Keys to Unlocking the Coding Juggling Act by Nancy Dukes

Do you ever feel like you are a member of a circus act juggling the balls of patient care, third party payer restrictions and requirements, and patient objections rather than a dental professional with the patients' best interest in mind?  In the insurance driven world in which you practice, in it is no wonder the dental practice is a very stressful work environment.  Whether or not the practice accepts insurance on assignment, you must master the art of being insurance aware not insurance driven. 

 How can this be accomplished with so much conflicting information floating around?  Third party payers suggest you alternate codes, insurance experts insists this is not appropriate, patients want to dictate how you should file insurance codes, and the entire team you work with has different levels of understanding concerning insurance coding.  There seem to be no good answers.  All you want, whether you are a clinician or business administrator, is to provide the very best care for your patient and have everyone understand that goal.

 In order to clarify coding challenges, let's look at the foundation first; then build on that.  Your goal is to truly have the freedom to provide the treatment which is in the best interest of the patient based on their individual evidence of need, right?  Now let's determine that patient treatment need.  That starts with a comprehensive diagnosis.  When it comes to periodontal disease, diagnosis is simplified when we answer a couple of questions:

• Is there bone loss?
• Is there bleeding?

If the answer to either is yes, then the patient is in some state of periodontal disease and requires treatment.  This may be treatment for gingivitis, a curable state or periodontitis, a non-curable state of disease.  Regardless treatment is necessary and your patient has come to you trusting that you will make recommendations based on evidence of need. 

 Diagnosis then becomes one of the keys to unlock the coding challenge.  To accomplish this, the practice MUST have a systemic TEAM approach to diagnosis, treatment planning, and patient education.  Everyone must be on the same page singing out of the same songbook.  Treatment plans must be developed based on standard of care not provisions of insurance policies, right?  Not doing so is actually doing a patient a disservice by perpetuating the patient's false understanding that the insurance carrier somehow knows and understands their individual dental situation better than you, the dental professional, providing the comprehensive evaluation does. 

 Communication via patient education is key to clarifying patient understanding of the fact that insurance benefits have no relationship to what is necessary for treatment or maintenance of disease.  Benefits can not be the sole consideration when making decisions about treatment or you betray the trust the patient has placed in you as their dental care provider, right?  The good news is that insurance plans reduce out of pocket expenses for those who are fortunate enough to have them.  Insurance plans are a supplement, not a pay-all as the patient has been lead to believe.  

 Still feel like you are juggling?  Let's review.  Here are the keys to unlock this coding juggling act so far:

• Diagnosis     
• Individualized evidence based care
• Communication/Patient Education         
• Systematic team approach

 This all sounds great right?  Let's now explore one of the most challenging coding dilemmas facing the dental practice today when it comes to periodontal therapy.  Can we alternate and when is it appropriate to code D1110 vs D4910?  Indeed the answer can be simplified if we consider the previously discussed keys to coding, diagnosis and communication.  Ask first, has there been bone loss then did the bone grow back after therapy?  The need for periodontal maintenance has nothing to do with pocket depths but everything to with diagnosis and bone loss.  It is not appropriate to bill D1110 and D4910 alternately, as this suggests the patient is alternating between disease and health every 3 to 4 months. 

 According to the American Academy of Periodontology, "if you are performing a prophylaxis on a patient who has evidence of periodontitis, the patient's periodontal condition is being ignored".  You must treat based on what is in the best interest of the patient and you must bill what you do.  This is mandated by the ADA.  Codes D1110 and D4910 are not interchangeable codes.  The D4910 code for periodontal maintenance is the ONLY coding option available for the patient with periodontal disease (bone loss).  The code descriptor states "this procedure is instituted FOLLOWING periodontal therapy and continues at varying intervals, determined by the clinical evaluation of the dentist, for the LIFE of the dentition or any implant replacements."  The code descripter is very clear. 

 When a dental practice is providing periodontal maintenance, D4910, and billing D1110 to obtain benefits, they are manipulating codes to obtain payment, which is the technical definition of fraud.  If they are billing D1110 to save out of pocket expense for the patient, they are under treating the patient based on the diagnosis.  This is considered "supervised neglect" in the dental industry.

 If a dentist following therapy determines that the patient has been cured and no longer requires periodontal maintenance to remain stable, a new diagnosis must be made.  This is rare, however there are situations where this might be the case such as the distal of second molars where third molars were removed or endodonticly treated teeth.  It is essential that the chart notes indicate the reasons why a change in maintenance treatment was made.  This documentation is absolutely essential so that it does not appear that you under treated or billed an incorrect code to obtain payment.  It is VERY unlikely that a patient diagnosis would change every 3 to 4 months once they have had bone loss and many carriers are watching this billing pattern closely. 

 So it is now simpler for you to decide if the patient needs prophylaxis or periodontal maintenance, right?  But how do you communicate this to the patient so that they will understand?  The whole third party payer issue is so complex.  Basically this is accomplished with a systemic team approach to comprehensive care and patient education.  The entire team must be capable of explaining all of the factors previously discussed with the patient.  Once the patient understands the evidence you base your decisions upon they gain an entirely new understanding of your recommendations for what is in their best interest.

 Let's summarize how the keys to unlocking the coding juggling act can be applied:

• Does your patient trust your clinical judgment based on evidence?
• Is there bone loss?
• Is patient suffering from an incurable form of periodontal disease?
• Does the entire team understand how periodontal maintenance differs from prophylaxis?
• Have you communicated all of the above to your patient?

 If you have answered yes to all of the above you now have the keys, diagnosis and communication, to unlocking the coding juggling act.  It is indeed simple when you rely on what you do best.  Treatment plan patients based on the evidence you see and their individualized needs, then communicate why you are making treatment recommendations.  Congratulations, you are a dental professional not a juggler in a circus act!  Stay true to your goal of providing care which in the best interest of the patient and the coding issue is no longer an insurmountable challenge.

 If you have questions about this area in your practice or would like to speak to a Jameson expert about your own particular needs or concerns, contact Jameson toll free at 877.369.5558.  We look forward to speaking with you.