Many dentists don't understand why claims for SRP are denied when the patient has abnormal pocket depths. A claim may be paid on a patient with 4mm pockets while at other times the same payer may deny the same procedure for another patient who had the same or similar clinical presentation.
This is very confusing for dentists. When the claim is denied some patients may think that the dentist is performing unnecessary procedures.
When patients or members of the dental office staff contact a payer to determine whether a benefit is available under a specific plan, they are usually given a yes/no response. Specific payment guidelines may not be provided. If these were provided, the process would be much more transparent and many of these situations could be avoided. Until this is common practice, the carrier should make it clear to both patients and dentists that while SRP may be necessary, their plan will only provide a benefit when the plan's particular clinical indicators are present. If third-party payers disclosed the actual payment parameters, dentists could then tell the patient in advance what the plan might cover.
The ADA Council on Dental Benefit Programs notes that a single payer can reimburse various employee groups differently. In some cases payers act as insurers. In other cases they simply administer a policy on behalf of an employer. Purchasers of plans that cover many lives can often negotiate changes in reimbursement rates to meet economic targets. Dentists should advise their patients that coverage is often based on employer funding of the policy purchased rather than the clinical need of the specific patient.
Dental benefits industry perspective
Payers' standard clinical policies relating to coverage of specific procedures are developed based on a review of the scientific literature, the experience of their dental professionals, dental advisory councils and claims histories. A payer's standard practice in an area such as SRP may be modified for a particular employer based on that employer's preferred or negotiated benefit design, analysis of the employer's claims history, or recommendations of their benefits consultant. Thus, two claims to the same payer with a similar patient profile may be treated differently based on the employers' group dental policy under which each patient is covered.
While a pocket depth of 4mm or greater is the most commonly recognized indicator in the literature for SRP, there are differences within dentistry and dental literature about the specifics of pocket depths as benchmarks. Thus, payers establish their own criteria based on all these factors which can differ from payer to payer and potentially, from one customer to another within a single payer's book of business.
Just as payers' clinical policies differ, claims for periodontal procedures and treatments are frequently subject to coding variations when submitted by dentists. The addition of code D4342 has been helpful in determining appropriate benefit reimbursements. In the past, when code D4341 (full quadrant) was the only SRP code, it was more difficult to determine coverage where diagnostics supported SRP for a small number of teeth in a quadrant. The use of D4341 or D4342 in reporting more than 2 quadrants within a single dental visit will usually trigger a request for additional information such as a full-mouth periodontal charting, full-mouth X-ray, periodontal diagnosis and the treatment plan.
Many payers now post their guidelines to their Web sites (usually in a member protected area due to the inclusion of CDT codes which are copyright protected), include them in the provider office reference guide or make them available to dentists on request.
Tips for minimizing claim denials or delays for SRP:
- Before submitting a claim for SRP, check the company's guidelines on their Web site or in the provider office reference guide.
- When submitting SRP for more than 2 quadrants within a single visit, include documentation—full-mouth periodontal charting, FMX, periodontal diagnosis and the treatment plan.