4910 vs. 1110: why they can't be altered.

Introduction

As we promised in the December column, I will address the most common questions that our readers struggle with in relationship to diagnostic, preventive and other dental hygiene services. I hope this will remind you to visit the ADA Web site at www.ada.org and submit recommendations to change the codes to reflect a more accurate nomenclature and descriptors for many dental hygiene and diagnostic codes that provide challenges to us in practice. I encourage you to participate in the code revision process on an ongoing basis! The Revision Code Committee met in February 2008--did any of our Access readers submit recommendations and did anyone get feedback from the Code Revision committee? Please let us know--I would love to hear how your experience went! Please email me at [e-mail] and title the email Cracking the Code.

A Review of Codes: D4910 and D1110

The D4910 supportive periodontal maintenance code and the D1110 adult prophylaxis code continue to produce the most controversy when it comes to dental coding for hygiene-related procedures. However, if one reads the latest code book that was implemented in 2007, there really should be no question as to how one uses these codes.

Once the patient has been through initial periodontal therapy, whether it is gingival flap or osseous surgery (D4260/D4261) or initial periodontal scaling/root planing therapy (D4341 or D4342), the patient has been diagnosed with a chronic gum infection. Periodontal surgery, scaling/root planing and definitive treatment do not eliminate the disease state; they only bring it to a maintainable level where the patient and the practitioners involved can together help prevent further bone and connective tissue breakdown.

The latest research shows that the three-month interval is the ideal frequency for most people with periodontal disease because it takes 3-11 weeks for the bacteria associated with periodontal disease to recolonize and reach the level where breakdown can occur again. (1) Of course, we know that those with better host response may only need to come for their maintenance visit every four months, while others who are less fortunate may need to come in every two months, but regardless of their recall interval, once they have been through initial therapy and the diagnosis is periodontal disease, the clinician needs to file the dental claim as a D4910 every time. Alternating between D1110 and D4910 is no longer acceptable and hasn't been for several years.

The meaning of the D1110 code has changed over the years, and today it means a patient who has gingivitis or a healthy dentition. If the patient has no connective tissue or bone loss, or if they have a diagnosis of gingivitis or less, they qualify for D1110. We must remember that 73% of the population has some form of periodontal disease, (2) so we should not see any practice where a majority of their coding in the hygiene department is a D1110! The D1110 code does not include any instrumentation on the root surface, as that would constitute more than a 3mm pocket and bone loss. Technically, if a patient has lots of recession, they will not qualify for a D1110 because the clinician would scale the root surface during the appointment.

If the patient has one or two teeth that exhibit bone loss and need instrumentation, then those teeth can be root planed using the D4342 code with the D1110. In the case of a patient who needs an adult prophylaxis and scaling and root planing for a limited number of teeth, one may want to fee out the prophylaxis on the first visit and the D4342 on the second visit for better reimbursement. It is important to do the professional service the individual patient needs first. In the case of a patient with a periodontal infection, I would treat the 4mm or greater pocket(s) that have bleeding first and help the patient to understand that they have an infection that needs ongoing treatment. They would then return to the office for the routine prophylaxis. If we do the adult prophylaxis first and they don't own their disease, then we may lose production completely on their D4342 visit when they don't show up.

It is not very productive for the practice or the patient to schedule multiple appointments if it can be done in one visit, regardless of insurance coverage. It is highly likely that you will never be able to predict the outcome of the insurance, so treat the patient the best way you can. If you do the D4342 for two teeth and do a healthy prophy (D1110) for the rest of the mouth, I would fee them out together, as this reflects the services that were rendered. We can't take ownership of the patient's insurance company, but only provide the appropriate services they need.

The D4910 code is to be used whether the general dental practice sees the patient at each maintenance visit or whether you alternate visits with a periodontal practice. Despite what many think, the periodontal practice doesn't own the D4910 code. As long as the practitioner can legally perform the services, then they must file the code based on the services rendered. Because periodontal disease is episodic in nature, as you know, there are specific areas in the mouth that need additional root planing at each visit. Therefore, we will continue to root plane the areas that need it and only polish and supragingivally scale those teeth that are healthy at each visit. The prophylaxis portion of the visit is part of the supportive periodontal therapy visit. The D4910 follows periodontal therapy and includes removing bacterial plaque and calculus both supragingivally and subgingivally. It includes site-specific scaling and root planing where indicated and coronal polishing. This is why we use the D4910 following active therapy at every maintenance visit (which is usually a three-month interval). With the D4910 code, we are trying to continue to treat, root plane and maintain the periodontal condition as well as provide bacterial removal to the healthy dentition.

When Can We Switch From D1110 to D4910?

With the introduction of the D4342, we no longer have to wait for an entire quadrant to become infected before we provide initial therapy. Because once the D4342 or D4341 is used, they are then maintained with supportive therapy and the D4910 can be used after that. Many contracts exclude coverage for the D4910 until 90 days after active therapy. However, if we bring the patient back for coronal polishing only, then a D1110 could be used within 90 days. Many hygienists have asked when we can return to the D1110. Although this will be the exception to the rule, in some patients, after one year or more, they may have no bleeding, pocket depths 3mm or less and no active disease and can return to the D1110. When the patient appears to have disease again, it will require more documentation and effort to reestablish coverage for the D4910. Remember, periodontal disease is episodic in nature, and because it is cyclic we don't know when our host response will cause bleeding, pocket depth and infection to recur. This becomes more complicated when the patient has moved or switched dental practices or insurance carriers.

A dental hygienist who works for a government agency recently asked me about the use of the D4910 versus D1110 and wasn't sure if it mattered which code she used. As stated earlier, the site where the service is delivered is irrelevant, as long as you file the code based on services rendered. Of course, there are many dental benefit plans that employers offer their employees that do not cover periodontal codes at all, because their employer has chosen to provide preventive care only. In this case, we still have to file it as D4910 if that is the service rendered. However, we can attach a narrative to the claim that states "please substitute the alternative benefit of D1110 if necessary." Keep in mind that if a patient has no periodontal coverage, the insurance company will pay for only two hygiene visits a year, regardless of whether they were D1110 or D4910.

If the patient does have periodontal coverage, they will most likely cover four appointments per year following active therapy. Very few insurance plans require osseous surgery to qualify for D4910 coverage. This was a problem many years back. I do find that the D4910 may be subject to a deductible because it is not part of the preventive services. In addition, periodontal codes such as D4910 may be reimbursed at 80% of usual, customary and reasonable (UCR) fees and not 100% UCR like the D1110. This is why, even if a patient does have coverage, it may not reimburse at the same level as when they had healthy dentition. This, of course, will vary based on the dental plan and whether they consider the D4910 part of preventive, basic or major section of their benefit plan. In addition, some plans will not cover the D4910 unless they have a minimum of two quadrants of scaling/root planing. Regardless, if we root plane and fee it out, from then on, we are obligated to use the D4910 and not D1110.

Since neither the D4910 or D1110 includes the examination fee, even if the patient has coverage for the supportive periodontal therapy visits every three months, the insurance company will still cover only two exams a year. If your office has been bundling the hygiene visit and the exam fee on your unhealthy patients, you need to know that this is incorrect. At least, if the patient has some periodontal coverage, the supportive periodontal therapy portion will be covered. If they have to pay just the exam portion, that would be better than no coverage. In many areas, it may not be necessary to even submit an examination fee with the periodontal code if the doctor examination was not completed on that day.

We need to remember that these patients are coming in more frequently to remove the bacteria that are breaking down their connective tissue and bone, not to have a decay check, but we need to evaluate the effectiveness of the ongoing therapy of the periodontium and treat appropriately. If new disease occurs or recurs, then additional diagnostic and treatments procedures must be considered.

References

(1.) Lovegrove JM. Dental plaque revisited: bacteria associated with periodontal disease. J N Z Soc Periodontol 2004; (87): 7-21.

(2.) Academy of General Dentistry, 2000.

Tammy Glenn Cahoon, BSDH, RDH, is a national consultant, speaker, clinician and president of Cahoon Enterprise Inc. A practicing clinician since 1983 in Richmond, Va., she is an active, enthusiastic member of the ADHA and a past recipient of several awards including the ADHA Distinguished Service Award. She is also the senior dental hygiene consultant with the Consulting Team of Annette Linder of Capital Associates, Inc. For speaker availability, email: [e-mail].