Fast Facts: Coding Episode 1
[Andrew Johnston, RDH]
Welcome back everyone! You are listening to another episode of Fast Facts- Coding Edition brought to you by A Tale of Two Hygienists in partnership with DentistRX. And now, please welcome your host, Teresa Duncan, MS.
Hi, welcome to your Coding: Fast Facts today we're going to talk about D1110 versus D4346. What are these codes? Well, they're the most common preventive codes that you're going to run into. And so let's just go over the first ones. D1110 is prophylaxis, adult, and real dry here. But let me go ahead and read you the exact definition of it. "Removal of plaque, calculus and stains from the tooth structures and implants in the permanent and transitional dentition." It's intended to control local irrotational factors. So that's going to become important in just a second when we go over scaling in the presence of inflammation and what localized and generalized have to do with each other with these two codes. Now, interestingly enough, it seems to be a boring code, but there's actually a lot that's packed in there. So you have, first of all, two tooth structures and implants. And that's something that was changed fairly recently in the code history were now including not just teeth, but implants into the prophylaxis code. And also we have permanent and transitional dentition. So what does that mean? Well, if most of the mouth is full of permanent teeth, then that is definitely transitional, but it's leaning more towards more permanent. That to me means that you could use the adult prophy. If you have mostly primary teeth, then you would use the child prophy and that's really just from reading the code. The problem comes when you have clauses that insurance pays out, they will allow benefits for a prophy code that would be paid out for an adult, usually after the age of 14 and most kids, as you know, are already showing lots of permanent teeth before then and so you will want to coat it as an adult prophy because you see more of adult teeth in the dentition. However, just be aware that most benefit plans will only allow if it's under 14, the benefits for a child. Now that doesn't mean that's not what you did. It just means that those are the benefits that are going to be appropriate for that particular beneficiary. It does not mean that you did the wrong procedure. It just means that the benefits are not necessarily matched up with what you did.
Now let's move on to 4346. Now this is, again, a fairly recent code, and while most of the codes get updated as we go, this one really hasn't changed much. The spirit is that there are conditions where there's tons of inflammation, but there are no bone loss. You don't see anything going on when you look at the radiographs. And so looking at radiographs and showing this to your patients is not going to really help. Intraoral images is going to help. So scaling in the presence of generalized moderate or severe gingival inflammation full mouth after an evaluation. Now that's important because we have to do an evaluation in order to prescribe this particular procedure. Indeed, we have to do an evaluation to prescribe all the procedures that we do. Prophy, radiographs, 4346, all of that.
Now here's where the description of the code becomes important. The removal of plaque, calculus and stains from the Supra and subgingival tooth surfaces when there is generalized moderate or severe gingival inflammation in the absence of periodontitis. It's indicated for patients who have swollen inflamed gingiva, generalized suprabony pockets, and then moderate to severe bleeding on probing. It should not be reported in conjunction with prophylaxis, scaling and root planing or debridement procedures. Now this is very important because there are many times where I'll get a question that, well, they've got lots of information in one area, most of the mouth, but it's not the whole mouth. That's not really the spirit of the code, though. If you read the code, it does say generalized. So it's pretty much got to be generalized, right? So what happens with those localized places where you have just in one spot? Unfortunately, prophy doesn't necessarily cover that. There is that little clause in prophy that says intended to control local irrational factors, but that doesn't really fall in line with localized inflammation. So unfortunately, when you have localized inflammation, you really don't have a good code to use other than D4999, which is your miscellaneous code. And maybe you could do that in addition to the prophy code for the rest of the mouth. But scaling in the presence of generalized moderate or severe gingival inflammation, that really isn't to be done at the same time as a prophy. What the intent was was that we would identify that that is the situation the patient has. Then we would do that procedure and have the patient come back after a period of healing to see if we've been able to solve that situation. As you know, having your hygiene background, there are many issues that could cause that. It could be genetic, it could be hormonal, it could be medicinal. It's going to be up to you and the doctor to figure that out and decide what the appropriate interval is. Now, when it comes to sending this in for coverage, and again, if you don't have insurance to deal with, and this is even better. But if you do have to send it in for coverage, just remember that radiographs do not help very much at all and in fact, from a treatment planning point of view and a patient communication point of view, I would absolutely be taking before and after intraoral photographs, because when the patient eventually gets to a healing phase, you'll want to be able to show them this is what it was when you first came in, and then that way they can keep an eye out for it. And also you have proof that you were able to get them back into a healthy holding pattern. Now, when you send this in for reimbursement, a lot of times, 4346 is just automatically processed as a 1110, which is unfortunate because there is more to it than just a prophy benefit allowance. You're doing a lot more work, there's a lot more education that goes into it. I'm assuming that you're doing a lot more discussion of medical history and what are the factors that are going into this. But unfortunately, the benefits have not kept up when it comes to the insurance point of view. So although you're charge for it might be more, your benefit allowance may not be. And that's something that your Admin team can give you a heads up on. Not that that's something you have to deal with, but at least you'll be aware when the patients come in and are asking about reimbursement.
There are times when you have perhaps a patient who has compromised health, say, for example, not that pregnancy is a compromised health status, but that is what they included in there. Or perhaps that they're having diabetic treatment, or perhaps they're undergoing some other long term medical treatment. There are some dental plans that will allow for a third and a fourth prophy just because they have that in their history. I know that there are Cigna plans that once the mother is noted as being pregnant, their dental actually kicks in and gives them an additional prophy. But I wouldn't count on that. I would always ask the patient if they're aware of this type of benefit and then have them call to get the benefits for it. We all know that there are pregnant mothers who definitely would appreciate being able to come in more often and have it reimbursed also. So when it comes to the exclusions and limitations for these two particular procedure codes, because 4346 is quite often processed at the 1110 level, then it's usually subject to the same clauses and limitations, which means your pro fee is typically covered every six months to two times a year. That's typically what we see. Now, if you see it as every six months, you need to know that it's six months plus a day. And I even would do six months plus two days or three days just to make sure that you get outside the buffer zone. You don't want to have to have the conversation with the patient that you were off by just one day. It's not a pretty scenario. I have been in those exact conversations, so you definitely want to adjust it on the computer, that it's six months plus one or two days. And in fact, most of your software is set up that way. So again, the only real caveat that I have for you with this is that you are going to run into situations where it's not quite generalized. It's mostly I would say I don't know if mostly generalized is a term. I know it's not. So if that's the situation, just know that there is a gap in the code there and so you are going to have to discuss with the patient that it doesn't quite fit. My recommendation would be 1110 + a D4999 miscellaneous code so that you can accurately reflect what was done in the mouth. So hopefully you won't have to run into too many head scratcher scenarios. But these are the two most common prophy codes or initial inflammation reliever codes that you're going to run into.
Hopefully this has been helpful and you can go forward and use these two procedure codes correctly in the future. Thank you.
[Andrew Johnston, RDH]
Thank you for listening to another episode of Fast Facts - Coding Edition, brought to you in part by DentistRX makers of the InteliSonic line of power brushes. Find out more by visiting their website at www.dentistrx.com. We'll see you next week for another Fast Fact!