In Dilaine's Coding Corner

Periodontal Maintenance explained

Most of us are familiar with the periodontal maintenance procedure. The descriptor for D4910 provides clear guidance as to its usage and what is included in the procedure. Some codes contain lengthy, detailed descriptors such as D4910. Our software limits the number of characters that can be entered or viewed when selecting the correct code. Hence, we often fail to review the entire code definition. This article addresses 3 of the most frequently asked questions. Let’s first look at the code as a whole. 

The code states: 

D4910 periodontal maintenance

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. It includes removal of the bacterial plaque and calculus from supragingival and subgingival regions, site specific scaling and root planing where indicated, and polishing the teeth. If new or recurring periodontal disease appears, additional diagnostic and treatment procedures must be considered.

When do I use CDT code D4910?

Below are 3 frequently ask questions in which the D4910 code could be utilized:

  • Q: My patient had periodontal maintenance (D4910). She returned 1 month later for periodontal scaling and root planing D4342 in one quadrant. Two teeth were treated. Her insurance denied with the reason being the localized scaling and root planing is inclusive to the D4910 procedure performed 1 month prior. Why is this the case when the subsequent scaling and root planing was a different treatment? 

A: A review of the D4910 descriptor states, “It includes…, site specific scaling and root planing where indicated,…”. Most dental plans have a frequency limitation between any scaling and root planing and periodontal maintenance procedures. The most common frequency is 90 days. If the patient’s plan frequency limitation is 90 days, then reimbursement will not be made. The charge becomes the patient’s responsibility unless a PPO contract prohibits charging the patient. 

Some PPO contracts include a frequency limitation. That frequency PPO provision could deem the service non-billable to the patient. For example, some PPOs require 90 days between any scaling and root planing and D4910, just like dental plans. If the treatments do not meet this requirement, it can be a write-off for the practice. Refer to your PPO processing policy manuals for clarity on such provisions. 

  • Q: I received a denial for D4910 due to frequency. How can I appeal this? My patient is seen for periodontal maintenance 4 times a year. His dental plan allows 2 periodontal maintenance procedures and 2 prophylaxis procedures per calendar year. 

A: First, review the clinical documentation. The documentation should indicate that a prophylaxis was performed as part of the D4910 procedure. Per the descriptor, D4910 includes “…removal of the bacterial plaque and calculus from supragingival and subgingival regions, and polishing the teeth”. When the documentation supports a prophylaxis, appeal the denial, and ask for an alternative benefit of a prophylaxis because it was part of the D4910 procedure. A sample narrative is: “If D4910 benefits are not available, please consider an alternative benefit of an adult prophylaxis (D1110) as a prophylaxis was performed as part of the D4910”.

  • Q: A denial for D4910 was received for my patient stating no history of periodontal therapy on file. This patient has been receiving periodontal maintenance for 5 years. She just changed jobs and has new insurance. Her insurance states that she must have a history of scaling and root planing within the previous 36 months. How can this denial be appealed?

A: Appeal. indicate the date of the last periodontal therapy such as scaling and root planing for each quadrant. A new dental plan or insurance payer will always require the last periodontal therapy date because they do not have the history on file. D4910 is indicated following active periodontal therapy, per the descriptor. 

Also, include historical complete periodontal charting and probing. The narrative should have dates of D4910 and documentation of any site specific scaling and root planing performed as part of the D4910 visits. The clinical documentation must be specific to the teeth numbers and sites that scaling and root planing was performed during the D4910 visit. Without specificity in documentation, chances of winning this type of appeal are not likely. 

Proper dental coding documentation is key

Documentation is critical in each of the three examples discussed in this article. Specificity in the clinical notes is a must for all procedures. The lack of details of what was performed and why it was performed is an ongoing problem for most dental teams. Consider holding random chart audits in your practice as a team. Use the results of your internal audit to learn and improve your documentation. Some payers will not accept a narrative, only the chart note for the referenced date of service. Thoroughness in documentation is not about reimbursement as much as proving quality patient care and medical necessity. 

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