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.
Building an Office Anti-Caries Protocol With Xylitol
I graduated hygiene school with all of the enthusiasm in the world! I really felt like I was going to save Americans from this horrible oral health crisis. Then I started working in the real world. I began to see patients that asked me questions that I had NO idea how to answer. I felt panicky, confused and frustrated. I had little knowledge beyond brush, floss, and fluoride.
I graduated hygiene school with all of the enthusiasm in the world! I really felt like I was going to save Americans from this horrible oral health crisis. Then I started working in the real world. I began to see patients that asked me questions that I had NO idea how to answer. I felt panicky, confused and frustrated. I had little knowledge beyond brush, floss, and fluoride.
I remember one time in particular I had a patient with excellent oral hygiene. She had great probe readings, little plaque and LOTS of cavities. She did not have any of the typical causes of decay (heavy soda drinking, etc.) She was so frustrated, and I was too. I went to another hygienist and presented her with my findings, she replied, “she must just have weak teeth.” The patient had no trace of congenital problems with teeth formation and I couldn’t accept the idea of “it must just be the way it is for her.”
I went home and began to research everything I could from dental journals, books and hygiene message boards. That is when I really started learning about the benefits of xylitol. There are actually over 2000 studies that have been conducted. It has the ability to drastically reduce decay (around 70 percent) and cut down plaque (50 percent,) which is more than patients usually remove by brushing.
I learned about how other countries use it in their schools but we are a little bit behind in the U.S. I also learned that when mothers had enough exposures to xylitol their babies had a huge reduction in decay because cavity-causing bacteria were not being passed.
I was so excited about xylitol and found my patients really shared my enthusiasm. I had great compliance and saw great results. I find that hygienist are not offering xylitol to their patients because of various barriers. Below are a few solutions to those barriers.
Lack of Knowledge: A lot of hygienist don’t feel confident talking about a product that they don’t know a lot about. I would recommend brushing up on the topic. I love Trisha O’heirs writing on the subject. Check out her article in dental town HERE.
Also, a xylitol company called Xlear does lunch-in-learns over Skype. You can also check out another amazing xylitol company called Xyloburst that has an awesome website full of information.
Here at Hygiene Edge we have also created a FREE informational handout for to give to your patients as well HERE.
Accessibility: I’ve heard from hygienists that they don’t like having to send their patients to the health food store or on online to get xylitol. A resolution to this is do what my office does and carry the product in-office. It was hard to keep on the shelves! We mostly sold the Spry 30 day system from Xlear. I’ve also personally been really impressed with Xyloburst’s selection of products; especially the suckers for kids!
Exposures: One barrier for hygienists is that the patients have to get five exposures throughout the day. This sounds like a lot but think of the concept of simply replacing out their existing gum/candy habit. A lot of already snack and chew gum so simply swap it out with the products they are using. I tell my patients to “Strive For Five”!
Expense: The beauty of having xylitol in your office is that you can lower the price a little bit. Xylitol is definitely more expensive than gum with sorbitol and other sugars but it’s a LOT cheaper than a cavity and precious tooth structure. I always let my patients decide and most are willing and grateful to try something “new.”
It will take some work but you too can create an anti-cavity protocol for your office that will benefit your patients long term.
Mixing and Pouring Dental Stone
Our latest video shows how to mix and pour stone for the perfect dental model.
Do you take impressions or pour up models at your office?
Medical History Update Tip
The first thing we always ask our patients when they sit in our chair is "Have you had any changes in your medical history?" Of course, they quickly answer no. Nothing is more stressful than half way through treatment, the patient casually mentions they had a heart attack a month ago or started taking a blood thinning medication a week ago.
Instead of asking if they've had changes, start off by asking your patient if they have been to the hospital since the last time they were at your office. Patients forget a doctor's visit or a change in medication, but they don't forget being in the hospital. If they haven't been to the hospital, they are now thinking on medical terms and will remember their slight changes in health with your follow up questions. Asking if they've been to the hospital will also give you an idea of how controlled their health is. If you know they have diabetes and they report they were admitted to the hospital for a day, you know the are not in control. If they have high blood pressure but their numbers were within the normal ranges for that day but they were hospitalized in the last few months, they probably are not well regulated. Knowing if they have been to the hospital will give you a better understanding of their overall health.
How do YOU update medical histories in your office?
Some Unexpected Dental Hygiene Advice From… Jillian Michaels.
I attentively watched the television screen as Jillian Michaels (an athletic trainer from the show “Biggest Loser”) barked orders at a lady to move faster and push harder on the treadmill. This was at the beginning of the season and the contestant was very out of shape and looked… well..miserable. She was sweaty, red and breathless as she made uncoordinated movements between her legs and arms. Jillian then said something very profound to this women,
"You have to get uncomfortable before you can get comfortable.”
I was caught off guard to hear such sound advice from a reality television show. But Jillian Michaels was absolutely right. This lady had to put herself in some VERY uncomfortable situations over and over until….. one day she could just jump on the treadmill and run miles without giving it a second thought.
This idea has become one of my personal mantras in dental hygiene. In Dental hygiene the list of ways to get uncomfortable are endless:
· Learning to help out in the front office
· Helping the dentist on his side
· Using new dental software
· Using a new type of instrument
· Substituting in a new office
· Performing a procedure you don’t have a lot of experience in
And the list could go on and on. But, just like the out-of-shape contestant, the more we push ourselves out of our comfort zone the more these once uncomfortable, momentous and overwhelming tasks become second nature and we are able to comfortably make large contributions to any dental office.
This theory was confirmed a couple months ago when I contacted a hygienist with over 30 years of experience last minute to fill in for our hygienist. This hygienist was able to get there just as the patient was showing up. She walked in confidently, asked all of the right questions, and then proceeded to go through her day like she had been there forever. The patients were happy, she meshed with the staff and even offered a hand in the front. This hygienist had undoubtedly gone through some uncomfortable and stretching experiences in the last 30 years and it had paid off.
So get out there and plan on getting uncomfortable because the sooner that happens the sooner you can get comfortable.
Dental Hygiene Analogies
Using analogies to explain to the patient their current health or treatment can really drive the point home. Here are a few examples to try in your practice of dental hygiene to relate to your patient and increase case acceptance.
1. Periodontal Disease- To explain periodontal disease, relate it to a coral reef. Just like fish with a coral reef, a mouth has many different kinds of bacteria. The coral is like calculus and the animals or bacteria live around or in the coral. The only way to get rid of the bacteria is to get rid of their ecosystem or remove calculus. Calculus is hard just like coral so it has to be professionally removed by a dental hygienist.
2. Bridges- Many patients with bridges say that their bridge is so tight that they don’t need to clean underneath it. You can relate a bridge to walking on the beach with shoes on. No matter how tight you tie your shoes, you will still get sand in them. Just like the shoe example, you’ll get bacteria around bridges no matter how tight they seem.
3. Home Care- When explaining how important home care is after periodontal therapy, relate it to taking care of a large cut or wound. If your patient had a large cut, doctors would require them to clean it and the bandages daily. We require the same thing- keeping the affected area daily with brushing, flossing, water pick, interproximal brushes, ect. Without that daily maintenance anywhere on the body, the area will not heal properly and cause infection.
What are some analogies you use in practice?
How To Answer Illegal Questions During Your Dental Hygiene Job Interview
Before you get all worked up by the title, thinking that a potential employer is out to get you, I want you first to keep in mind that the interviewer is probably just trying to genuinely get to know you better as a person. They are trying to read your body language and see if your personality is a good fit for the office. If they ask improper questions it is most likely that they don’t even realize that they are doing so.
So, what are some of those most common illegal questions that you may get asked in an interview?
Illegal: Do you have any children?
Legal: Do you have any impairment that requires special accommodation?
Illegal: How old are you?
Legal: Are you 18 years or older?
Illegal: Are you married?
Legal: No legal version to this question.
Illegal: What religion are you?
Legal: No legal version to this question.
Illegal: What is your national origin?
Legal: Are you a citizen of the United States, or what languages do you speak, read, and write?
Some of you may not be concerned by having one of theses questions asked to you, but the reason that they are illegal is because they could cause the employer not to hire you based on the following:
Race
Color
Sex
Religion
National origin
Birthplace
Age
Disability status
or
Marital status.
These topics could potentially cause the employer to discriminate against you, a.k.a. not hire you because of your religion or because of your age. We don’t think it makes a difference but, it can, and that is why there are certain protections and rights set up for us. I knew of a dentist who didn’t want to hire anyone recently married because it was thought they were just going to start a family and quit. I have also heard of an office that didn’t want someone who is "old" taking care of patients. They wanted a “young fresh face.” (Not a place I would want to work!)
Once again my purpose for this article is just to make you aware that it happens and how to prevent it from happening to you. I would recommend that, before you interview, you review the questions above so you can be prepared to answer how you choose. If you are concerned that you may be discriminated against, on one of the above topics, then prepare your answer ahead of time by following some of the options below.
Option 1- You could state, “That is not an interview question I feel comfortable answering.”
With this type of of an answer you are sure to turn off your future employer which may prevent you from landing a job at an amazing place. See some of the better options below.
Option 2- Simply answer the question. If it doesn’t bother you then shrug it off and maybe even ask them the same question back. You don’t have to elaborate on the subject, but if you are proud that you have 3 children by all means, let them know.
For example, you could state, “Yes I have 3 wonderful children, do you have any children yourself?”
Option 3- Answer the legal version of the question.
For example, maybe you have a dark complexion and you are asked what nationality you are. You could state:
“I’ve actually lived in many places, but I am legally allowed to work in the U.S., if that’s what you’re asking.”
Option 4- Relate the question back to your employment.
For example, if you are asked if you are married (illegal), you could say:
“You know, I’m not quite there yet, but I am very interested to know more about how you like your hygiene department run. Can you tell me more about that?”
Another example is, what if they ask what religion do you practice (illegal) you could say:
I have a strong belief set and I have great respect for all religions and beliefs. I promise that I will treat your patients with the utmost care and consideration.
_______________________________________________
Interviewing is always stressful. Practice, practice and practice some more, with friends and family, so that your interview will be successful. Best of luck!