Coding done right
December 01, 2016
A new scaling code in CDT 2017 has dentists interested in what it entails, when they use it and how dental plans will reimburse for it.
Dentists can begin using "D4346 Scaling in the generalized presence of moderate or severe gingival inflammation — full mouth, after oral evaluation" as of Jan. 1. The code reflects the procedure for patients with gingival disease and no attachment loss. Dentists who have delivered the procedure have not been able to document and report it with an appropriate CDT code until now.
"The procedure is more than a prophylaxis because the clinical condition of the patient's gingiva is compromised as evident by the level of inflammation, but less extensive and intrusive than scaling and root planing since the patient does not have bone or attachment loss," said Dr. Ron Riggins, chair of the Council on Dental Benefit Programs Code Maintenance Committee, which added the code during its March meeting. "Using this CDT code to document a time consuming prophylaxis, often referred to as a hard 'prophy' is not appropriate."
Dr. Riggins said many dentists who have attended education programs on this procedure asked when it would be clinically indicated and how the claims reporting D4346 will be adjudicated. The questions prompted staff in the ADA Practice Institute to investigate how dental plans will reimburse for the code.
"When it comes to coverage, it will vary by payer and benefit plan design," Dr. Riggins said. "Frequency limits, for example, may parallel those for a prophylaxis, or limited to once per two to three years, or once per lifetime. Reimbursement amounts should be, in most cases but not always, between a prophylaxis and a scaling and root planing. The common thread in payer responses is that utilization will be watched."
The ADA will also be watching to see how dentists utilize this code and how payers reimburse for the procedure. When the Code Maintenance Committee decided by an overwhelming majority vote to add D4346 the expectation was that over time there would be less downcoding of this procedure to a prophylaxis, along with less upcoding to a scaling and root planing.
"This procedure supports prevention of periodontal disease," Dr. Riggins said. "The overarching goal is to recognize that this is a procedure that prevents disease progression as well as supports a patient's long-term oral and overall health. By doing the right thing, dentists would accurately report the service provided, and payers would appropriately reimburse for the reported service. It's a matter of ethical and equitable actions by both," Dr. Riggins said.
To learn more about this new code and the CDT, visit ADA.org
. Search for "Guidance on the D4346 Scaling Procedure" to watch a webinar and download the free publication "Guide to Reporting D4346. The guide was first published in May but has been updated and incorporates content and feedback from the webinar.
To order the manual
, CDT 2017 Companion guide
or CDT Code Check app
, visit adacatalog.org
or call 1-800-947-4746. Use promo code 16136 before Jan. 31, 2017, to save 15 percent on all ADA Catalog products.