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Code Definitions… Tricks of the Trade….

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1 Code Definitions… Tricks of the Trade…

2 D 4341 – Quad SRP D4341: general bleeding on probing mm pockets plus presence of calculus along with radiographic evidence of bone loss. CDT 2009/2010 defines a quad as “4” teeth or more. D4910 follows SRP with typical 90-day exclusion.

3 D 4341 – Quad SRP Most insurance companies have a
24-36 month exclusion for retreatment Include diagnostic films to document bone loss. Narrative check list is often not appropriate.

4 D4342 – SS SRP D4910 always follows D4341/D4342.
For a few isolated teeth – D1110 may be appropriate. Always put the tooth # on the insurance form. D4342 is active therapy – not prophylactic (D1110) or supportive (D4910).

5 D4342 – SS SRP along with D1110 If both 4324 & 1110 are necessary:
Consider D1110 1st appt., D4342 2nd When D4342 is performed first - may trigger 90 exclusion of prophy

6 The Big Reveal by MetLife, CIGNA, Delta Dental
As reported in: Insurance Solutions Newsletter September/October 2008 issue

7 The Big Reveal by MetLife, CIGNA, Delta Dental
D4341 / D4342 – MetLife requires >4mm pockets + attachment loss Pseudopockets without bone loss should be coded D1110

8 The Big Reveal by MetLife, CIGNA, Delta Dental
MetLife now pays SRP once every 24 months. MetLife reviewed 1,750,000 claims for D4341 / D4342 in 2007. All 3 now allow payment for D1110 and D4342 on the same day.

9 The Big Reveal by MetLife, CIGNA, Delta Dental
D4910 – MetLife pays 4x year for most policies. SRP should only be reported again if there is evidence of progression of disease (further attachment loss, bleeding, recession, discharge, etc.).

10 The Big Reveal by MetLife, CIGNA, Delta Dental
MetLife no longer denies D4910 if billed within 90 days of D4341/D4342. MetLife requires 2 quads of D4341 before covering D4910 (unless narrative states only one quad was infected).

11 The Big Reveal by MetLife, CIGNA, Delta Dental
CIGNA DHMO only covers D x year for the first 12 months following active therapy. Delta varies depending on Delta plan.

12 The Big Reveal by MetLife, CIGNA, Delta Dental – D4381
CIGNA does not define a minimum pocket depth for D4381. When a CIGNA plan covers D4381 there if benefit for up to 8 teeth at the time of SRP. If 9 teeth are treated, CIGNA denies all. Delta requires 5 mm pockets that bleed.

13 The Big Reveal by MetLife, CIGNA, Delta Dental – D4381
Delta covers up to two teeth per quad but not until the 6 week re-evaluation after SRP. MetLife will cover D4381 w/ 6 mm pockets at the time of SRP.

14 The Big Reveal by MetLife, CIGNA, Delta Dental – D4381
MetLife will only pay D4381 on the same tooth once in 12 months. MetLife believes systemic antibiotics are more appropriate when more than 12 teeth are infected.

15 Narrative Check List (for internal use – not insurance)
Active disease with alveolar bone loss _____ or greater loss of perio attachment Radiographic evidence Bleeding on probing Gingival recession Furcation involvement Inflammation Increasing tooth mobility Subgingival calculus Suppuration

16 Narrative for All Four Quads on the Same Day
Purpose: to disinfect the entire mouth _____ minutes spent on appointment _____ anesthesia used _____ pre-medication used Apprehensive patient Medical condition:____________________ Travel time _________________________

17 D4355 Gross Debridement Only used when comprehensive exam D0150 or comprehensive periodontal exam cannot be performed due to excessive and bulky calculus, heavy plaque and debris buildup. Comprehensive evaluation generally follows debridement typically 14 days later. D4355 generally reimbursed 25-33% of the time.

18 D4355 Gross Debridement D4355 is not a definitive treatment.
A prophy, referral to periodontist, or scaling and root planing always follows this preliminary procedure. D4355 should not be reported as a “first prophy.”

19 D4381 Localized Delivery of Antimicrobial Agents
Placement of FDA-approved localized antimicrobial agents such as Arestin®, PerioChip® and Atridox®. It is adjunct to D4342 or D4910. The code may not be reimbursed at the initial SRP appointment. Trend is to pay at first appointment.

20 D4910 Periodontal Maintenance
This procedure follows perio therapy and continues at varying intervals, determined by the clinician. D4910 does not include the evaluation – always charge separately. This procedure is on-going and therapeutic, not preventive.

21 D4910 Periodontal Maintenance
Typically has a 90-day exclusion following active therapy. It is improper to alternate between 1110 and 4910. The patient cannot be a perio patient one visit and prophy visit the next.

22 D9910 Application of Desensitizing Medicaments
May be used as an adjunct to SRP or for treating sensitivity Not typically reimbursed Consider D9110 – palliative treatment – for sensitivity at an emergency visit.

23 Subgingival Irrigation Local Drug Delivery
Atridox® – doxycycline gel that conforms to the gum surface and then solidifies over the next few days.

24 Subgingival Irrigation Local Drug Delivery
Elyzol® – is a gel or strip applied to the gum that is composed of metronidazole. Effective against parasites as well as bacteria. Studies show Elyzol achieves a greater bacterial reduction where doxycycline works faster.

25 Subgingival Irrigation Local Drug Delivery
PerioChip® – Placed into the gum pocket after scaling, the chip slowly releases chlorhexidine – a powerful bacteria-killing antiseptic. Reduction of pocket depths is reported – but it is not known whether these improvements are sustained.

26 Subgingival Irrigation Local Drug Delivery
Minocycline microspheres (Arestin®) contain antibiotics in tiny capsules. Studies report they are more effective in reducing pocket depth and bone loss than standard perio maintenance. Patients obtain these benefits regardless of their smoking status, age, gender, or extent of disease.

27 Local Drug Delivery Perio Protect™ – home care treatment program for perio disease. Medial device is a set of custom fabricated Perio Protect Trays . The trays guide antimicrobial agents into the infected area (gingival sulcus) and maintain the medication for a specific time. Must be a licensed Perio Protect partner.

28 Systemic Antibiotic Therapy
Periostat® - subantimicrobial dose doxycycline (SDD) . Very low dose (20mg) doxycycline is too low to affect bacteria . The drug blocks matrix metalloproteinase – enzymes that destroy the connective tissues holding the teeth.

29 Systemic Antibiotic Therapy
Taken 2x day for months. Several 12-month studies report significant improvements in tooth attachment and pocket depth with no increased incidence of side effects.

30 Irrigation Recommendations
Povidone-iodine: 10% concentration applied repeatedly by an endodontic syringe to obtain a contact time of at least 5 minutes. Generally performed after SRP. May also be done prior to mechanical debridement to reduce risk of bacteremia.

31 Irrigation Recommendations
Povidone-iodine: Ultrasonic scaler usage - 10% solution is diluted by mixing 1 part solution with 9 parts or less of water. Povidone-iodine mouth rinse/gargle has shown a reduction in gingival surface bacteria by about 33%.

32 Irrigation Recommendations
Povidone-iodine: American Heart Association suggests that antiseptic mouth rinse applied immediately prior to dental procedures reduces the incidence or magnitude of bacteremia.

33 Irrigation Recommendations
Sodium hypochlorite (household bleach) Benefits: Broad antimicrobial activity Rapid bactericidal action Relative non-toxicity No color, no staining Ease of access, very low cost

34 Irrigation Recommendations
Sodium hypochlorite (household bleach) Household bleach usually contains % chlorine. 1 part bleach combined with 49 parts water makes appropriate working solution of 0.1% or 1000 p.p.m. Working solution: 1 tsp. bleach to 16 oz. water delivered subgingivally via oral irrigator at a high pressure setting.

35 Irrigation Recommendations
Chlorhexidine Chlorhexidine mouth rinse to combat biofilms in supragingival and oral mucosal sites are performed with ml of % solution for 30 seconds 2x / day. Chlorhexidine has a propensity to dark-stain teeth and tooth-colored restorations.

36 Irrigation Recommendations
Chlorhexidine .2% Chlorhexidine is usually not effective for subgingival irrigation. It causes less change in subgingival microbes than low strength povidone-iodine.

37 Irrigation Recommendations
Chlorhexidine Chlorhexidine chips for subgingival placement are capable of reducing mean probing depths by less than 1mm in 4-6 mm deep pockets. It may not cause noticeable reduction in periodontal pathogens compared to thorough SRP.

38 Case Typing Case Type PD (mm) BOP (Y / N) CAL (mm) Visual Inflammation
Clinical Attachment Loss Case Type PD (mm) BOP (Y / N) Bone Loss% Mobiliy (Grade) Furcations (Grade) CAL (mm) Visual Inflammation 0 - Health 0-3 No None I - Gingivitis 0-4 Yes Nove Yes (local or generalized)* II – Slight Chronic Periodontitis¹ 4-5 10 I 1 1-2 III – Moderate Chronic Periodontitis¹ 5-6 33 I & II 1 & 2 3-4 IV – Severe Chronic Periodontitis¹ ≥ 6 I, II or III 1, 2, 3 or 4 ≥ 5 V – Aggressive Periodontitis age is significant factor² * Localized disease is defined as ≤ 30% of sites, Generalized ≥ 30% of sites ¹ Specific referral may be indicated for additional treatment beyond initial treatment ² Specialty referral should be considered

39 Guidelines for the Management of Patients with Periodontal Diseases (AAP 2007)
LEVEL 3: patients who should be treated by a periodontist. LEVEL 2: patients who would likely benefit from co-management by the referring dentist and periodontist. LEVEL 1: patients who may benefit from co-management by the referring dentist and periodontist. 39

40 Soft Tissue Classifications (According to AAP)
Health - Prophy Coral pink gingiva. Pointed papilla. No bleeding upon probing. Probing 0-3mm.

41 Soft Tissue Classifications (According to AAP)
Case Type I – Diagnostic Code: “Gingivitis” Plaque induced / non-plaque origin Localized or generalized ( 30% sites) Edematous gingiva. Bulbous papilla. Probing 0-4mm. Immediate bleeding upon probing may delay up to maximum of 30 seconds after probing.

42 Soft Tissue Classifications (According to AAP)
Case Type II – DX Code: “Slight Periodontitis” Localized or Generalized ( 30% sites) Edematous and smooth gingiva. Probing 3-4 mm. Delayed bleeding upon probing. Light to moderate calculus sub-and supragingival.

43 Soft Tissue Classifications (According to AAP)
Case Type III – DX Code: “Chronic Periodontitis” Localized or Generalized ( 30% sites) Horizontal and vertical bone loss Tissue red, texture smooth Probing 4-6 mm Slight mobility Furcation involvement Bleeds easily Heavy sub-gingival calculus

44 Soft Tissue Classifications (According to AAP)
Case Type IV – DX Code: “Aggressive Periodontitis” Localized or Generalized ( 30% sites) Horizontal and vertical bone loss Probing 6+ mm Generalized tooth mobility 44

45 Decisions / Changes Case Typing…

46 Mirror Explorer Probe Scaler Gracey 1-2
Prophy Challenge: Mirror Explorer Probe Scaler Gracey 1-2 All other instruments packaged separately

47 Diagnostic Assessment
Health Gingivitis Slight Perio-dontitis Moderate Perio-dontitis Advanced Perio-dontitis Aggressive / Refractory Prophy Fl2 OHI D0417* D0150 D0120 D0180 D0274 D0277 D0210 D0330 D4355 D9950 (occ anal) D9950 (occ anal) Referral D0417 Collection and preparation of saliva sample for laboratory diagnostic testing

48 Narrative + perio charting for increased fee
Gingivitis Coding Appointment 1 DX Code: Gingivitis Plaque induced / Non-plaque origin Localized or generalized ( 30% sites) D0120 Periodic oral exam D0150 Comprehensive oral examination D0160 Problem focused exam D0180 Periodontal exam Narrative + perio charting for increased fee

49 Caution: paid without exam or x-ray --
Gingivitis Coding Appointment 1 D0210 Intraoral complete series (including bitewings), or D0330 Panoramic film, with D0274 Bitewings – 4 vertical films, or D0277 Vertical bitewings ( films) New Code # BWX Caution: paid without exam or x-ray -- try 9110 palliative D4355 Full mouth debridement D1330 Oral hygiene instructions

50 Gingivitis Coding Appointment 2
D0170 Re-evaluation – limited, problem-focused D1110 Coronal Polish D1204 Adult fluoride, or D1206 Varnish fluoride D1330 Oral hygiene instructions

51 Periodontal Coding Appointment 1 D0120 Periodic oral exam
D0150 Comprehensive oral examination D0160 Detailed and extensive oral evaluation – problem focused, by report D0180 Periodontal exam D0210 Intraoral complete series (including bitewings)

52 Periodontal Coding Appointment 1
This appointment includes comprehensive perio screening for pocket depths, bleeding, and severity, furcation involvement, recession from the CEJ, plaque score, mobility, and bone loss.

53 Periodontal Coding Appointment 1
D0417 Collection and preparation of saliva sample for laboratory diagnostic testing D4355 Full mouth debridement D1330 Oral hygiene instructions D4935 Consultation for diagnosis and treatment plan

54 Periodontal Coding Appointment 2 & 3
D4341 Periodontal scaling / root planing by quadrant OR… Current theory - Do as many quadrants as possible in one appointment to not cross-contaminate completed quads. Never more that 30 days between therapies.

55 Periodontal Coding Appointment 2 & 3 D4381 Arestin®, PerioChip®, etc.
D4342 Periodontal SRP 1-3 teeth, #_____, #_____, #_____ D4381 Arestin®, PerioChip®, etc. D1330 Oral Hygiene Instructions

56 Periodontal Coding Appointment 4
D4380 Re-evaluation of periodontal therapy (examine tissue response, re-measure pockets) D1110 Coronal polish D1204 Adult fluoride D Fl2 varnish D1330 Oral hygiene instructions

57 Decisions / Changes Treatment Sequencing…

58 Ongoing Maintenance Case Indicator Health Gingivitis Slight
Perio-dontitis Moderate Perio-dontitis Advanced Perio-dontitis Aggressive / Refractory 6 Months Prophy OHI 3 / 4 / 6 months D4910 D4381 UL, UR, LL, LR D4342 Other Referral to Specialist

59 Periodontal Recare Sequence
Appointment 5: 1st recare or 4-6 week evaluation D0170 Re-evaluation D0180 Periodontal exam D4910 Periodontal maintenance D1330 Oral hygiene instructions D1204 Adult fluoride D1206 Varnish Fee Waived

60 Fluoride Advantages CARD C = Caries reduction A = Antimicrobial
R = Remineralization D = Desensitizing

61 ADA Fluoride Assessment
28% caries reduction with 1 min swish 37% caries reduction with 4 min foam or gel 74% caries reduction with varnish


63 Varnish D1204 – topical application of fluoride – adult
D1206 – topical fluoride varnish: therapeutic application for moderate to high caries risk patients. NOT to be used for desensitization. D9910 – application of desensitizing medicament.

64 Site Specific Perio Treatment
You must make today’s appointment look different than the last appointment’s prophy. Use the chart’s documentation as your starting point: Mrs. Smith, I see by your chart that the last time you were here the hygienist determined there was a gum problem on the upper right between your molars.

65 Site Specific Perio Treatment
The first thing I want to do is check that area. If you have not had the healing I would expect at this point, I will do a non-surgical procedure to clean the area for you and place an antibiotic in the pocket to promote healing. You cannot continue with the active gum infection. Let me go ahead and get that numb for you while we continue with your healthy mouth cleaning.

66 Site Specific Perio Treatment
This is a disease-related procedure and insurance may cover it differently than the healthy cleanings you are used to. Would you like me to have Sue, our financial coordinator, step back and explain how your insurance will aid you with this procedure?

67 Anesthesia Oraqix® – (2.5% lido, 2.5% prilo.)
Emla – Profound (10% Lido, 10% Prilo, 4% Tetracaine) / Profound Lite Steven’s Pharmacy Costa Mesa, CA (800) 352-DRUG

68 Decisions / Changes Periodontal treatment sequencing… Fluoride…

69 Exam Definitions D0120 – Periodic oral evaluation – established patient D0150 – Comprehensive oral evaluation – new or established patient (absent from active treatment for 3 or more years)

70 Exam Definitions D0180 – Comprehensive periodontal evaluation – new or established patient. Patient shows signs or symptoms of periodontal disease and for patients with risk factors such as smoking or diabetes. Includes: evaluation of perio conditions, probing and charting, evaluation and recording of patient’s dental and medical history and general health assessment. Record: dental caries, missing or un-erupted teeth, restorations, occlusal relationships and oral cancer evaluation.

71 Increasing Exam Efficiency
There are 3 types of patient exams: 1- to 3-minute exam - Patient is in excellent health - No or minimal case presentation is needed. 3- to 5-minute exam - New or re-presented treatment is discussed by doctor.

72 Increasing Exam Efficiency
7+ minute exam Complete treatment plan presented. Time necessary is noted in huddle. Doctor does cursory exam at no charge. Patient is re-appointed for “status exam.” Fee is charged at status exam.

73 The Exam Call doctor for exam Run behind!!! Data collection
Treatment planning Scale / polish 40-50 minutes of app’t.

74 The Finish – The Exam Data Collection Treatment planning
Call doctor – min Scale / polish Call doctor again 40-50 min Call doctor again Run behind!!!

75 The Finish – The Exam Green Time Do the hygiene “dance” behind doctor
Red Time Do the hygiene “dance” behind doctor Role eyes at dental assistant Apologize to next patient for being late Data Collection 10-15 minutes into app’t Call Doctor again No time to discuss TX plans w/pt Yellow Time Green Time Doctor examines at his convenience

76 The Finish – Doctor enters for the exam

77 The Finish – The Exam Acknowledge – Affirm the Patient
“What have you been talking about?” “What would you like me to look at?” Blood Pressure Medical History / Medications Perio Status Life Status – “Blue Sheet” Next Hygiene Visit Patient Concerns Previously Diagnosed Treatment New Findings

78 Baton Pass to the Business Team
“Cheryl, Dr. Smith would like Linda to schedule an appointment to complete treatment on the lower right - either at the end of the week or beginning of next week.”

79 Decisions / Changes Treatment Planning… The Exam…

80 Before you go for a great evening…
Prioritize the Top 5 ideas you would like to discuss or implement in your office. Enjoy yourself this evening – Don’t eat or drink too much! See you at 8:00 am tomorrow Thank YOU!

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