Getting the Doctor Back into Hygiene — It Should Not Be This Hard

Here we go again. Coming soon to a dental office near you are newly revised procedure codes and definitions for 2018. Will they make more problems or solutions? Better yet — did we solve a catastrophe before it got way too far out of hand?

The management, reimbursement and subsequent coding of non-surgical periodontal care has, for years, been a nightmare for all segments of the dental profession. New patients call the office and only want their teeth cleaned. Administrative teams schedule the new patients on the hygiene book. Hygienists are trying to chart as well as clean up bloody garbage pails, all in 50 minutes. Now to top it all off, patients only want their free cleaning, free X-rays and a snazzy new toothbrush. Oh yeah, all of this to be paid 100% by their insurance.

The Real Problem

So what is the real problem and where is the hidden solution? Who is missing from this not so fictitious of characters? You got it… Where is the dentist?

Of all the code changes coming into play for 2018, none will be as defining, satisfying, and to some, truly frustrating as the reworked nomenclature and descriptor of our old friend “Gross Debridement.” Better known by far too many as simply “FMD.” Yep, we are talking about full mouth debridement. That nasty old do-nothing smelly zombie of a concept that has been silently sabotaging hygiene departments since the early death of 01130.

Whenever faced with the use of the slang term “FMD,” I will frequently inquire of the attendee (one who asked the question): “Can you help me understand what you mean by FMD?” At which point the inquisitor will glowingly respond something to the nature of: “You know — 4355 — full mouth debridement.”

In other words, they selectively, by choice, choose the words that fit their wants, needs and desires without consideration of a known, factual truth.

Since its inception in 1995, the nomenclature for 4355 has read something to the effect that debridement was necessary, in some form, to render an evaluation and diagnosis.

“full mouth debridement to enable
comprehensive evaluation and diagnosis”

The unknowing as well as intentional teachers of misinformation suffer the ailment I refer to as “selective amnesia.” This condition is identifiable via ICD-10 coding as R41.3: Other amnesia. Don’t use part of a statement or descriptor to falsely support the justification of an otherwise nonexistent course of action. To quote the Preface of CDT© American Dental Association: “Nomenclature may be abbreviated when printed on claim forms or other documents that are subject to space limitation. Any such abbreviation does not constitute a change to the nomenclature.” Now on to the actual change.

Beginning January 1, 2018, the modified nomenclature for D4355 will read:

“full mouth debridement to enable a
comprehensive oral evaluation and diagnosis
on a subsequent visit”

As for the descriptor, its modification will simply read as:

Full mouth debridement involves the preliminary removal of plaque and calculus that interferes with the ability of the dentist to perform a comprehensive oral evaluation. Not to be completed on the same day as D0150, D0160 or D0180.

Is this change really anything new or is merely the reinforcement necessary? My clients have been exposed to the appropriate use of the code since its initial inception. Here it is, straight from my 1994 version of my Dental Insurance and Reimbursement Documentation Coding and Claim Submission Manual.

The appropriate use of code D4355 rests squarely on the shoulders of the licensed diagnostician and not the hygienist. Do not unbundle procedure code D4341 as not all patients scheduled to receive active therapy require the use of this debridement procedure (D4355).

Debridement is academically defined as the removal of foreign material and devitalized or contaminated tissue from or adjacent to a traumatic or infected lesion until surrounding healthy tissue is exposed. Such debridement would be considered satisfactorily completed when the necessary healthy tissue would be exposed to promote healing. This definition must rest on total removal of any and all debris within the depths and surrounding walls of the contaminated, infected periodontal pocket. Anatomical considerations may involve the identification of:

• supragingival debridement, where debris is located coronal to the gingival margin as attached to the clinical crown;
• subgingival debridement, which involves the removal of debris from within the confines of the infected periodontal pocket — especially all discernible calciferous deposits that would harbor disease-producing bacterial endotoxin. So will this redefinition provide for any earth shattering changes in the standard operational procedures of the dental office? Can and will the concept of “evaluation” as opposed to simple “examination” finally begin to supersede the ever growing misguided concepts of what was ethical patient and practice management? What about the doctor’s treatment plan?

Incomplete mechanical debridement or “gross debridement” is simply anything less than satisfactorily completed debridement. The operator would have intentionally left in place debris and/or unhealthy, diseased, infected tissue. Gross debridement would therefore appear to be akin to gross decay removal from a large carious lesion.

If the dentist diagnostician is supplied with four or more bitewings or a full set of periapicals and finds bone loss, with depths of pockets 4mm or greater, gross debridement would be inappropriate as a treatment modality. Gross debridement is part of root planing and scaling and as such is neither separately identifiable nor payable.

All gross scaling and its various connotations are nothing more than the initial removal of heavy calculus and as such would be considered to be part of either prophylaxis or root planing and scaling, when completed—no more, no less.

DO NOT use code D4355

• on behalf of a patient if that patient has been diagnosed and/or is receiving active treatment
• as a treatment modality if a diagnosis has been established
• in conjunction with the treatment of types I, II, III, IV, or V periodontal disease and/or prophylaxis
• on the same date of service as either a comprehensive, periodic, limited, periodontal or detailed/ extensive oral evaluation.

DO use code D4355

• when a new patient presents in your office with such an abundance of calculus and plaque that radiographic interpretation would be inconclusive and any attempt at a comprehensive oral evaluation would be fruitless
• and allow the patient to return for a comprehensive oral evaluation. Remember that, following any type of debridement procedure, the periodontal tissues will be so irritated that the true health status of the patient will be tainted
• only when the procedural definition and intent are appropriate. Remember that gross scaling is dead as both a treatment and reimbursement modality.

You see, by removing the dentist from the diagnostic and evaluation process prior to the hygienist initiating treatment, we have lost the overall operational concept of “appropriateness of care.” In most all instances of what was confusingly referred to as FMD, the unidentifiable action took place prior to the involvement of the dentist. Unfortunately, we had many hygienists diligently working away to clean up the patient in anticipation of the doctors arrival LATER in the appointment.

Do you see the foundation of the earlier identified problem? Why is this patient in the hygiene department when the actual intent of the initial visit is, in fact the evaluation of the patient and not the actual cleaning?

Like it or not, the code speaks for itself. Now it’s time to do the right thing. Bill for what you do and code for what you finish.

Let’s talk.

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