Documentation musts for reimbursement of scaling and root planing

Periodontal treatment has changed as time has allowed us to learn new facts about the disease and the best types of treatment. Different autogenous and non-autogenous grafting materials are now used more often.

Dental implant placement is a more common scenario in periodontal treatment. Bone regeneration has become more successful and standard as newer products and techniques have improved outcomes.

Periodontics is a category that includes nonsurgical and surgical procedures. The Code on Dental Procedures and Nomenclature (CDT) has grown with the addition of new codes. It can be frustrating for billers to ensure that the procedures are coded and thus billed correctly. Unpaid claims for periodontal services are common and severely slow down cash flow.

Building a foundation of periodontal care for your patients includes proper documentation so that insurance plans cannot deny your claims for clinical reasons. If there is evidence of periodontal disease, performing a D0180  -- Comprehensive periodontal evaluation on a new or established patient -- is the best way to develop a baseline periodontal history.

The comprehensive periodontal evaluation will support scaling and root planing when the dentist reviews the patient's overall health and provides detailed six-point periodontal charting. Current radiographs must be included to plainly show the bone level of each tooth in the arch and the integrity of other tooth structures.  A good baseline will help identify if the periodontal disease progresses. Coding for scaling and root planing indicates the number of teeth treated in each quadrant.

D4341 -- Periodontal scaling and root planing (four or more teeth per quadrant) -- and D4342 -- Periodontal scaling and root planing (one to three teeth per quadrant)

You must indicate the teeth numbers on the claims and have the evidence to support the need for scaling and root planing for each tooth listed. Practices that do not have a program for periodontal care are simply ignoring their patients' periodontal disease. This is evident in posting on industry message boards when new practice owners ask for advice about how to begin treating perio when the practice has ignored it for decades.

Scaling and root planing have been standards in nonsurgical treatment for decades, but many claims are still denied. Most periodontal scaling and root planing claims are denied due to insufficient supporting documentation. What you send with the claim determines whether it is paid or not. 

Most plans require more than the standard periodontal chart, with pocket probing depths of 4 mm to 5 mm and clinical notes stating bone loss to approve the claim. If you bill for a quadrant of root planing, which according to coding standards, is four or more teeth but only two teeth qualify, you will most likely get a denial or a request for more information. Coding correctly backed by evidence is the key here.

If many claims are denied for scaling and root planing, you need help diagnosing correctly or providing supporting documentation. If you are in a preferred provider organization network, you may not bill the patient for claims denied due to a lack of medical necessity.

 Insurance plans are looking for the following three items on your claims for scaling and root planing:

1. Proof of clinical attachment loss (CAL). Bare bones probing depths are insufficient.

CAL refers to the loss of attachment between the tooth surface and the surrounding gum tissue. It is measured from a fixed reference point, the cementoenamel junction (CEJ).

In cases without any recession, the formula for CAL is the following:

Loss of attachment (mm) = Probing depth (mm) - Distance from gingival margin to the CEJ.

Bone loss is mandatory for the perio claims (not just written notes but backed with attached evidence.) A computed tomography (CT) scan or perio chart with CAL would be required to demonstrate it, or you are improperly coding the claim. A dental CT scan is an imaging procedure that scans the teeth and surrounding tissue. 

In general, probing depths of 3 mm or less signify periodontal health. Losing attachment is usually associated with depths of 5 mm or more. A measurement of 4 mm is the middle ground. Many plans do not consider 4 mm depth periodontal disease.

The American Academy of Periodontology recommends probing six points circumferentially around every tooth at every recare visit, not just for the patient record but also from a medical/legal standpoint. 

2. Radiographs must show areas of bone loss or loss of attachment. 

3. Chart any missing teeth (any clinical team member) to help identify the teeth being treated.

Dentists and their clinical team, which includes hygienists and dental assistants, often leave it up to the front desk to get claims paid without realizing that the clinical team needs to provide the evidence. Getting claims paid is more than just a front desk duty. The help and support of the entire team can expedite this daily task.

How can the entire team help get claims for scaling and root planing paid?

1. At your morning huddle or morning meeting, the front desk should check for documentation in the clinical chart for all upcoming treatments. Do you have what you need to bill the claim correctly?
   
   
2. The front desk should review a verified insurance coverage breakdown and what the plan needs as documentation for scheduled procedures.
   
   
3. Each patient scheduled for scaling and root planing must have the necessary documentation or the team, most likely the dental assistant, will arrange to get the information at that appointment.
   
   
4. The hygienist checks the chart and verifies the treatment for that day. The front desk checks to see that the codes for the treatment are correct (approved by the dentist). Will there be assisted hygiene in obtaining radiographs and charting? Sometimes, evidence is not gathered due to staff being unavailable or time restrictions.
   
   
5. The front desk will inform the patient of any out-of-pocket costs before the appointment.

It pays in many ways to establish a periodontal program protocol for your patients. 

References

1. Staging and Grading Periodontitis.https://sites.perio.org/wp-content/uploads/2019/08/Staging-and-Grading-Periodontitis.pdf.
2. Ostrander S. New AAP Periodontal Classification Guidelines - Today’s RDH. Today’s RDH. Published July 31, 2018. https://www.todaysrdh.com/new-aap-periodontal-classification-guidelines/.

Estela Vargas, CRDH, is the founder and CEO of Remote Sourcing, a dental insurance billing and revenue recovery service. She is a graduate of Miami Dade College's dental hygiene program. Vargas' extensive background in the clinical arena of dentistry is coupled with her experience as a practice administrator and business executive. 

The comments and observations expressed herein do not necessarily reflect the opinions of DrBicuspid.com, nor should they be construed as an endorsement or admonishment of any particular idea, vendor, or organization.