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Which is Best On A New Patient?

Ask the Expert ForumCategory: Insurance CodingWhich is Best On A New Patient?
Avatarguestuser Staff asked 5 years ago

I would like to know which is best on a new patient who has heavy sub and supragingival calculus: is it better to use the code for gross debridement or prophy? The patient knows she needs to return for 4 quads and the doctor said it’s better to code for prophy since it will be paid at 90%.

1 Answers
Karen Davis, RDH, BSDHKaren Davis, RDH, BSDH Staff answered 11 months ago

Your question is one that is often asked and I think the implied question is really about insurance reimbursement rather than a clinical indication, but I’ll answer it from both perspectives.
If a patient presents with such significant deposits that you are unable to gather data to make a diagnosis until some of the deposit is removed, then obviously you must perform a preliminary debridement first and use of D4355 is the appropriate billing code to use. It is not therapeutic in nature and simply “clears the way” for the patient to receive a comprehensive periodontal evaluation which is generally performed at a subsequent visit. Additional therapeutic treatment, i.e. SRP, is performed following an accurate periodontal diagnosis. Reimbursement for the use of code D4355 varies greatly but in some cases is applied to a detectible for periodontal treatment and in many cases is not be included with contract benefits at all so it becomes an out-of-pocket expense for the patient.

Prophylaxis is intended to control “local irritational factors” based upon the ADA definition and is preventive in nature so in a situation where a patient has such heavy deposits the clinician cannot accurately probe, it seems that patient is beyond the intent or scope of a prophylaxis, and again, the D4355 preliminary debridement would be in order. Prophylaxis is reimbursed at whatever percentage is allowable based upon the individual benefits. It may be as high as 90% or as low as 50% depending on the type of plan the patient has and the fees of the practice.

I’m sure you and your doctor don’t want to allow insurance to dictate the care you provide any more than you want patients to only accept treatment reimbursed by insurance. But, a caution here… it can be a slippery slope if you attempt to make clinical decisions for patients based upon common insurance benefits or limitations rather than the diagnosis of the patient. While not always popular, I would advise all clinicians to avoid considering insurance benefits for patients as you develop treatment plans. Procedures should follow the diagnosis. Insurance is nothing more than assistance to help patients defray the cost of quality dental care.

It is great when patients have assistance, but was never intended to “cover” all a patient would ever need for optimal oral health. That is a message dental professionals ideally should help patients understand, as there seems to be much misunderstanding surrounding insurance.

Thank you for raising the issue. KAREN