What Code To Use When Patients Have Heavy Calculus But No Periodontitis

We have all been in a situation when a patient has bucket loads of calculus but doesn’t present with periodontitis. It has been 3+ years since they have had any dental care and you know you will need more than the average 20 minutes to complete the treatment. There is really no dental code for this situation, so below are some options for care. Decide what is best for your office and make a plan to get everyone on board so that when the situation comes up, it will be a smooth transition.

OPTION 1:

When to use: Use option 1 if you need more than one visit to complete treatment.

Bill the prophy code D1110 and complete the right side of the mouth. Then at the second appointment charge another D1110 for the left side.

Pro:

1. If the insurance covers D1110 twice per year any time. The patient gets full coverage of cleaning the entire mouth.

Con’s:

1. At their 6 month check up, the next prophy would have to be paid out of pocket depending on the time of year they came into see you.

2. Some insurances will only cover the D1110 exactly 6 months and 1 day apart. If this is the case, the patient must be informed that the second prophy will be paid out of pocket.

Special note: If you start with the right side, the patient will notice an annoying difference with their tongue on each side and will want to return for care of the left side.

How to present the treatment plan:  "After assessing the health of your mouth, I have noticed that you have generalized gingivitis with a heavy amount of build up on your teeth. If we leave the build up there, it may quickly turn into a more serious disease called periodontitis. Since it has been such a long time that you have had treatment, I am going to need more time to complete your treatment. I recommend that we clean the left side of your mouth today and then schedule you back for one more 30 min visit to do the right side. Here is what the cost will be…...

Treatment plan:

APT 1: D1110 - $64-$100 covered at 100% by your insurance

APT 2: D1110 - $64- $100 out of pocket expense

Option 2:

When to use: Use option 2 if you have extra time in the schedule to complete all of the treatment in the same day but you will be taking more time than just the average 20 minute prophy time.

Charge D1110 and then bill D1999 (and unspecified preventive procedure) for the extra time you took to complete the treatment.

For example every 5 minutes extra you use you could charge $10. So if you take an extra 15 minutes to complete the treatment you would charge the patient $30.

How to present the treatment plan: "After assessing the health of your mouth, I have noticed that you have generalized gingivitis with a heavy amount of build up on your teeth. If we leave the build up there, it may quickly turn into a more serious disease called periodontitis. Since it has been such a long time that you have had treatment, I am going to need more time to complete your treatment. Luckily, we are running ahead of schedule and I can complete it all today. Here is what the cost will be…...

Treatment plan:

APT 1:  D1110 - $64 covered at 100% by your insurance and D1999-$30 for the heavy buildup removal.

OPTION 3:

When to use: Use option 3 if you can’t see to do a proper exam because there is too much calculus or biofilm. The patient should be rescheduled for an assessment to determine if periodontal therapy or a prophy is needed.

Charge D4355 (Full mouth debridement) IF you can justify that a proper exam cannot be completed unless the biofilm and heavy buildup is removed first.

Then in 1-2 weeks, perform a follow up assessment and D1110 (prophylaxis).

Pro:

  1. The patient gets full coverage from insurance of care for the dental treatment.

Con’s:

  1. The D4355 code states,  “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.”

Therefore you must be able to justify, and state in your notes, that a comprehensive exam cannot be performed based on the amount of calculus and biofilm present.

       2. Removing just the gross debris leaves a risk for periodontal abscess and a potential of the patient thinking that they are “clean” and not return for the rest of the care. That is why this code should be used only in rare cases.  

How to present the treatment plan: "After assessing the health of your mouth, I have noticed that you a heavy amount of build up on your teeth. Due to the amount of build up, I will need to remove some of it for the dentist to do a proper exam. Then I will need to see you in 1 week to re-evaluate the health of your gingiva and teeth.  Here is what the cost will be…"

Treatment plan:

VISIT 1: D4355 - $64 covered at 80% by your insurance.

VISIT 2: Re-evaluation of periodontal health with new treatment plan presented.


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