By Cindy Hartwell, dental benefits analyst at CDA Practice Support
CDA Practice Support is receiving calls from dentists and their staff concerning claim denials for scaling and root planing services by dental benefit plans. In this article, I review the criteria utilized by dental plans when reviewing claims for scaling and root planing and why some of the plan denials are correct based on the American Dental Association’s definition of scaling and root planing.
First, let’s look at the difference between the D4341 and D4346.
In the ADA Guide to Reporting D4346, version 4, published July 2018, the code descriptor for D4341 (periodontal scaling and root planing – four or more teeth per quadrant) reads, “The code is to be used to report a procedure that involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. It is indicated for patients with periodontal disease and is therapeutic, not prophylactic, in nature.”
The descriptor continues: “Root planing is the definitive procedure designed for the removal of cementum and dentin that is rough, and/or permeated by calculus or contaminated with toxins or microorganisms. Some soft tissue removal occurs. This procedure may be used as a definitive treatment in some stages of periodontal disease and/or as a part of pre-surgical procedures in others.”
The ADA in 2017 introduced a new code: D4346 (scaling in presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation). That code descriptor reads, “this code is to report 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, inflamed gingiva, generalized suprabony pockets, and moderate to severe bleeding on probing. It should not be reported in conjunction with prophylaxis, scaling and root planing, or debridement procedures.”
In its guide to reporting the D4346, the ADA explains why the code was implemented. The guide states that the code D1110 is largely a preventive procedure but can be therapeutic depending on the periodontium’s overall health. It is applicable for patients with generally healthy periodontium where any deposits are removed to control irritational factors and also for patients with localized gingivitis to prevent further progression of the disease.
The ADA guide goes on to explain that codes D4341 and D4342 are therapeutic procedures and are indicated for patients who require scaling and root planing due to bone loss and subsequent loss of attachment. Instrumentation of the exposed root surface to remove deposits is an integral part of this procedure.
Before D4346 was implemented, there was no code available to report therapeutic treatment of patients with generalized moderate to severe gingival inflammation with or without pseudo-pockets but exhibiting no bone loss. With the implementation of the D4346 code, that gap was filled.
As a result, dental benefit plans are focusing not just on the submitted periodontal markings, but they are also looking for radiographic evidence of bone loss. Without the radiographic evidence of bone loss, a plan is likely to deny the scaling and root planing claim.
Keep in mind that if the radiographic evidence of bone loss is only visible on one to three teeth, the code D4342 exists to report this service as it is used to report periodontal scaling and root planing for one to three teeth per quadrant.
It is important to remember that while dental plans are required to recognize the current CDT codes, they are not required to pay or provide benefits for the code.
Dental offices are encouraged to log into the plan’s online portal and review their patient’s benefit design for coverage. While logged into the online portal, review the plan’s updated provider handbook to stay on top of plan processing policy changes. If you cannot access the online portal for a plan or cannot locate the above-mentioned information in the portal, contact the plan for assistance.
For more information on reporting the D4346, CDA encourages members to refer to the ADA Guide to Reporting D4346.
CDA Practice Support offers individual member assistance with dental benefit questions. Simply submit your questions online using the dental benefit submission form accessible through your
cda.org account. Practice Support will analyze the issue, evaluate it for possible resolution and communicate clear next steps.
To submit your dental benefit questions online, visit My Account, click the link for Dental Benefits Issue Submission and follow the prompts.