Practical Claims and Coding: Oral and Systemic Disease Insurance Coding and Patient Education

By Carol Tekavec, CDA, RDH

Dentists and physicians have known for years that illnesses and conditions of the mouth, gums, and teeth are directly related to illnesses and conditions in the rest of the body. Research provides evidence to back this up. Oral health and its relationship to diabetes, heart disease, stroke, and even premature, low-birth-weight infants is in the news. Patients are looking for more complete information and are turning to their dentists.

Increased knowledge of systemic diseases and dental care helps patients embrace the importance of regular dental visits. In addition, knowledge of the relationships between periodontal conditions and serious illnesses can help your patients say "yes" to treatment you recommend. Unfortunately, dental benefits for periodontal treatment are usually limited. Patient education is important.

Here are some ideas:

• Help patients understand the role of infection and inflammation in oral and systemic disease. Patients need to know that recent studies indicate bacterial infection and tissue inflammation are important causative factors in periodontal disease as well as in diseases such as diabetes, heart disease, stroke, and other serious problems. Inflammation appears to be one of the most important links between systemic and oral conditions. If the cause of the inflammation does not go away or becomes worse, harm may occur to organs, the heart, joints, and nerves. Periodontal disease can be a prime suspect when the inflammatory process does not shut off.

• Help patients understand periodontal treatment and the body's overall immune response. For many patients, root planing and scaling of the teeth, or surgical intervention by a dentist may be indicated. Medicines, irrigation, or oral prescriptions might also be needed. When periodontal disease is reduced or eliminated, the body's immune system can begin or accelerate the healing process.

• Explain the limited nature of dental insurance for periodontal services. After learning how important oral health is to their general health, many patients want to know why their medical plans do not cover their dental treatment. They rightfully ask, "How did the mouth get separated from the rest of the body?" While dentists and physicians have long accepted that mouth and body conditions are intimately related, benefits for oral treatments have traditionally been restricted to tooth-only plans. This is still the case, although a few insurers such as Aetna are beginning to accept financial responsibility for additional or more frequent oral services. Delta and Met-Life, among others, are starting to offer payment for more than two annual cleanings for pregnant or diabetic subscribers who have both medical and dental plans through their companies. Oral-cancer screenings are also beginning to get better coverage. In the future, we might see even more cooperation. Future benefits may be improved; however, patients need to know what their dental benefits for periodontal treatment are today.

• Codes and typical insurance contract guidelines. It is important that dentists diagnose and prescribe whatever treatment is appropriate for a patient, regardless of insurance coverage. Still, there are typical insurance contract restrictions that patients need to know:

1. D1110-Prophylaxis-Adult: The ADA definition is "Removal of plaque, calculus, and stains from the tooth structures in the permanent and transitional dentition. It is intended to control local irritational factors." This code is typically paid twice a year. There may or may not be a required lapse of six months between the two services.

2. D4355-Full-Mouth Debridement to Enable Comprehensive Evaluation and Diagnosis: This code is typically paid at the same rate as the D1110. Companies who provide for a higher designated benefit usually pay only after any deductible has been satisfied, and often on a once every three to five years or once per patient lifetime limit. The code is usually not paid at the same time and on the same claim form as any evaluation (exam) code.

3. D4341 (Quadrant) and D4342 (1-3 Teeth) — Periodontal Scaling and Root Planing: For payment, most carriers require certain data collection to accompany the claim. Usually this includes full-mouth periodontal probing depths, bleeding, furcations, mobility, and recession. With required documentation, many carriers will pay these codes once every two years.

4. D4910 — Periodontal Maintenance: This code is usually a benefit twice a year with required documentation, and only after "active therapy," which is considered scaling, root planing, and or surgery. Documentation includes those items listed in No. 3.

5. Periodontal probing? There is no separate code for probing. Probing and recording are considered to be part of any evaluation procedure.

6. D4381 — Localized Delivery of Antimicrobial Agents: This code is not frequently covered. A few carriers will consider it twice a year for a maximum of two teeth per quadrant that present with at least 5mm pockets and bleeding. Some carriers require that root planing and scaling must have previously been delivered.

7. Surgical interventions: Many codes exist for periodontal surgery. Most are covered with the restriction of annual benefit limits, which are typically $1,000 to $1,500.

Patients who require periodontal treatment usually are required to pay for most of that treatment personally. Multiple visits required for tissue-management programs are seldom paid by insurance. Helping patients understand their treatment needs and insurance limitations can be important for the health of patients and the practice.

Carol Tekavec, CDA, RDH, is the author of "Dental Insurance Coding Handbook 2005-2008." She is the designer of a dental chart, lecturer with the ADA Seminar Series, and practicing clinical hygienist. Call her at (800) 548-2164, or visit her Web site at www.steppingstonestosuccess.com, where you may also read her patient brochures "Your Mouth Can Make You Sick" and "Insurance Covers This, Right?"