A Coding Conundrum…Let’s Look at 4346
Dr. Joan Monaco, NJDA Director of Dental Benefits
The 2017 version of the ADA’s CDT Dental Procedure Codes contains 11 new codes, 5 revised codes and one deletion. Although there isn’t much difference between CDT 2016 and CDT 2017, the new changes could cause a delay in your claim reimbursement if your software system or staff is not up to date. One code in particular seems to be the topic of many questions so I would like to talk in depth about the new periodontal code D4346.
Before understanding the use and implications of 4346, let’s re-visit some basics regarding periodontal treatment procedures, CDT codes and how/when they should be considered. In my mind, I break down potential treatment scenarios into categories: Gingivitis, Early Periodontitis, Moderate Periodontitis and Advanced Periodontitis.
Before we get to 4346, Let’s Look At…D0110 - Prophylaxis
When a patient is scheduled for an initial comprehensive exam or check-up, the first code that comes to mind is good old D0110. The ADA defines D0110 Prophylaxis - adult as “Removal of plaque, calculus and stains from the tooth structures in the permanent and transitional dentition. It is intended to control local irritational factors.” Note, there is no distinction between supragingival or subgingival. In my mind, this would be the definitive procedure in all patients where there is no loss of attachment…which includes all forms of gingivitis.
D4355 – Full Mouth Debridement to Enable Comprehensive Evaluation and Diagnosis
Frequently, that statement is met with resistance by those that firmly believe every patient that walks in the door should not receive a prophylaxis – instead they submit a claim for D4355. I like to think of it as creative billing submissions. It’s an additional procedure they can charge for and inconvenience the patient with, by having them come back another day for an actual prophy. There are times when this is indeed indicated, and if you read the definition of the code, it is pretty self-explanatory. D4355 –Full mouth debridement to enable comprehensive evaluation and diagnosis is defined as “The gross removal of plaque and calculus that interfere with the ability of the dentist to perform a comprehensive oral evaluation. This preliminary procedure does not preclude the need for additional procedures.”
I have to ask myself…What About this Definition is it that People do not Understand?
I have personally experienced this confusion when my 16-year-old daughter (who religiously reports for 6 month recall appointments) switched over to a general dentist (also a personal friend) for a new patient exam, cleaning and full mouth series. I didn’t give the visit much thought until I received the EOB from my husband’s dental carrier where I see that D4355, and FMX are billed out. WHAT? This kid had NO SUPRAGINGIVAL CALCULUS that I could see (believe me, crazy mom dentist that I am, I check at home with my mirror and explorer before the visit). And to top it off, when I asked my daughter what was actually done she said “a little scraping and no polishing” and she said she was re-appointed for the cleaning visit. So getting back to the definition…this general dentist could not see clinically what they needed to see to perform a comprehensive exam?? I think not. I could see clinically that she had no obvious carious lesions or calculus (even lower anterior) with my home dentistry mirror and explorer…and guess what, the comprehensive exam and FMX confirmed it as well. So how does the office get reimbursed for D4355, then a D0110, comprehensive exam and fmx (at a later date) when in reality all she needed was the prophy? Well, the answer is that every carrier does it differently, but usually D4355 is auto-adjudicated through the claim system and unless it becomes a “pattern of practice,” the insurance company will pay the claim assuming the submission is legitimate.
But We Digress…On to D4355
In the words of Dr. Art Bilenker, “Oh, but I digress”…so – I see firsthand that someone I know and respect is misinterpreting the code and its use. Let’s look at it through the world according to Joan….D4355 should be used when a patient presents with so much calculus and schmutz (for lack of a better word) that your hygienist needs a jack hammer to remove the gunk so you can actually see the teeth. That’s my interpretation of D4355. So yes, if a patient presents like that and you can’t possibly see what you need to see clinically to make diagnostic decisions, then submit for the D4355 and re-appoint the patient for the D0110 and exam at a later date. The definition says “…calculus that interferes with the ability of the dentist to perform a comprehensive oral evaluation.” Oh, and by the way, that appointment should not take 15 minutes. If there is so much schmutz blocking your view, a good 30—45 minute appointment would be appropriate. I’m just saying, for those of you that subscribe to the 15 minute D4355 code submission on 16-year-old patients with no calculus…..mark my words….IT WILL CATCH UP TO YOU!
Moving on…..I would like to believe we can all make the distinction between gingivitis, early, moderate and advanced perio, but I have many claim denials and frustrated dentists that show me the opposite. I can discuss the intricacies regarding the distinct differences and what your clinical documentation should demonstrate in another rant, but I would like to address the D4346 code. So how does that come into play when we are still so confused over D4355 versus D0110?
At Last, D4346!
Well, D4346 is Scaling in the presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation. “The removal of plaque, calculus and stains from supra – and sub-gingival tooth surfaces when there is generalized moderate or severe gingival inflammation in the absence of periodontitis. It is indicated for patients who have swollen, inflamed gingival, generalized suprabony pockets, and moderate to severe bleeding on probing. Should not be reported in conjunction with prophylaxis, scaling and root planing, or debridement procedures.” If you note my bold highlighting, this code does make the distinction of supra and sub-gingival calculus as opposed to a D0110 where there is none.
So back to the world according to Joan. Short disclaimer, I should qualify that this is my personal opinion and not the opinion of the NJDA. D4346 is for the patients that come in with a ton of inflammation and bleeding – moderate calculus – but should respond to general scaling. For example, a college student in the middle of mid-terms or finals; a pregnant women; diabetic patient, etc. These patients report with severe inflammation but NO LOSS OF ATTACHMENT. Perhaps pseudo-pockets and bleeding on probing. That’s when you would submit D4346. Re-appoint the patient for prophy and re-evaluate the tissue. If they responded to the scaling, then perhaps all that is required is a prophy. If they didn‘t respond to the treatment, then perhaps scaling and root planing or additional debridement may be in order.
Summing It All Up
So let’s re-cap. A patient reports with some sub and supra calculus, but not generalized inflammation and bleeding. D0110 prophylaxis should be performed. If a patient reports with so much calculus you can’t see the teeth, D4355 or if a patient comes in with some supra and sub gingival calculus but also has generalized moderate inflammation and bleeding and (NO LOSS OF ATTACHMENT) then D4346 should be performed. If you see loss of attachment then you are talking early, moderate or advanced perio and D4341/4342 scaling and root planning would be indicated.