Can you submit for D1110 Prophylaxis (adult) and D4342 Scaling and Root planning (1-3 teeth per quad) on the same date of service?
I recently attended a CE course on CDT Dental Coding & Reimbursement; yes, I too need to make sure I keep my skills up to date so I can provide the most accurate information to our members.
One discussion came up about billing for services when a patient reports for a typical recall appointment.
Here is the scenario:
Patient reports for recall appointment. The hygienist provides the service but notes that there is an area of the mouth that needs additional attention. The dentist determined that several teeth were candidates for scaling and root planning. Having the patient in the chair and ready and able to sit through another procedure, the question arose “Is my insurance going to cover this?”.
I think this happens quite frequently in the dental office these days and we, being the very courteous accommodating people we are, will try to arrive at the answer by calling the carrier and inquiring about the patient’s benefits. I think that is a wonderful service we provide as a profession although I also think we are doing the patient a disservice if we don’t stress that the service is needed (medical necessity) regardless of patient’s coverage. I think a lot of things, but that’s not what this coding corner is about.
The question quickly became …can you submit for D1110 Prophylaxis (adult) and D4342 Scaling and Root planning (1-3 teeth per quad) on the same date of service.
Anyone who knows me should know what my response will be….report what you do and do what you report. So by that I mean – if you performed D4342 and D1110 on the same date of service, it should be reflected in your patient chart notes and yes you should report that on the ADA 2019 claim form….notice I said “2019”. Yup, that’s right folks, back in July, ADA changed the claim form yet again to be compliant with HIPAA. Insurance carriers may/may not accept the 2012 ADA form at some point, but I haven’t heard anything definitive yet; I’ll keep you posted on that one.
In the words someone I have immense respect for ….Dr. Art Bilenker – “I digress” (oh, and by the way, he is a Colonel – GO ARMY!)
I digress, I digress….back to D4342….
So yes, report what you do. The claim form is a legal certification document. Regardless of what the reimbursement outcome, you need to report what you do!
Now, the second thing you will always hear me say is ….”let’s go to the video tape”… um, I mean – let’s go back to the CDT descriptor language and make sure we are using the code properly and that it reflects the service you have provided. My book is a mess. I literally go through that thing several times a day. I have spilled my tea, have sticky notes everywhere, pages are ripped and bent…well, you get my drift; the book gets tremendous use. It’s my bible for lack of a better analogy.
Back to the CDT…
D1110 Prophylaxis adult:
Removal of plaque; calculous and stains form the tooth structures in the permanent and transitional dentition. It is intended to control local irritational factors.
D4342 scaling and root planning (1-3 teeth per quad):
This procedure involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. It is indicated for patients with periodontal disease and is therapeutic, not prophylactic, in nature. Root planning is the definitive procedure designed for the removal of cementum and dentin that is rough, and/or permeated by calculus or contaminated with toxins or microorganisms. Some soft tissue removal occurs. This procedure may be used as a definitive treatment in some stages of periodontal disease and/or as a part of pre-surgical procedures in others.
It seems to me there is no language in the descriptor for an adult prophy that precludes the reporting of any other procedure on the same date of service and no language in the descriptor of D4342 which precludes at the same visit the provision of a dental prophylaxis. Having said that, reimbursement for these procedures is based on specific benefit plan provisions and third-party payer policies.
So what does that mean in English?
Some plans may pay for both services when delivered at the same time, while others might impose a specified time interval.
In a different scenario – what if the patient were a perio maintenance patient and they presented with a localized area of pocketing (let’s say 6mm probing depths). If you treated that area on the same day as the D4910, it would likely be considered part of the perio maintenance appointment on the same day. Why? Back to the video tape….because the description indicates that “site specific scaling and root planning” is included in the D4910.
So where does that leave us?
Can you submit for both 4342 and 1110 on the same day? – Absolutely, if that’s what you did, that’s what you report.
Will they issue a benefit for both?….well, the answer is “it depends”. It depends on the plan, it depends on the carriers polices, it depends on what the patient’s frequency limitation is ….it depends.
Can you submit for 4342 and 4910 on the same day? There is nothing that says you can’t submit that if that’s what you do– however, the code descriptor says that the D4342 is included as part of D4910 and I believe that will be reflected in the reimbursement as well.
A safe and happy Thanksgiving to all.