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QUESTION: I’m writing about code D4355. We’ve got an Explanation of Benefits (EOB) that states, “Full mouth debridement is a covered benefit if rendered by itself, in conjunction with, or within 36 months of a limited oral evaluation, nutritional and tobacco counseling, oral hygiene instructions, radiographic images, adjunctive prediagnostic tests, palliative treatment, or after-hours office visits. Full mouth debridement (FMD) will not be covered if any other preventive, diagnostic, or periodontal service has been performed on the same day or within the previous 36 months.”
What the heck? If we do a D0150, and the doctor recommends FMD, it can't be done for 36 months? This makes no sense. How could FMD be coded to be paid for services needed and rendered?
ANSWER FROM PATTI DiGANGI, founder of DentalCodeology:
The EOB can only explain what a policy covers or not. In this case, the contract was written with exclusions and limitations. Though the contract doesn’t seem to make sense logically, the contract is the contract.
Challenges and frustrations with third-party reimbursement often stem from confused and convoluted interpretations of the key terms: codes and coverage.
• Codes: The CDT codes support uniform, consistent, and accurate documentation of the services delivered for both third-party reimbursement and electronic health records.
• Coverage: Coverage is a contract between a third-party carrier and most often, a patient’s, spouse’s, or parent’s employer. Some dental offices have contracts with dental benefit carriers. All of these are also contract negotiations. Coverage or non-coverage is not based on the whim of a third-party carrier; it is based on those contracts.
The challenge here is also likely a misunderstanding of the D4355 code, which was redefined a couple of years ago. Most practice management software does not give the full definition. It reads:
• D4355 full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit. Definition: Full mouth debridement involves the preliminary removal of plaque and calculus that interferes with the ability of the dentist to perform a comprehensive oral evaluation. Not to be completed on the same day as D0150, D0160, or D0180.
This D4355 code specifically states no evaluations can be completed the same day. Yet, we don’t perform treatment without a preliminary view of the presenting conditions. The accurate code that can be submitted with D4355 is:
• D0191 assessment of a patient. Definition: A limited clinical inspection that is performed to identify possible signs of oral or systemic disease, malformation, or injury, and the potential need for referral for diagnosis and treatment.
A further issue is the dentist prescribing D4355 treatment after the D0150 evaluation. The language of the D4355 code specifically prohibits this. The D0150 code specifically calls for the dentist to provide a diagnosis. What is the diagnosis for this treatment?
My experience is that many dentists and hygienists are still thinking of gross/fine scale philosophy of periodontal treatment. As I have written in this column before, the gross/fine theory of periodontal care has not been accurate for many years.
The American Academy of Periodontology (AAP) Classification of Periodontal and Peri-Implant Diseases and Conditions 2018 defines four levels of periodontal health and includes a staging and grading system for periodontitis as well as classification of peri-implant disease. It might be helpful for the dentist and hygienist to learn this updated system. Dental benefit carriers have certainly learned it.
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