Coding for the perio patient

Dear Dianne,

I hope you can clarify a few protocol questions for me. My first question is about new patients. Here’s my example. A new patient who presents with periodontal disease is on the hygiene schedule. What do we do on the first visit? Do we do a cleaning D1110 or D4341? What about insurance status? Some people say if a patient refuses scaling and root planing, we should not work on the patient and refer him or her for a second opinion. Other people recommend we have the patient sign a waiver for SRP and do “at least” a prophy.

What if the patient has just a few pockets and needs site-specific treatment (D4342), and also needs fillings or a crown? What is the risk to the dentist? Is it malpractice to do D1110 to a periodontal patient or is it advised to do D4355 if necessary, then D4341? How about if a patient cannot afford the treatment, or what if insurance does not authorize the treatment?

It seems like there are mixed opinions from friends and hygienists on these situations. What would you advise, or where can I find more specific information about it?

Thank you, Gigi

Dear Gigi,

You’ve asked some great questions, and I’ll attempt to answer them here. Of course, questions about protocol are likely to generate different opinions.

Let’s start with new patients. Many offices schedule new patients on the hygiene schedule first, primarily because hygienists are very proficient at gathering data. A new patient will have no history in the practice and will require radiographs (unless he or she brings in current radiographs), restorative and periodontal charting, and all the preliminary items, including intraoral and extraoral assessments and a medical history review. You have to determine what level of hygiene care the patient needs. If you determine through your periodontal charting that the patient has periodontal bone loss evidenced through the radiographs and periodontal charting, then you have to decide on severity. Determining the severity will guide the treatment planning.

One of our great challenges today is to find balance between the clinical ideal and the patient reality.

For our purposes, let’s say that the patient is a Class III moderate periodontitis case type with pocketing in the 6 mm to 7 mm range. There is moderately heavy supra and subgingival calculus. There may be furcation involvement and Class I mobility. The patient will require local anesthesia in most areas. Once you’ve gathered the data and determined the class type, you should tell the patient, “Based on what I see in your mouth and on your x-rays, there appears to be some problems with the bone around some of your teeth. I need the doctor to look before I proceed further.” At this point, you speak to the doctor outside the patient’s hearing range and inform him or her of the periodontal problem and case type. The doctor should then come in, meet the patient, look in the person’s mouth, examine the x-rays and periodontal charting, and say to the patient, “Based on what I see in your mouth and on the information gathered thus far, you have periodontal disease. It is a chronic infection that, over time, destroys what supports your teeth. The good news is that this is treatable in a nonsurgical way, and we typically have very good results. Our hygienists are specially trained to treat these problems, so I’ll let (hygienist’s name) explain to you what will be needed to get this infection under control.” Now it is up to you to sit down with the patient and explain the treatment sequence. Please do not use the phrase “deep cleaning.” Rather, use “advanced hygiene care” or “definitive periodontal care” to describe your work. If the patient is insurance dependent, the administrative staff will need to obtain preauthorization of benefits before you proceed with definitive care.

If your new patient has no signs or symptoms of disease, the treatment is a prophy. But you can’t determine that until you complete your assessments.

If your patient has early periodontitis, the clinical signs will be slight bone loss with pockets in the 4 mm to 6 mm range. The early periodontitis patient will have three or fewer teeth in the quadrant that are periodontally involved that will require site-specific periodontal treatment. The appropriate treatment is to perform a D1110 on all the nonperiodontally involved teeth, then site-specific periodontal scaling, D4342, on any teeth exhibiting bone loss. Some insurances will allow D4342 on the same day as D1110 and some will not.

If the patient needs definitive periodontal care but refuses to proceed with appropriate care, he or she is exercising the right of informed refusal. Informed refusal is a concept that recognizes that all competent individuals have a right to have the final word in what happens to their bodies. It is a hot topic in legal circles.

However, dentists also have the right to either extend an alternative form of treatment or no treatment at all to such patients. In some situations, it would be best to refer the patient to a periodontist. In other situations, the dentist might feel it is appropriate to allow an alternative short-term treatment, such as a debridement, with the expectation of providing definitive treatment in the future. The best advice I can give you is to have a meeting with your employer and discuss what options he or she feels are appropriate. It’s often a case-by-case decision. Anytime there is a diagnosis and the patient refuses the treatment recommendation, you should have the patient sign a “Refusal of Treatment Recommendation” document (one can be found on DentistryIQ in the Downloadable Forms section) that spells out what treatment is needed and that the patient understands the ramifications of no treatment.

The primary risk to the dentist regarding periodontitis is when disease is present but goes undiagnosed and is therefore not reported to the patient. Hygienists bear some responsibility in this matter because dentists depend on them to find areas of bone loss and bring it to their attention. Up-to-date periodontal probing and recording is a vital part of diagnosing periodontitis.

The debridement code D4355 is sometimes misused. The descriptor says, “The gross removal of plaque and calculus that interfere with the ability of the dentist to perform a comprehensive oral evaluation.” It should not be used as a first-visit prophy, nor should it be reported on every new patient.

The D1110 prophy code descriptor states, “The removal of plaque, calculus, and stains from the tooth structures. It is intended to control local irritation factors.” The descriptor doesn’t state that it’s for use on “healthy” patients, but we consider it a preventive procedure. It would not be the appropriate treatment for a patient with active periodontal disease, although we do indeed remove plaque, calculus, and stains from active-disease patients.

One of our great challenges today is to find balance between the clinical ideal and the patient reality. Certainly, there are individuals who need definitive periodontal treatment but are not able to pay for care. In those cases, the doctor may allow the hygienist to provide a short-term alternative, such as a debridement with a power scaler. It is not ideal treatment, and the patient must be informed that the treatment is meant to be a short-term alternative and that definitive care is still needed. This is much like a doctor providing a build-up on a tooth that needs a crown when the patient says he or she cannot afford the crown at that time. In some situations, the doctor may decide to allow the hygienist to provide complementary care or care at a reduced fee.

I urge you have a discussion with the doctor on the different scenarios you have presented and arrive at a protocol that won’t leave you guessing what to do when these situations arise. Finally, you asked about a resource. I recommend Dr. Charles Blair’s “Coding with Confidence” manual, available at practicebooster.com/store.asp.

All the best,

DIANNE GLASSCOE WATTERSON, RDH, BS, MBA, is an award-winning author, speaker, and consultant. She has published hundreds of articles, numerous textbook chapters, and two books. Dianne’s new DVD on instrument sharpening is now available on her website at wattersonspeaks.com under the “Products” tab. Visit her website for information about upcoming speaking engagements. Dianne may be contacted at (336) 472-3515 or by e-mail at [email protected]..