PART 2-How To Increase Production-With The Medical History Interview
You may see some form of the following questions on your health history. As I go through them I will discuss the ways you will increase production while improving oral health.
UPDATED 4-6-24
In part one of this series, I discussed how in increase production with radiographs. Now I want to address how to do this with the medical history interview.
I often get asked the question, “How can I increase the hygiene department's production?” There are two main reasons why this is being asked. The first is the hygienist is being told that they don’t produce enough or second, because you work on commission you would like to earn what you are worth. In both of these scenarios, you HAVE to find a balance between producing and improving oral health.
I daily ask myself the question while reviewing my charts, “hHw can I help my patients today?” If you can provide high quality care, the finances will come.
You may see some form of the following questions on your health history. As I go through them, I will discuss the ways you will increase production while improving oral health.
Do you take any medications?
This increases the patient's risk for caries and causes xerostomia. A full caries prevention protocol needs to be implemented. Consider a fluoride treatment, fluoride toothpastes, xerostomia products and electric toothbrushes.
Do you smoke, use alcohol, have diabetes, or do your gums bleed when you brush?
Prepare for a potential perio case, and lots of oral hygiene education, as these are risk factors for periodontitis. You may be preparing for laser use, HybenX, Arestin, Perio protect, Etc.
Do you participate in high contact sports?
I had a friend get kicked in the face during a soccer game breaking his teeth right off at the gingival margin. I am now an advocate for athletic mouth guards to my patients involved in contact sports. These are as easy to make as a whitening tray. They just take a quick impression and pour up to make one in office. You can even create customized colors and designs. Check with your supply company to get some in your office.
Do you have any concerns with the look of your smile?
Does your office offer 1 hour bleaching like Zoom, Sinsational Smile or whitening trays? Patients love white teeth, so keep alginate and impression trays close by and offer to take the impressions that day to get the process started.
Do you grind your teeth?
This is a sign that a patient may have sleep apnea. Does your office offer sleep apnea devices or referrals to sleep physicians?
Are your teeth sensitive?
Use the dental code D9910 and place Gluma, Crest Pro Relief polishing paste or a fluoride varnish or silver diamine fluoride. Have a brainstorming meeting as an office to set a protocol and cost for desensitizing.
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:
The patient gets full coverage from insurance of care for the dental treatment.
Con’s:
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.
Want more help with codes and billing. Check out our 1 page guide to billing and coding for hygienists in our store. On sale now.
Are you expected to be an expert on codes? Then check out this ONE page guide to billing and coding. This simple digital download contains information about frequently used codes in the hygiene department. It reviews when to bill for a procedure, and what the general coverage for such procedures are.
CDT Code Updates 2015
Here at Hygiene Edge we thought you may be interested to find out some of the newest CDT code updates that are available out there for hygienists to use in our daily practice. I always recommend coding for the services you provide even if you don’t charge for them.
Here at Hygiene Edge we thought you may be interested to find out some of the newest CDT code updates that are available out there for hygienists to use in our daily practice. I always recommend coding for the services you provide even if you don’t charge for them.
D9931 Cleaning and Inspection of a Removable Appliance
Have you ever had to clean a removable denture? Even after I have put the denture in the tartar cleaner and placed it in the ultrasonic for 15 minutes the calculus is usually still there. If this is the case I will take my ultrasonic on a very low setting and scale off the remaining calculus (take the ultrasonic to the calc. only.) Now when I do this procedure I can add the proper code for the treatment completed.
D1353 Sealant repair — Per Tooth
Of course when my patients sit in the chair I am looking to see if the sealants that were placed at the last visit are preforming their duties properly. There have been a few times where I have found the need to give a little touch up. Now when I do this I have this code to utilize.
D4921- Gingival Irrigation
This addition actually comes from the CDT 2014 updates. If you are putting an anti-microbial irrigation into pockets following root debridement you should use this code in your treatment plan.
D1208- Fluoride (Excluding Varnish)
If you are placing fluoride varnish use the code D1206 and if you are using any other type of fluoride application such as gels, foams, or swishes, then use D1208.
While of course submitting a code to the dental insurance doesn’t mean you will get reimbursed, still code for the services you provide. This creates value to the patient as they look through their itemized walk out statement and they can see all of the services that were provided that day.
-Shelley