I recently received this common dental coding question.
I am confused about the correct code for a perio patient who has undergone scaling and root planing (SRP) and is returning for perio maintenance. I’ve always been told, “Once, always,” but someone pointed out to me that’s not true. I was referred to clinical coding script number 11 at CDT 2023 Coding Companion. On page 83 it states, “If the dentist determines that the patient’s periodontal health can be enhanced by periodic routine preventive procedures…then this service should executed and reported as D1110 …” What is correct?
Answer to this dental coding dilemma
People have been asking this question for decades, and even some insurance carriers accept and reimburse alternate codes. This means less money for the dentist and more money for the carriers.
It is important to understand some history of the codes. In 1996, HIPAA mandated the American Dental Association to set the codes for dental procedures. As of 2005, the descriptor for D4910, periodontal maintenance, is: “This procedure is applied after periodontal treatment and is continued at various intervals, determined by the dentist’s clinical assessment, for the life of teething or any implant replacements. It includes removal of bacterial plaque and tartar from the supragingival and subgingival areas, site-specific scaling and root planing where appropriate, and tooth polishing. If new or recurrent periodontal disease occurs, additional diagnostic and treatment procedures should be considered.” (This is on page 35 of CDT 2023 Coding Companion.) The designation “for a lifetime of dentition” was added to the original descriptor in 2002 when it was recognized that periodontal disease was a lifelong condition that needed to be managed rather than cured.
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What does AAP have to say
Additionally, the American Academy of Periodontology does not support the provision of a D1110 service to a patient who has received non-surgical periodontal treatment. This was shown in their answer to “Frequently Asked Questions from AAP Classifications 2018”. The question asked was: “What does the consensus statement mean, ‘A patient with periodontitis is a patient with periodontitis for life?’
The AAP’s response was, “A patient who has periodontitis remains at risk for further periodontal destruction even with treatment. It is important to define a patient with periodontitis as an ‘at risk’ individual because this patient requires a more intensive level of maintenance and evaluation from a patient who did not have periodontitis.Thus, a patient with periodontitis who has been treated and is now stable it should not return to a level of evaluation and maintenance identical to a patient who has never had periodontitis (ie, annual or semiannual examination/prophylaxis).
This explanation makes sense to me, especially considering the research related to the pathogenic bacteria responsible for periodontal conditions and the host response to these pathogens. When I talk to attorneys about this, in my experience, the AAP’s recommendations will go far beyond what the ADA offers as an interpretation, since the AAP’s specialty is dealing with periodontal disease.
Why the ADA continues to promote that a patient can suddenly be a candidate for adult prophylaxis after SRP is puzzling given that this completely contradicts the provisions of their own descriptor! It causes so much confusion for patients. Having worked for a periodontist for many years, I have often been asked by patients who alternate visits with their general dentist, “Why does it cost more to get my teeth cleaned here when I feel the same as when my hygienist does it at Dr. Smith’s?’
This is a good question! I believe dentists are concerned that the patient will not want to pay the additional cost (copays and rebates vs. 100% coverage for D1110), so they are willing to suffer a loss in production. In today’s economic struggles, why do that?
Hygienists and dentists must convey to patients that the periodontal maintenance process may feel the same, but provide so much more intangible knowledge and skills as provided in the description. Hygienists are more than just ‘cleaning teeth’. We help patients manage their chronic, and hopefully stable, periodontal condition. In addition, additional clinical skills are required for teeth, root surfaces, implants, and more so that you do not damage any of the periodontal structures while doing so. This is the specialty of hygienists!
Editor’s note: This article appeared in its November-December 2023 print edition RDH magazine. Dental hygienists in North America are eligible for a free print subscription. Register here.
Kathy S. Forbes, BS, RDH, has been a dental hygienist, educator, speaker, author, consultant, seminarian and study club leader for over 40 years. He holds a license in the ODA for Current Dental Terminology, which allows her to provide the most up-to-date understanding of existing procedure codes. Kathy currently serves as director for the Dental Codeology Consortium, reviewing and developing procedure codes related to dental hygiene practice that are presented to the American Dental Association’s Code Maintenance Committee in March of each year.
