The Hygiene Academy November 2008 Paragon Management Associates, Inc. Page 1 Code Definitions…...

The Hygiene Academy™ November 2008Paragon Management Associates, Inc. Page 1

Code Definitions…

Tricks of the Trade…


D 4341 – Quad SRP

D4341: general bleeding on probing 4-5 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.


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.


D4342 – SS SRPD4342 – 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).


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


The Big Reveal by MetLife, CIGNA, Delta Dental

As reported in:

Insurance Solutions Newsletter

September/October 2008 issue

888-825-0298

www.dental-ins-solutions.com


D4341 / D4342 – MetLife requires >4mm

pockets + attachment loss

Pseudopockets without bone loss

should be coded D1110



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.



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.).



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).



CIGNA DHMO only covers D4910

2x year for the first 12 months

following active therapy.

Delta varies depending on Delta plan.



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.


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.



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.



Narrative Check ListNarrative Check List(for internal use – not insurance)(for internal use – not insurance)

Active disease with alveolar bone loss Active disease with alveolar bone loss _____ or greater loss of perio attachment_____ or greater loss of perio attachment Radiographic evidenceRadiographic evidence Bleeding on probingBleeding on probing Gingival recessionGingival recession Furcation involvementFurcation involvement InflammationInflammation Increasing tooth mobilityIncreasing tooth mobility Subgingival calculusSubgingival calculus SuppurationSuppuration


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 _________________________


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.


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.”


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.


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.


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.


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.


Subgingival IrrigationLocal Drug Delivery

Atridox® – doxycycline gel that conforms to the gum surface and then solidifies over the next few days.


Subgingival Irrigation Local Drug DeliveryLocal 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.


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.


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.


Local Drug Delivery

Perio ProtectPerio Protect™ – home care treatment program for – home care treatment program for

perio disease.perio disease.

Medial device is a set of custom fabricated Perio Medial device is a set of custom fabricated Perio

Protect Trays .Protect Trays .

The trays guide antimicrobial agents into the The trays guide antimicrobial agents into the

infected area (gingival sulcus) and maintain the infected area (gingival sulcus) and maintain the

medication for a specific time.medication for a specific time.

Must be a licensed Perio Protect partner.Must be a licensed Perio Protect partner.


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.


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.

Systemic Antibiotic Therapy


Irrigation RecommendationsPovidone-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.


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%.

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.



Sodium hypochlorite (household bleach)

Benefits: Broad antimicrobial activity Rapid bactericidal action Relative non-toxicity No color, no staining Ease of access, very low cost



Sodium hypochlorite (household bleach) Household bleach usually contains 5.25-

6.0% 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.



Irrigation RecommendationsChlorhexidine

Chlorhexidine mouth rinse to combat biofilms

in supragingival and oral mucosal sites are

performed with 10-15 ml of .12-0.2% solution

for 30 seconds 2x / day.

Chlorhexidine has a propensity to dark-stain

teeth and tooth-colored restorations.


Chlorhexidine

.2% Chlorhexidine is usually not

effective for subgingival irrigation.

It causes less change in subgingival

microbes than low strength povidone-

iodine.



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.



Case TypingCase TypingCase Type

PD(mm)

BOP(Y / N)

BoneLoss%

Mobiliy (Grade)

Furcations

(Grade)

CAL (mm)

VisualInflammation

0 - Health 0-3 No 0 None None 0 No

I - Gingivitis 0-4 Yes 0 None Nove 0Yes (local or generalized)*

II – Slight Chronic Periodontitis¹ 4-5 Yes 10 I 1 1-2

Yes (local or generalized)*

III – Moderate Chronic Periodontitis¹ 5-6 Yes 33 I & II 1 & 2 3-4


IV – Severe Chronic Periodontitis¹ ≥ 6 Yes 33

I, II or III

1, 2, 3 or 4 ≥ 5


V – Aggressive Periodontitis age is significant factor²

≥ 6 Yes 33I, II or

III 1, 2, 3 or 4 ≥ 5


* 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

Clinical Attachment Loss


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.


Soft Tissue Classifications (According to AAP)

Health - Prophy

Coral pink gingiva.

Pointed papilla.

No bleeding upon

probing.

Probing 0-3mm.


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.



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.



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

Case Type IV – DX Code: “Aggressive Periodontitis” Localized or Generalized ( 30% sites)

Horizontal and vertical bone loss

Probing 6+ mm

Generalized tooth mobility



Case Typing…

Decisions / Changes


Prophy

Mirror Explorer Probe Scaler Gracey 1-2

Challenge:

All other instrumentspackaged separately


Diagnostic Assessment

Assess-ment Health Gingivitis

Slight Perio-

dontitis

Moderate Perio-

dontitis

Advanced Perio-

dontitis

Aggressive / Refractory

Prophy

Fl2

OHI

Prophy

Fl2

OHI

D0417*

D0150

D0120

D0180

D0274

D0277

D0210

D0330

D0417*

D0150

D0120

D0180

D0274

D0277

D0210

D0330

D4355

D9950 (occ anal)

D0417*

D0150

D0120

D0180

D0274

D0277

D0210

D0330

D4355

D9950 (occ anal)

Referral

D0417*

D0150

D0120

D0180

D0274

D0277

D0210

D0330

D4355

D9950 (occ anal)

Referral

D0417 Collection and preparation of saliva sample for

laboratory diagnostic testing


DX Code: Gingivitis Plaque induced / Non-plaque origin

Localized or generalized ( 30% sites)

D0120 Periodic oral exam D0150 Comprehensive oral

examinationD0160 Problem focused examD0180 Periodontal exam

Gingivitis Coding Appointment 1

Narrative + perio charting

for increased

fee



D4355 Full mouth debridement

D1330 Oral hygiene instructions

D0210 Intraoral complete series (including bitewings), or

D0330 Panoramic film, with

D0274 Bitewings – 4 vertical films, or

D0277 Vertical bitewings (7-8 films)

New Code # 273 -3 BWX

Caution: paid

without exam or x-

ray --try 9110 palliative


D0170 Re-evaluation – limited, problem-focused

D1110 Coronal Polish

D1204 Adult fluoride, or

D1206 Varnish fluoride




D0120 Periodic oral examD0150 Comprehensive oral

examination D0160 Detailed and extensive

oral evaluation – problem focused, by report

D0180 Periodontal exam

D0210 Intraoral complete series

(including bitewings)

Periodontal CodingAppointment 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.

Periodontal CodingPeriodontal CodingAppointment 1Appointment 1


D0417D0417 Collection and preparation of

saliva sample for laboratory

diagnostic testing

D4355 Full mouth debridement


D4935 Consultation for diagnosis

and treatment plan



D4341Periodontal scaling / root planing by quadrant




OR…

Periodontal CodingAppointment 2 & 3

Current theory - Do as many quadrants as possible in one appointment to not cross-contaminate completed quads.

Never more that 30 days between therapies.


D4342 Periodontal SRP 1-3 teeth, #_____, #_____, #_____




D4381 Arestin®, PerioChip®, etc.D1330 Oral Hygiene Instructions

Periodontal CodingAppointment 2 & 3


D4380 Re-evaluation of periodontal therapy(examine tissue response,

re-measure pockets)

D1110 Coronal polishD1204 Adult fluoride D1206 Fl2 varnish




Decisions / Changes

Treatment Sequencing…


Ongoing Maintenance

Case

Indicator Health Gingivitis

Slight

Perio-dontitis

Moderate Perio-

dontitis

Advanced Perio-

dontitisAggressive / Refractory

6 Months•Prophy•OHI

6 Months•Prophy•OHI

• 3 / 4 / 6

months• D4910• OHI• D4381 • UL, UR,

LL, LR• D4342• Other

• 3 / 4 / 6



• 3 / 4 / 6



• 3 / 4 / 6



• 3 / 4 / 6


LL, LR• D4342• Referral

to

Specialist


Periodontal Recare SequencePeriodontal Recare Sequence

Appointment 5: 1st recare or 4-6 week evaluation

D0170 Re-evaluationD0180 Periodontal exam

D4910 Periodontal maintenanceD1330 Oral hygiene instructionsD1204 Adult fluorideD1206 Varnish

Fee Waived


Fluoride Advantages

CARD

C = Caries reduction

A = Antimicrobial

R = Remineralization

D = Desensitizing


ADA Fluoride AssessmentADA Fluoride Assessment

28% caries reduction with 1 min 28% caries reduction with 1 min swishswish

37% caries reduction with 4 min 37% caries reduction with 4 min foam or gelfoam or gel

74% caries reduction with varnish74% caries reduction with varnish



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.


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.


Site Specific Perio Site Specific Perio

TreatmentTreatmentThe 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.


Site Specific Perio Site Specific Perio

TreatmentTreatmentThis 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?


Anesthesia

Oraqix®® – www.Oraqix.com(2.5% lido, 2.5% prilo.)

Emla – www.Drugs.com(2.5% lido, 2.5% prilo.)

Profound (10% Lido, 10% Prilo, 4% Tetracaine) / Profound LiteSteven’s Pharmacy Costa Mesa, CA (800) 352-DRUG


Decisions / Changes

Periodontal treatment sequencing…Fluoride…

Anesthesia…


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)


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.


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.

Increasing Exam EfficiencyIncreasing 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.

Increasing Exam EfficiencyIncreasing Exam Efficiency


The Exam

Data collectionTreatment planningScale / polish40-50 minutes of app’t.

Call doctor for examRun behind!!!


The Finish – The Exam

Data Collection Treatment planning Call doctor – 10-15 min

Scale / polish Call doctor again 40-50 min

Call doctor againRun behind!!!


The Finish – The ExamThe Finish – The Exam

Data Collection10-15 minutes into app’t

Green Time • Doctor examines at

his convenience

• Call Doctor again• No time to discuss TX plans w/pt

Yellow Time

Red Time

• Do the hygiene “dance” behind doctor• Role eyes at dental assistant• Apologize to next patient for being late


The FinishThe Finish – – Doctor enters for the examDoctor enters for the exam


Acknowledge – Affirm the PatientAcknowledge – 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

The Finish – The Exam


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.”


Decisions / Changes

Treatment Planning…

The Exam…


Before you go for a great Before you go for a great evening…evening… Prioritize the Top 5 ideas you would Prioritize the Top 5 ideas you would

like to discuss or implement in your like to discuss or implement in your office.office.

Enjoy yourself this evening – Don’t eat Enjoy yourself this evening – Don’t eat or drink too much!or drink too much!

See you at 8:00 am tomorrowSee you at 8:00 am tomorrow

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The Hygiene Academy November 2008 Paragon Management Associates, Inc. Page 1 Code Definitions…...

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