About a decade ago, I was hired at an office one day a week. The dentist had recently purchased a retiring dentist’s charts, so there was an influx of new patients. These patients loved their old dentist and his very gentle hygienist. I quickly discovered that his “conservative” style left less than optimal dentistry behind. And that “gentle” hygienist recorded no periodontal readings in the paper charts, left ledges of subgingival calculus, and lots of bleeding gums.
I was stuck in a dilemma. I had to tread carefully, not to disrespect the revered retired dentist but to inform these patients of the condition of their mouths.
I worried that if I told the patients about their unaddressed periodontal condition, they would think this young whipper-snapper dentist and aggressive hygienist were just after their wallets. And they’d find a different office.
So, with many of these new patients, while I talked about their bleeding and probing depths, I decided that it was important to build trust. So, I did a “bloody prophy” and brought them back in three months to see how their gums responded to the subgingival scaling.
Now that I understand more about coding and dental hygiene diagnosis, I’m left to wonder, could I have lost my license for that?
Insurance does not set the standard.
In dentistry, we don’t have diagnostic codes, only procedure codes, meaning we select the code based on the treatment we provided. In hygiene, this involves an oral evaluation to determine the appropriate treatment. Understanding the descriptors that go with each code is important so you can apply them correctly (see table 1). Clearly these patients with ledges of subgingival calculus and bleeding were not D1110s, but that’s what I coded them as because, truthfully, that’s all I really knew. No one taught me coding in hygiene school, and I didn’t understand why it mattered. Not to mention, that’s what the patients were used to and what their insurance covered.
This is a toughie because insurance does not determine our treatment. As much as we’d like to maximize our patients’ insurance benefits, the condition of our patients’ mouths dictates treatment. Proper coding is important because, according to Julie Whiteley, BS, RDH, “the code is part of our record of treatment. Accuracy, along with proper documentation, is part of our job. Also, we are bound by the law and HIPAA requirements to code for what we actually did.”1 What I’m coming to realize is there’s actually no such thing as a “bloody prophy,” only an improperly coded appointment.
Patient autonomy
If I had followed the standard of care, many of those patients would have been scheduled for nonsurgical periodontal therapy (NSPT). But what if they said no and just wanted their teeth “cleaned”? Do patients have autonomy in deciding their care?
I contacted a lawyer, a coding expert, and an office manager who often serves as an expert witness in malpractice suits.
What I learned is that, yes, a patient can always decline treatment, but documentation of their condition is critical. Beverly Wilburn, DAADOM, an expert witness in malpractice suits, says a signed waiver refusing treatment will not hold up in court. Regarding litigation, courts are looking for a pattern of neglect. One bloody prophy, or improperly coded procedure, won’t necessarily strip you of your license, but a routine of not diagnosing, not documenting, and most importantly, “continuing” to treat below the standard of care for the patient’s condition can add up to supervised neglect.
There’s a gap in the code
So how could I have coded these patients properly while still letting them refuse treatment as we built trust and gave them time to understand their condition? Coding expert Teresa Duncan, MS, says I should have used D4999 (unspecified periodontal procedure). There isn’t a “not ready for treatment; I did the best I could” code. It would be nice to have an in-between code that reflects a patient who understands their condition but hasn’t accepted treatment yet.
Should they stay, or should they go?
Let’s say some of those patients, after a few three-month recalls, weren’t improving, and after lots of education and understanding the consequences of no treatment, they still refuse NSPT and/or perio referral. Then what’s the next step? Keep doing the bloody prophies or dismiss the patient from the practice?
There comes a point when we need to consider our license and whether we are guilty of supervised neglect. Unfortunately, there’s no rule that tells us when that is. Lawyer and dentist Ed Zinman, DMD, JD, says we should always ask ourselves the Golden Rule: What’s in the best interest of my patient? As we take our place at the health-care table, this becomes clearer. We must properly code for the condition we are presented with.
Unfortunately, dealing with a patient who refuses treatment is not a black-and-white question. There’s a lot of gray here. If you assess, document, and communicate the patient’s disease at every appointment, will you lose your license? Probably not. Are you providing your patient with optimal care? Absolutely not. Is something better than nothing? I don’t know. Is this happening with a lot of your patients? Can someone show a pattern of supervised neglect? These are all questions each clinician will have to ponder.
Editor's note: This article appeared in the January/February 2025 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.
Reference
- Demystifying hard-to-code scenarios. DentistryIQ. March 26, 2019. https://www.dentistryiq.com/dental-hygiene/student-hygiene/article/16363579/demystifying-hard-to-code-scenarios
