated appropriate use of this newly re-resurrected procedure code. It’s failure is as simple as the definition of insanity whereby again doing the same action in anticipation of a different result. Speaking of definition, let’s start off with a comparison of the brand new not yet reportable procedure code known as D4346, and compare it to what originally was known as 04345 that went away in 1995.
04345 periodontal scaling performed in presence of gingival inflammation
Gingivitis can be characterized clinically by marked changes in color, gingival form, position, surface appearance, presence of bleeding, and/or exudate. With no loss of attachment or bone loss in gingivitis, this scaling treatment procedure is more precise in describing therapy for generalized gingivitis and is not meant to be performed on a routine basis. Upon completion of treatment, the gingival tissues should be normal and can be maintained by adult prophylaxis on a regular basis. This is a scaling only procedure; it may require single or multiple visits. Should not be reported in conjunction with an adult prophylaxis; for reporting periodontal scaling performed in conjunction with root planing, see D4341.
D4346 comes to life on January 1, 2017.
D4346 scaling in presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation
The removal of plaque, calculus and stains from supra- and sub-gingival tooth surfaces when there is generalized moderate or severe gingival inflammation in the absence of periodontitis. It is indicated for patients who have swollen, inflamed gingiva, generalized suprabony pockets, and moderate to severe bleeding on probing. Should not be reported in conjunction with prophylaxis, scaling and root planing, or debridement procedures.
Both codes were clearly intended for the treatment of full-blown, generalized Case Type I Gingival Disease – not for the mere identifiable inflammation associated with periodontitis. To prevent the failure of this highly anticipated procedure code, we must clearly define and clarify the diagnostic difference between gingivitis and periodontitis. According to the same (Stedman’s Dictionary for Dental Professionals; 1st Edition, 2007) reference utilized in the ADA publication the terms are defined as:
Gingivitis – Inflammation of the gingiva as a response to bacterial plaque on adjacent teeth; characterized by erythema, edema, and fibrous enlargement of the gingiva without resorption of the underlying alveolar bone.
Gingivitis is classified in ICD-10
K05.00 acute, plaque induced
K05.01 acute, non-plaque induced
K05.10 chronic, plaque induced
K05.11 chronic, non-plaque induced
Periodontitis – Inflammatory disease of the periodontium occurring in response to bacterial plaque on adjacent teeth; characterized by gingivitis, destruction of alveolar bone and periodontal ligament, apical migration of the epithelial attachment resulting in formation of periodontal pockets, and ultimate loosening and exfoliation of teeth.
Periodontitis is classified in ICD-10
K05.20 aggressive, unspecified
K05.21 aggressive, localized
K05.22 aggressive, generalized
K05.30 chronic, unspecified
K05.31 chronic, localized
K05.32 chronic, generalized
Now for the fun part – What will the benefit plans do as concerns reimbursement for this newly reincarnated procedure code known as D4346?
- Unfortunately, most benefit plan administrators and insurance companies are preparing to pay D4346 as if it were merely a prophy. They will probably use the same reimbursement tables, contract limitations and exclusions as D1110.
- More than one dental director has informed me that their intention is to decline any and all benefits for D4346 in the absence of clinical documentation and diagnostic specifics. Then, and only then, will they consider reimbursement.
- Pay it with a relative value somewhere between 1.5 to 2x the prophy while simultaneously eliminating D4341, D4342, and D4910 benefits for 12 to 24 months. This payment criterion will also eliminate patient benefits for D4355, as well as any potential, immediate surgical interventions. This payment parameter more clearly addresses the appropriate treatment of generalized gingivitis, as opposed to gingival inflammation as a result of periodontitis.
- And lastly – some plans will consider it a contractual exclusion and simply not acknowledge the validity of the procedure as a stand-alone treatment entity. After all, the tables and clinical examples within the ADA document are self-contradicting and generally misleading.
So, at this time, here is my potential conclusion to the political blundering of procedural calamity also known as D4346.
If the patient presents with documentable loss of alveolar bone and or periodontal attachment, you are looking at the treatment of periodontitis. Treatment begins with D4342 or D4341 – period, end of story. You don’t start with D1110, D4355 or D4346. May soft tissue mismanagement now rest in peace along with gross scaling.
If the patient presents with no or only localized gingival inflammation the treatment is merely D1110 prophylaxis. If need be, consider shortening the time between scheduled recare visits. This is to be between you and your patient as benefit plan limitations may apply.
If the patient presents with full-blown generalized (all four quadrants as well as all six sextants) gingival inflammation with a diagnosis of gingivitis consistent with no documentable loss of periodontal attachment or alveolar bone, consider this to be the appropriate use of procedure code D4346.
For the original clarification of this topic (CLICK HERE) see the “Summer 1990” issue of this publication from 26 years ago, and learn first hand why we at Limoli and Associates are your original source for all facets of “Dental Insurance and Reimbursement” ©.
It is my honor to be of service.
See you on the road.
Tom M. Limoli
“The Nation’s Leading Reimbursement Expert”
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How on earth does 4355 Debridement fit in to all of this maze? And what about the re-evaluation visit after S&RP, can we bill it after a 4345/4346? Or am I completely out of touch with reality here? BTW: building a new website now.
The challenge with the poor definition of D4346 is the word “generalized.” For the condition to be generalized it must be in all 4 quadrants as well as all 6 sextants. Most everyone has some “localized” inflammation and if scaling and polishing is all that is done – that is D1110 prophylaxis. It the condition is “generalized” in all 4/6, diagnosed first by the doctor, documented in the clinical record with radiography/photography, as well as treated to the extent requiring follow-up seven to ten days later – that is D4346. More to come ………..