What is the proper way to bill out for a 6wk SRP & perio re-evaluation? Code 0160 is not valid. If I bill 0180 then the patient has 2 complete perio re-evals. And also, we are polishing/ treating the rest of teeth, but not allowed to bill out for 4910 at that visit. In my training it is BILL as DO and DO as you BILL. We are completing an exam and cleaning at this visit but insurance never wants to pay for these services . Jenn
This question comes up a lot in dental practices, and unfortunately there is no a perfect answer. There is not a specific ADA procedure code for a periodontal re-evaluation following nonsurgical therapy. D4910 periodontal maintenance most closely describes the procedures performed during the periodontal re-evaluation. Due to the fact that active therapy includes treatment of a biofilm infection, the re-evaluation should include instrumentation and debridement of biofilm, and may also include site specific scaling and root planing in areas that have not undergone complete healing yet. The interval for performing the re-evaluation should be individualized, but generally takes place 6 – 12 weeks following active therapy. A limitation of benefits for some patient’s insurance plans specify that a D4910 will not be reimbursed sooner than 12 weeks or 3 months following active therapy, so you should inform the patient that in some cases it is billed as an out-of-pocket expense.
A good rule to keep in mind when considering insurance benefits for patients needing any type of periodontal therapy is that most insurance agreements between the insurance company and the employer include various restrictions and limitations for payment that have nothing to do with what the patient needs clinically. It is simply a limitation of the contract. For example, we know that most periodontal patients require periodontal maintenance approximately every 90 days to keep active disease under control following therapy; yet most plans limit reimbursement to 2 per year. Patients should be informed that insurance is a great benefit to help defray costs of care; but it should not be considered “coverage” as that implies complete cost of care.
KAREN DAVIS, RDH, BSDH