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Since 1991, people have had questions about alternating codes D4910 with D1110 for follow-up of periodontal care.
Even those who think they know the answers don't quite understand the why. It all comes down to dental-medical necessity. Not sure what that is? Patti DiGangi has been writing the DentalCodeology series of books to help professionals understand the process and use critical thinking, which is more important than knowing a bunch of code numbers.
Coding should not depend on what a benefit package will cover. It should be based on the individual dental-medical necessity determined at each visit. Dental-medical necessity is a thought process and terminology not well known in dentistry. Yet, as a dental hygienist, you know and probably document it daily. Dental-medical necessity documentation simply requires recording the reason a procedure is needed. In other words, treatment is based on the documented risk assessment and the diagnosis.
Insurance carrier parameters
In the world of dental benefits, there are parameters used for periodontal treatment coverage. Though the parameters vary policy to policy, let’s consider a current example from United Concordia Dental, which states, “To be considered for a benefit, diagnostic materials must demonstrate the following, consistent with professional standards:
Let’s tackle these backwards.
The third parameter of root surface calculus is based on the philosophy that calculus is the cause of periodontal breakdown, a theory that has not been supported in periodontal research since the 1960s. Waiting for bone loss is somewhat akin to waiting for a heart attack before treating someone with high blood pressure.
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The second parameter, bone height, must be evaluated to determine if there is loss. What is a normal bone height measurement if measured from the alveolar crest to the CEJ? One would think that every professional instantly knows the answer. Yet, as we asked the question around the country, the opposite is more often true. Very few dental hygiene professionals seem to know the answer is 1.5-2mm. This measurement can only be taken on radiographic images.
The first parameter, clinical loss of periodontal attachment, involves a measure of periodontal attachment. This is a derived measurement combining probing depth and distance of the gingival margin relative to the CEJ. Suppose we are evaluating tooth No. 2, and the sulcus depth measures 3-2-3. That sounds okay, yet what if there is recession? Would it make a difference the recession is 3-3-3 or 3-2-3 or 1-1-3 or 3-3-1 or 3-2? Each of those a distinctly different levels of attachment and same tooth. If inflammation is noted in an area with 3mm AND 3mm of recession, how clinically significant is it? The parameters of this carrier seem to count it toward something-Do you?
Coding following periodontal care
Many times, hygienists have been told the insurance company said it was okay to alternate D4910 and D1110. What must be understood is the carrier can only say what would be covered under the policy. This does not mean this is accurate coding.
What if patient comes back for her three-month appointment and her periodontal condition is stabilized? Can she go back to D1110? The American Dental Association has said it is a matter of clinical judgment of the dentist. It is appropriately reported as D4910, but if the treating dentist determines the patient can be treated with routine prophylaxis, D1110 may be appropriate. D1110 can be used, but later you cannot go back to D4910 without a new diagnosis and treatment of an active periodontal infection with bone loss. The words of the D4910 state, “…if new or recurring disease occurs…” The problem, as we have discussed before, is the way all this is measured.
Follow-up care for a patient who has received active periodontal therapy can receive the D4910 code. Again, a carrier can only say what is covered under a policy. This does not mean this is the correct coding. Back in 2006, a dentist from the ADA Dental Benefits Office said, “D1110 and D4910 are not interchangeable and should not be alternated. The dentist must make the diagnosis, but then the proper code for the procedure provided needs to be used. It does appear that you could choose one code or the other, based on the diagnosis, but it would never be appropriate to alternate them.”
A narrative can be added to a claim form stating, “If periodontal maintenance (D4910) is not available for reimbursement, please provide the alternative benefit of (D1110) prophylaxis.” This is different than changing the code. Purposely changing a code for the purpose of increasing reimbursement can be considered fraud.
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Key to understanding
The challenge in understanding alternate coding is based on past thinking confusing current choices. Dentistry has so long been accustomed to thinking directly about the treatment and often skipping over documenting risk assessment and diagnosis. When those steps are routinely documented, coding is much simpler. No games need to be played. The coding is clear-cut. Fraud is no joke to anyone holding a license. Taking the time to understand coding leads to success.
What do you think? Have any ‘war-stories’ to share? Let's help each through this mine field.
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