According to the Code on Dental Procedures and Nomenclature, this procedure is performed following periodontal therapy and continues for the life of the dentition. Periodontal maintenance is often denied, however, because many carriers have limited benefits for this procedure. Reports received from our member dentists indicate that some payers have limited this procedure to being paid as a benefit only within 2 to 12 months of SRP.
No mention of a time period following periodontal treatment is provided in the Code. Some payers have qualified periodontal maintenance by denying benefits for this procedure unless two or more quadrants have received prior therapy.
It seems that each carrier has different policies/limitations for this procedure. This is very confusing for both dentists and patients. While the dentist is performing and reporting the correct procedure, benefits are denied solely because of the plan's limitations. However, absent a full explanation that accompanies the denial, the patient may think that the dentist is incorrectly reporting or performing dental procedures. Disclosure of the processing policies in the employee benefit booklet and in an Explanation of Benefits would be very helpful to avoid inadvertent negative implications with respect to the doctor-patient treatment. Allowance of an alternate benefit for a lesser procedure should also be disclosed in the benefit booklet and the EOB.
The ADA Council on Dental Benefits believes it is incumbent upon dentists to deliver appropriate care to patients based upon clinical need, not by third party reimbursement that may be forthcoming. After
Periodontal therapy has been completed, newly exposed root structure and altered architecture often make debridement of plaque and calculus more difficult. This does not change with time. Patients should be told in advance that plan provisions may not provide for reimbursement of D4910 for extended periods. We must code for what we do, and educate our patients that all procedures are not covered by all plans.
Dental benefits industry perspective
Quite frankly, this code is a challenge for benefits administrators as well. In order to appropriately determine the benefit for procedure code D4910, it is necessary to have knowledge of the patients' prior periodontal history. Often, this information is not available during claims processing. If the patient has no prior claim history with the payer, or previous periodontal services were not paid by the current payer, it is difficult to properly assess the benefits level available to the patient.
If you are aware that the current payer does not have previous periodontal history on a patient, submitting periodontal charting with the claim will assist in the determination of benefits. Since most payers electronically store claim forms, submitted diagnostics and electronic attachments, an existing record will reside with the payer should there be any question as to the handling of the benefits reimbursement. Thus, resubmission of diagnostic materials would not be necessary on a patient whose periodontal therapy was covered by the payer.
Many payers require an examination, targeted periodontal probing, and a periodontal diagnosis for reimbursement of code D4910. As stated in the Code on Dental Procedures and Nomenclature, this procedure is instituted after periodontal therapy.
Although no time frame is outlined in the CDT, most payers require a waiting period of 8 to 12 weeks. If there are unusual circumstances that would require a different interval of treatment, documentation by the dentist with the original claim submission should forestall requests for additional information to determine the patient's benefits.
At times, payers are limited by specific guidelines from employer group and dental group contract language. When plan limitations exist, and continued D4910 are reported, many payers will allow payment for an adult prophylaxis, which is an integral component of the more global D4910, to provide some level of coverage for the insured patient.
Tips for minimizing claim denials for periodontal maintenance:
- If there are unusual circumstances that require a different interval of treatment than the one specified in the patient's plan documents, the dentist should provide documentation with the original claim submission.
- If a patient is covered under a new group policy, submission of the patient's history of treatment with the initial claim for D4910 will assist in the determination.