Prophy vs Perio Maintenance

It’s what you DID — NOT who or where it was done!

Dental Insurance Today — August 2017

It is a sad state of affairs when I see procedure coding taken completely out of context for the betterment of one’s own political agenda or simple lack of knowledge. So is the case with the age-old discussion of “When does perio maintenance become a prophylaxis?” Believe me when I say it has nothing to do with simply the calendar or GPS.

How many times have you had to deal with:

• The patient wants a regular cleaning and not that perio one.
• Once a D4910 it’s going to be perio maintenance forever. Right?
• D1110 then D4910 then D1110…
• We did perio maintenance and they called it a cleaning.
• Perio patients never get regular cleaning.

The Solution?

The solution to this problem is simple if you merely put the process of appropriate procedure coding in its rightful place. That place, just like the patient’s benefit plan, has to ALWAYS be last. Dead last. Everything else has to have happened at its appropriate time so that the procedure coding can, almost, automatically take place. Follow these simple processes and you will begin to control the overall reimbursement nightmare.

First and foremost must be the actual documented diagnosis as provided only by the appropriately licensed dentist. This will become even more of a mandated identification as well as documentation issue with the 2018 introduction of tele-dentistry coding …and punctuation. 🙂

• D9995 teledentistry – synchronous; real-time encounter
• D9996 teledentistry – asynchronous; information stored and forwarded to dentist for subsequent review

These are anticipated to be reported, in addition to any other procedures delivered to the patient on the actual date of service. Look for more on these new procedure codes as state and federal regulatory agencies define what is and is not the actual practice of dentistry.

Those who have participated with my live workshops know the mantra:

Bill What You Do
and
Code What You Finish

It’s not unlike the sequential treatment planning flow of first remove, then repair and, lastly, replace — in that order. Start with documenting why something needs to be done. That is your diagnosis. Then move to what specifically was done. This is the actual composition of your clinical note concerning the events from the date or multiple dates of patient treatment. Then simply bill the patient, or responsible party, for what was actually done. Simple enough!

Now what code number(s) identify the completed procedure(s) for that date of service? If the patient has a plan of benefits that may or may not participate in the PATIENT’S agreed and accepted TOTAL COST OF CARE, what is billed the patient is exactly that which is billed via code number to the patient’s plan. You will never, ethically or legally, have something billed to a patient but not to their plan.

Simplifying the Process

Here is your process for simplifying the overall reimbursement process. Document why and what was done. That way you can bill for exactly what you did. Now you are ready to code for what you finished.

Now let’s move our focus on to what was actually documented as being done on behalf of the patient. To accomplish this, let’s identify three specific techniques that are part of the REMOVE phase of treatment planning. They are:

Scaling is the removal of plaque, calcareous deposits and stain from the teeth using suitable instruments. Removal from tooth surfaces…

Root planing smooths the surface of a root by removing abnormal toxic cementum and/or dentin that is rough, contaminated with toxins or microorganisms or may be permeated with calculus. Removal of cementum and/or dentin…

Polishing is the removal of mucinous film, superficial stain, or deposits to provide a smooth surface that will be more resistant to future accumulations of foreign substances such as materia alba, calculus, and mucinous plaque. Removal of film by friction…

So what is the actual difference between prophylaxis and periodontal maintenance? The answer is simply determined by confirming what was actually done on behalf of the doctor’s diagnosis. Was it only scaling? Was it scaling and polishing? What and where was root planed? It is here that the actual definitions from Current Dental Terminology will be helpful.

D1110 prophylaxis – adult
Removal of plaque, calculus and stains from the tooth structures in the permanent and transitional dentition. It is intended to control local irritational factors.

D4910 periodontal maintenance
This procedure is instituted following periodontal therapy and continues at varying intervals, determined by the clinical evaluation of the dentist, for the life of the dentition or any implant replacements. It includes removal of the bacterial plaque and calculus from supragingival and subgingival regions, site specific scaling and root planing where indicated, and polishing the teeth. If new or recurring periodontal disease appears, additional diagnostic and treatment procedures must be considered.

Notice that the descriptor for prophylaxis specifies the limitation with the terminology “from the tooth structures.” Removal from the tooth is accomplished by definition as either scaling, polishing, or both. Now compare it with the descriptor for periodontal maintenance and you will see that both scaling and polishing are included in addition to the terminology “root planing where indicated.”

If it’s not indicated you won’t do it because you can’t do it. The doctor’s diagnosis confirms that there is nothing to root plane. It’s not indicated. It’s not necessary. It’s not done. If root planing is not performed on behalf of the patient, it can’t be D4910.

From the definition of D4910 we must have all three of the following:

1. Removal of the bacterial plaque and calculus from supragingival and subgingival regions.
2. Site specific scaling and root planing where indicated.
3. Polishing the teeth.

As concerns fee data and the differing relative values between D4910 and D1110, perio maintenance is a good 45% to 65% more than that of the fee for prophylaxis.

Oh, but what about the terms supragingival and subgingival? Isn’t a prophy above the gum line and perio maintenance both above and below the gum line? Nope — the term coronal was removed from the prophylaxis terminology back in 2005. Sorry.

As always, bill for what you do and code for what you finish.

Let’s talk.