2 D 4341 – Quad SRPD4341: 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 retreatmentInclude 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) orsupportive (D4910).
5 D4342 – SS SRP along with D1110 If both 4324 & 1110 are necessary: Consider D1110 1st appt., D4342 2ndWhen D4342 is performed first - may trigger 90 exclusion of prophy
6 The Big Reveal by MetLife, CIGNA, Delta Dental As reported in:Insurance Solutions NewsletterSeptember/October 2008 issue
7 The Big Reveal by MetLife, CIGNA, Delta Dental D4341 / D4342 – MetLife requires >4mm pockets + attachment lossPseudopockets 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 attachmentRadiographic evidenceBleeding on probingGingival recessionFurcation involvementInflammationIncreasing tooth mobilitySubgingival calculusSuppuration
16 Narrative for All Four Quads on the Same Day Purpose: to disinfect the entire mouth_____ minutes spent on appointment_____ anesthesia used_____ pre-medication usedApprehensive patientMedical condition:____________________Travel time _________________________
17 D4355 Gross DebridementOnly 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 sensitivityNot typically reimbursedConsider 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 DeliveryPerio 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 destroythe connective tissuesholding 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 activityRapid bactericidal actionRelative non-toxicityNo color, no stainingEase 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 ChlorhexidineChlorhexidine 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 ChlorhexidineChlorhexidine 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 ClinicalAttachment LossCase TypePD(mm)BOP(Y / N)BoneLoss%Mobiliy (Grade)Furcations (Grade)CAL (mm)VisualInflammation0 - Health0-3NoNoneI - Gingivitis0-4YesNoveYes (local or generalized)*II – Slight Chronic Periodontitis¹4-510I11-2III – Moderate Chronic Periodontitis¹5-633I & II1 & 23-4IV – Severe Chronic Periodontitis¹≥ 6I, II or III1, 2, 3 or 4≥ 5V – Aggressive Periodontitis age is significant factor²* Localized disease is defined as ≤ 30% of sites, Generalized ≥ 30% of sites¹ Specific referral may be indicated for additional treatment beyond initial treatment² 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 - ProphyCoral pink gingiva.Pointed papilla.No bleeding uponprobing.Probing 0-3mm.
41 Soft Tissue Classifications (According to AAP) Case Type I – Diagnostic Code: “Gingivitis”Plaque induced / non-plaque originLocalized 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-andsupragingival.
43 Soft Tissue Classifications (According to AAP) Case Type III – DX Code: “Chronic Periodontitis”Localized or Generalized ( 30% sites)Horizontal and vertical bone lossTissue red, texture smoothProbing 4-6 mmSlight mobilityFurcation involvementBleeds easilyHeavy 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 lossProbing 6+ mmGeneralized tooth mobility44
51 Periodontal Coding Appointment 1 D0120 Periodic oral exam D0150 Comprehensive oral examinationD0160 Detailed and extensive oral evaluation – problem focused, by reportD0180 Periodontal examD0210 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 testingD4355 Full mouth debridementD1330 Oral hygiene instructionsD4935 Consultation for diagnosisand treatment plan
54 Periodontal Coding Appointment 2 & 3 D4341 Periodontal scaling / root planing by quadrantOR…Current theory - Do as many quadrants as possible in one appointment to not cross-contaminate completed quads. Never more that 30 days between therapies.
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 appointmentlook different than the last appointment’sprophy.Use the chart’s documentation as yourstarting 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?
69 Exam DefinitionsD0120 – Periodic oral evaluation – established patientD0150 – Comprehensive oral evaluation – new or established patient (absent from active treatment for 3 or more years)
70 Exam DefinitionsD0180 – 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 excellenthealth- 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 examComplete 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 planningScale / polish40-50 minutes of app’t.
74 The Finish – The Exam Data Collection Treatment planning Call doctor – minScale / polishCall doctor again40-50 minCall doctor againRun behind!!!
75 The Finish – The Exam Green Time Do the hygiene “dance” behind doctor RedTimeDo the hygiene “dance” behind doctorRole eyes at dental assistantApologize to next patient for being lateDataCollection10-15 minutesinto app’tCall Doctor againNo time todiscussTX plans w/ptYellowTimeGreen TimeDoctor examines athis convenience
77 The Finish – The Exam Acknowledge – Affirm the Patient “What have you been talking about?”“What would you like me to look at?”Blood PressureMedical History / MedicationsPerio StatusLife Status – “Blue Sheet”Next Hygiene VisitPatient ConcernsPreviously Diagnosed TreatmentNew 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.”
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 tomorrowThank YOU!