Karen Davis

Karen Davis, RDH, BSDH, is founder of Cutting Edge Concepts® and a consultant with The JP Institute of San Diego, California. She practices dental hygiene with Dr. Tom McDougal in Dallas, Texas. Karen speaks internationally and has authored numerous articles related to practicing comprehensively. She was recognized in Dentistry Today's Top Clinicians in Continuing Education for 2006 and 2007. Karen serves on the Corporate Council for Dimensions of Dental Hygiene. She will answer questions related to insurance coverage and coding.


 

Insurance Coding

Localized SRP 1-3 Per Quad

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Q: We are dealing with the aftermath of a hygienist who "prophied" patients with localized early perio disease every 6 mos for years. Most often we are seeing people with localized 4-5 mm probes with bleeding affecting 2-3 teeth per quadrant. When we inform the patient of their periodontal disease it is generally at an appointment where they were expecting another "prophy". We are trying to educate our patients and give them the best treatment without "scaring" them away. Is it appropriate the do a prophy and bill it as such to the insurance at this visit while educating the patient about why they need to return for an appointment with localized SRP, and then schedule the SRP for asap? I was told that we could not bill a prophy "in the presence of disease", but what if the bone loss is restricted to 1-3 areas per quadrant and the patient will return for localized SRP? We do have the patient return for a 4-6 week re-eval and could clean areas without bone loss at this time, but I like to do that first while educating the patient but worry about inappropriately billing a patient with perio as a prophy and my office manager worries about frequency limits if we do a prophy before localized SRP and then bill again for prophy or perio maintenance at 4-6 week re-eval. We follow the re-eval with a 3-4 month periodontal maintence visit.

A: From what you are describing, these are patients that present with both mostly healthy areas of their mouth but with localized areas of active infection. From a clinical perspective; the patient needs BOTH preventive and periodontal treatment; however, whether you bill those separately or not is up to your practice. In some cases a practice would diagnose and bill for the localized periodontitis and simply include a prophylaxis with that treatment at no additional charge. In other cases, and the way I would approach it, the patient would have a diagnosis for localized periodontitis on the day they were scheduled for their "regular" prophylaxis, and the dental hygienist would initially provide the preventive care (prophy) on healthy sites ONLY; then the patient would be treatment planned to return for localized active therapy. To me, the advantage of this approach is that it helps to draw clear distinctions between preventive and therapeutic care. They are not the same - even though in many practices they have both been provided under the description of "Adult Prophylaxis". When a history of prophylaxis have not resolved area of localized perioontitis; clearly the patient requires more definitive therapy.

They need:
1. A clear diagnosis,
2. Agreement that they wish to proceed with necessarytherapeutic treatment, and
3. Closely-monitored follow-up to insure the disease is under control.

Whenever we have diagnosed a patient for localized periodontitis during their prophylaxis visit, we do make a note on their record and on the claim submitted to insurance that states: "This patient was diagnosed with localized periodontitis during their prophylaxis treatment; and will require additional therapy to treat the infection." That helps to eliminate confusion. The concern from your adminstrator about not providing a prophylaxis in the "presence of disease" is likely due to an antiquated definition of prophylaxis. Over 20 years ago in the ADA definitions, it did state something similar to that but the current definition simply states what it is and that it is preventive in nature, but does not address presence of disease, or not. Essentially, you could use the prophylaxis appointment to treat early stages of gingivitis; however, treatment of periodontitis requires definitive therapy.

Q: Also, at the 4-6 week re-eval after localized SRP should we bill for a prophy or a periodontal maintenance?

A: The ADA definition of periodontal maintenance states that this follows active therapy for the lifetime of the dentition; therefore I would provide and bill for periodontal maintenance; although you will likely discover on patients with very localized disease; some can been seen at loner intervals than every 3 months. This should be individualized based upon their risk factors and effectiveness of daily disease control. Bottom line, many patients do have insurance limitations related to ongoing treatment and maintenance of periodontal diseases; but from a clinical perspective our decisions should always be based upon diagnosis.


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