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Periodontal Prophy’s

Ask the Expert ForumCategory: Insurance CodingPeriodontal Prophy’s
Avatarguestuser Staff asked 7 years ago

Many periodontal pts have a plan that only allows 6mo periondontal prophy’s. We all know they need to be treated every 3 months, to serve the patients can we call two of the four they receive in a year prophy’s ? Please let me know how your office would handle this. Thank you in advance, Penny Cooper,RDH

1 Answers
Karen Davis, RDH, BSDHKaren Davis, RDH, BSDH Staff answered 1 year ago

The answer to this very common question is likely not the answer you are hoping for. The truth of the matter is that dental insurance benefits should always be considered independent of what the patient needs clinically. Since the definitions of the prophylaxis D0110 and periodontal maintenance D4190 are based upon different clinical conditions it would not be appropriate to alternate D0110 and D4910, but rather provide D4910 at whatever interval is appropriate for the patients. For most this will be every 3 months, for some every 4. Obviously, that means that the patient must pay out of pocket for some of their periodontal maintenance visits. The annual maximum benefit for most dental patients is around $1500. For a small percentage of patients this may adequately reimburse for most of their dental needs at whatever percentage their contract allows for various procedures. For others, it will fall way short of assisting with all of their needs on an annual basis.

Dental insurance is a great benefit to help offset the costs of dental treatment, but rarely “covers” all costs. Patients need to be educated on this reality about dental insurance, as most tend to view it through the eyes of their medical insurance which follows a very different reimbursement schedule. Just look at the significant differences between monthly medical premiums and monthly dental premiums. Obviously, the lower cost for dental premium translates in to less reimbursement and fewer benefits. In my office we explain the limitations of dental insurance reimbursement from the very first appointment, yet congratulate the patients that do have insurance since some reimbursement is better than none at all. It is important to help patients have realistic expectations about dental insurance. That education must come from the dental team. Often, patients are misled to believe it “covers” more than it really does from their employer. – KAREN DAVIS, RDH, BSDH