Thursday Troubleshooter: Misuse of code 4346 means dental practice is committing fraud
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QUESTION:RDH magazine published an article regarding the new code for gingivitis. I have just moved from one state to another, and the dental hygienist in the new office I’m in believes that prophy just covers above gum line cleaning, and that anything below should be billed as gingivitis treatment. Is this true? If it is, this is against everything I was taught during hygiene school, which is to never leave "stuff" below the gum line during a prophy. Please help me to understand this new code. Thank you.
ANSWER FROM DIANNE GLASSCOE WATTERSON, RDH,Watterson Speaking and Consulting LLC:
No! This is not true. The current descriptor for code D1110 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." Is the root part of the tooth structure? Of course it is! What your office is promoting is fraud, plain and simple. D4346 is scaling in the presence of generalized moderate or severe gingival inflammation—full mouth, after oral evaluation. (This code came into effect January 1, 2017.) It is the removal of plaque, calculus, and stains from supra- and sub-gingival tooth surfaces when there is generalized moderate or severe gingival inflammation in the absence of periodontitis.
It is indicated for patients who have swollen and inflamed gingiva, generalized suprabony pockets, and moderate to severe bleeding on probing. This should not be reported in conjunction with prophylaxis, scaling and root planing, or debridement procedures.
The definition of “… generalized moderate to severe gingival inflammation …” is, when 30% or more of a patient’s teeth at one or more sites are involved. If gingivitis is localized, the correct code is D1110.
Please share this with your team or the dentist so that there is no more misunderstanding. It’s important that you help them understand how to work with the code so that they are no longer committing fraud. Good luck!
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