Periodontal Maintenance vs Prophylaxis - Can You Alternate These Codes?
This debate has persisted for decades within the dental community and its teams. On one side, there are those who firmly assert, "once perio, always perio." Conversely, there are those who argue, "it depends on the current health of the tissue."
The ADA code descriptions in the past were more weighted towards the once perio always perio philosophy, but in recent years have been modified to be less so. The 2023 ADA coding guide says specifically the codes are not mutually exclusive and that a PX can be done between PM visits. This new guidance is in line with the ADA’s overall stance that codes should allow for as much clinical decision-making as possible.
For the current discussion, let's sidestep the clinical debate, recognizing that it lacks a definitive resolution, or it would have been settled years ago. In this article, we will concentrate on the more practical aspect of the question since that is what we grapple with daily when preparing and submitting patient claims.
What is the optimal approach for handling coding on behalf of periodontal patients?
First, let's revisit the primary purpose of codes. Codes are fundamentally designed for insurance billing; they did not exist before the involvement of insurance companies in the field. Therefore, we must take into account how insurance companies actually handle and interpret these codes.
Many insurance companies have established systems that stipulate a Prophylaxis (D1110) must be followed by either a Scaling and Root Planing (SRP) or another Prophylaxis. It's common to observe that once a D1110 "Prophylaxis" is utilized, the benefits for any subsequent D4910 "Periodontal Maintenance" claims are nullified. This poses a significant concern, as alternating codes in this manner may lead to the patient losing benefits for the future. Insurance companies implement this practice based on the historical perspective held by many: "once perio, always perio." Naturally, this approach also serves to reduce their future costs.
So, from an insurance company perspective, if you submit multiple claims for your perio patient using alternating codes, you may be creating a problem with many insurance companies and policies.
If this is the case with insurance, why would an office ever alternate the codes? The main reason is patients desire to pay less. “I want my free cleaning” is the bane of every dentist and hygienist when it comes to routine care for patients.
Rarely, your office may come across a policy that specifically pays for two D1110 and two separate D4910. These policies make up less than 1% of the plans sold in the country, but they do exist. The simple solution when your patient has a policy like this is to ask for an alternative benefit. Most dental team members recognize the alternative benefit concept when a claim is submitted for a composite filling and gets an alternative benefit of an amalgam. These are typically automated by the computer-driven EOB from the insurance company. However, a D1110 is not always seen or automatically processed as an alternative benefit of a D4910. One would want to specify in the claim the request for an alternative benefit in the remarks section.
“Please provide an alternative benefit of a D1110 for this patient if D4910 is not available.”
Asking for consideration of the alternative benefit will allow you to access all the patient’s benefits, without changing your coding every visit.
Another concern with opting for D1110 instead of D4910 pertains to the financial aspect of dental offices. A D4910 typically commands a higher fee than a D1110. Therefore, by alternating the codes, the dental office is deliberately seeking and receiving less income for the performed work. In the current economic climate, where offices nationwide are grappling with challenges related to the profitability of hygiene in general, intentionally reducing fees would only exacerbate these profitability concerns.
Finally, we consider patient perception. It's challenging enough to persuade a patient to accept the necessity of paying more instead of having their "free cleaning" visit following a periodontal disease diagnosis. If you illustrate to the patient that the codes can be alternated, they might easily infer that the codes are rather fluid. Consequently, they may pose the next "logical" question: "Why can't you always use the lower-priced service code?"
While there might be some clinical debate about switching between a D4910 and a D1110, examining the situation from the insurance and patient perspectives suggests that sticking with the D4910 and avoiding alternation can be more straightforward. One can always inquire about alternative benefits for the rare policies that offer them. Sticking with D4910 aids in patient understanding, prevents the loss of insurance benefits, is simpler organizationally, and contributes to maintaining profitability, ensuring that hygiene departments do not incur losses for the office.
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