Welcome to Burkhart’s hygiene webinar to support hygiene systems in your practice. We’ve designed this webinar with the entire dental team in mind, as each team member plays a critical role in ensuring comprehensive patient care. Kathy Edwards, RDH, presents this information to help fellow hygienists, dentists, and their teams navigating through the sometimes confusing world of periodontal disease as it relates to proper coding and treatment modalities.
Follow along below.
Full Webinar Script
I’ve always thought, if dental hygiene could be as simple as providing the best care possible – without insurance obstacles, without coding rules, or patient resistance – we wouldn’t need webinars like these.
However, we do need these. By the end of this webinar, you should have the tools and strategies to navigate those obstacles to strengthen your systems for periodontal care for your patients.
Burkhart and Burkhart’s Practice Support Team are passionate about providing you with the expertise necessary to enhance your team and your practice’s success. So let’s get started.
To make sure we’re all on the same page, let’s start with the quick code overview. (Download the slides.)
1110 is your basic prophy code designed for healthy patients that do not exhibit bone loss. It falls in the 1000 range of preventative codes. The CDT definition includes the statement “to control local irritational factors.” This procedure is designed to treat gingival inflammation, both localized and mild, caused by irritational factors.
If the tissue has some mild or localized gingivitis with no bone loss, 1110 is indicated.
Gingivitis is the first stage of periodontal disease and may, or may not, progress to periodontitis. A good rule of thumb is that a prophy procedure does not involve scaling on root surfaces, even those that are above the gumline.
The next code, 4346, is for scaling in the presence of gingival inflammation. It’s important to note that this code is also not used when bone loss is present. It’s ideal for patients that exhibit generalized moderate to severe inflammation without bone loss.
1110 and 4346 are similar codes in that the patient does not have bone loss, and they differ in the amount of inflammation present. The prophy code covers mild inflammation, and 4346 covers moderate to severe inflammation. Pseudo pockets may be present for either one of these codes. If radiographic bone loss is present, you must consider a different pathway towards health, including utilizing one of the scaling and root planing codes.
4355 is a debridement code. This is justified when the level of calculus or plaque buildup on the teeth makes it impossible to do a comprehensive clinical exam due. The patient typically has a debridement and returns on a different day for the exam.
4355 should not be considered definitive treatment, it’s more of a preliminary process to allow the dentist an opportunity to do a comprehensive exam. You’ll need to do a definitive hygiene service, either a prophy or root planing when the exam is done. It can be difficult to get insurance coverage for 4355, and it is used infrequently.
4910, the next code, is for maintenance – this is done after a patient has been treated for the disease, usually through SRP or periodontal therapy, and are now stable. 4910 can also be reported after a surgical procedure, namely gingival flap or osseous surgeries. 4910 needs a trigger code for acceptance in an insurance world.
The trigger codes are 4341 or 4342 – your SRP codes, 4240 or 4241 – your gingival flap surgery codes, or 4260 or 4261 – the osseous surgery codes.
4910 is not a preventative code. It’s therapeutic and used when patients have bone loss as evidenced on dental films.
Typically a patient who is in a periodontal code will stay in a periodontal code, with few exceptions, for life.
4341 and 4342 are, of course, your SRP codes. 4341 is used to report a full quadrant of scaling and root planing and 4342 is used to report treatment of one to three teeth within a quadrant, so a partial quadrant.
It is possible to use 4341 and 4342 in different quadrants on the same patient depending on how they present. An example would be for a patient that needs 4341 for the upper right and upper left. Yet, on the lower arch, they’re missing all their molars and only the premolars exhibit bone loss and need SRP. In this case, 4342 would be used for the lower right and lower left.
SRP codes are considered to be active therapy in the treatment of periodontal disease. There may be times when a patient only needs active therapy in one or two quadrants of their entire mouth. In these cases, it’s advisable to complete a prophy for the entire dentition and bring the patient back to take care of the quadrants needing active therapy. In this way, you will be reimbursed for the prophy provided as well as the SRP.
Keep in mind that these codes are written by the American Dental Association to create a language of sorts that dental practices can use to effectively communicate with insurance companies. It removes the need to interpret language as it’s reduced to a numerical code. We work with dental practices across the country and we’ve heard 4341 described as SRP, SRPC, deep cleaning, periodontal therapy, root planing, etc. Without numerical codes, it would be confusing.
Codes are also designed to create consistency among dental practices. A patient with bone loss that extends to the middle third of the root would be identified and coded the exact same way if they’re in Seattle or they’re in Houston, as an example.
The coding committee meets annually to update these codes. Anyone can offer a suggestion to the committee for consideration, including dental workers and insurance companies.
Periodontitis: Staging & Grading
Fortunately, the American Academy of Periodontology provides detailed guidance to help clinicians select the proper code and treatment based on how the patient presents.
The patient should be staged and graded based on the extent of the clinical attachment loss, bone loss, and inflammation present.
Historically, clinicians have looked to pocket depths for staging. You can see on the chart in this slide that you also have to look at the radiographic bone loss when selecting the stage. In fact, you will see that the AAP refers to radiographic bone loss, noted here as RBL, frequently.
As an example, a patient in the Stage III category has a radiographic bone loss from CEJ the crestal bone height that extends to the middle third of the root. This is fairly easy to identify with good diagnostic films. In these cases, a prophy code would not be appropriate.
Example: Stage III or IV
The area with the most severe destruction determines the stage, as that area indicates the need for more complex management. For example, if a patient presents with generalized, mild, Stage I dentition; pocket depths are 4mm or less, and there’s a clinical attachment loss of 1-2mm, but they have one area with 5mm pocket depths, and you can see the bone loss extends to the middle third of the root on the films; that patient is classified as Stage III or IV based on the most severe condition in their dentition.
We advocate for vertical bitewings to fully evaluate bone health.
As you listen to this recording you may want to reevaluate the codes you are using in your own practice.
An excellent exercise is to bring hygienists and dentists together to review patient films the day before they’re scheduled as part of your huddle process. Evaluate the x-rays together for patients on the schedule for a prophy. Critically evaluate the films to determine if the patient has bone loss and is eligible for the prophy code they are scheduled for or if you need to identify them as a possible transition to a periodontal code.
Most Overused Hygiene Code?
When reviewing your own coding in your practice, know we typically find 1110, the prophy code, is often overutilized. Usually, the patient doesn’t qualify for the preventative code when they have radiographic bone loss.
The definition of 1110, as outlined by Dr. Charles Blair, notes an adult prophy is preventative in nature and includes scaling and polishing with the removal of plaque, calculus, and stains. The removal of all calculus and plaque above the CEJ is part of a prophy.
“Coding with Confidence” written by Dr. Charles Blair is an excellent resource when determining proper coding.
Goal to keep your patients with a bone loss out of the recare system and into the periodontal maintenance system.
An equally important goal is to reduce burnout for hygienists. There’s no greater burnout than working in a prophy palace. It diminishes the value the hygienist can bring to the patient and to the practice.
Half of American Adults Suffer from Gum Disease
According to the AAP, a staggering 47% of the population suffers from gum disease. Recent research from the CDC also supports this graphic. Almost half of the population has some level of gum disease, mostly undiagnosed and untreated.
Can you imagine if 47% of carious lesions went undiagnosed and untreated?
Dentistry has traditionally been a repair business. The hygiene focus was heavily tied to supporting restorative diagnosis and case acceptance – that’s because a dentist looks at the chip in a tooth, and the hygienist looks at the inflamed tissue around the gumline of the tooth.
To have a healthy practice, both the hygienist and the doctor need to see the chip and the inflammation.
If we follow the science and the studies we expect approximately 50% of Americans don’t qualify for a prophy code based on the definition.
Based on the pie graph in this slide – we might expect 50% of your patient base to receive a prophy, 40% to be active periodontal maintenance, and 10% to be receiving SRP at any one time.
Periodontal disease is a chronic disease with periods of acute breakdown. That’s why SRP should not be looked at as a once and done program. Patients should be educated you will continue to actively monitor their gum condition and, if another round of periodontal therapy is needed, you’ll discuss it with them. Let them know that that would not be unusual. You can look at the data in your own practice to see how close you come to these healthy benchmarks.
Measure Your Perio Program Health
This is the standard formula. Run a procedure code report for a 12-month period of time, add up all the hygiene codes listed on this slide, calculate the percentage of preventative care services you provided, and compare them to periodontal therapy codes and periodontal maintenance.
This practice was heavily prophy-based. Sometimes this indicates overutilization of the prophy code. You can look at bone levels on x-rays of your 1110 patients to see if this is the case for your practice.
However, there are legitimate reasons why this practice could have a higher prophy rate and still use accurate coding protocols. Let’s look at those outliers next.
Three common outliers may exist in your practice causing a legitimate higher-than-average prophy rate.
If you refer your perio patients to a periodontist regularly we would naturally expect you would have a higher prophy rate. If you have a high demographic of young people, ages 14 to 25, we would expect a higher prophy rate there as well. (Most of the studies done to determine periodontal disease statistics do not include 14-year-olds. However, most dental practice systems include 14-year-olds in the adult prophy percentage.)
There can also be a philosophy of care from the doctor that is heavily weighted towards trophies.
Periodontal Philosophy of Care
If the hygiene team doesn’t fully understand the doctor’s periodontal philosophy of care that’s the first step in creating a healthy program.
There are four steps to creating this philosophy of care.
You’ll need to determine in your practice:
When do you treat?
When do you retreat?
When do you refer?
When do you dismiss for non-compliance?
You will want some basic guidelines but also acknowledge each patient is unique and should be treated on a case-by-case basis.
A good example of when to treat could be to identify the periodontal stage the patient is in, identify the level of bone loss, and treat periodontally if bone loss is present.
If you have a patient who refuses periodontal treatment, perhaps they need more information to understand the condition. However, if they continue to refuse treatment and are an advanced bone loss case, you need to decide how much risk you’re willing to take if you keep inappropriately treating them in the hygiene department.
At some point, it may make more sense to let the patient know you are still available for all their restorative needs. However, you will be providing a referral to a gum disease specialist for future hygiene treatment as their condition is outside your scope without their willingness to complete the recommended periodontal treatment.
Plan a team meeting to discuss the periodontal philosophy of care. When everyone’s free to ask questions and review x-rays together, it is very beneficial in creating a consistent understanding and approach for treatment. If you have turnover in your team, it’s valuable to review the information again.
Use Periodontal Visual Aids
Visual aids can speed up the understanding process for the patient. This saves them the energy required to develop a mental image as you are trying to explain their condition.
The Practice Support Team has a wellness report available you may edit with your own logo and philosophy. It has simple but clear images showing the progression of periodontal disease. You can check the box next to the patient’s condition to personalize it for them. This becomes more valuable than a typical brochure that ends up in a garbage can after the visit. This is customized by you to be specific to your patient’s condition. We find this to be a very helpful tool when incorporating new periodontal protocols.
Models are also valuable ways to quickly explain periodontal conditions not readily understood by your patients. The old adage a picture speaks a thousand words is certainly true in this case and is a great time-saver for clinicians.
How Will Patients Feel the Difference?
It is also important to make sure the patient can perceive a difference between a prophy and a maintenance appointment. An SRP appointment is not likely to be confused with the prophy or maintenance but sometimes the prophy and maintenance feel the same to the patient and they don’t understand why one has a higher fee. You can help your patients understand this in several ways.
Verbalize the areas you’re actively monitoring that showed a breakdown in the past and let them know you’re continuing to remove biofilms from the root surfaces in those areas. Talk through the entire appointment in this manner. As a hygienist myself, this is my preferred method of making sure a patient knows the difference.
You can also take advantage of your ultrasonic scalers. Use the scalers frequently for periodontal patients and infrequently for your prophy patients.
Perhaps you would like to put an irrigating syringe on each tray for periodontal maintenance visits and explain why you’re using it.
You should always identify a reason to return that’s specific to each patient to bring value to the next visit. “I’m looking forward to seeing you in another three months.” Does not instill as much value as: “I’m looking forward to seeing you in another three months. I will check the two areas on the lower right that are still causing challenges. If the gums are not stable, we can talk about other options at that time.” Building value reduces no-shows.
The last section of this webinar is to review our most frequently asked questions.
How does the scenario happen that a practice overutilizes the prophy code 1110?
Depending on where the hygienist went to school, they may or may not have been trained on coding. They received training on providing safe and effective care, but there wasn’t a focus on codes. They may actually be providing a 4910 maintenance visit but coding it as a prophy visit.
It can also happen because, historically, a prophy is covered at 100% by insurance companies and, often, maintenance is covered at 80%. This can mean that there’s an out-of-pocket expense for the patient.
Coding a prophy can be the path of least resistance. You don’t have to build value in the service, and you don’t have to have an awkward financial conversation.
There may also be a high patient resistance that has led to overutilization of the prophy code.
Keep in mind, you are really worth the fee being charged for maintenance. It’s a good value for the patient. If dental offices only provided care covered at 100%, they would not be providing ideal patient care, and they would likely fail. The out-of-pocket expense for a maintenance visit is nominal compared to the out-of-pocket expense for other dental treatments such as crowns and implants.
What about patients with generalized recession but whose pocket depths are shallow?
The cause of the bone loss is not as important as the loss itself.
Does this picture look like the picture of a prophy patient who you’re still in the stages of preventing bone loss? A patient with generalized bone loss is at risk of losing teeth in the future – they still need close management. If you’re scaling below the CEJ routinely (we’re looking right at it in this particular slide) and it just doesn’t happen below the gumline they’re still a periodontal patient.
There are so many reasons for bone loss, yet, it really doesn’t matter how they got there. It matters how you treat them now that they are there.
Do you have talking points for patient acceptance?
Talking points for patients resisting periodontal treatment are a frequently requested resource.
Hygienists know what to look for regarding tissue health and bone level and the proper code for the patient. But it can be hard to walk that out when there’s resistance from the patient.
You can benefit from neuroscience studies telling us how you can be influential.
- Sit at eye level with the patient, and you’re more trustworthy.
- Don’t cross your arms, and you’ll be more open to the conversation.
- Sit slightly forward, and you’ll be more engaged.
- How do you perceive yourself? Do you appear more authoritative or more caring?
Once your body language is in place – and you are in a mental place of caring – consider going through this five-step sequence.
First, gather the data you need, including x-rays and periodontal charting.
Then move into the section where it’s being diagnosed. If this is not a new patient, you may want to consider something like, “Mrs. Smith, we’ve been monitoring your condition for some time. Today I’m finding the upper right is starting to become more impacted by the effects of gum disease. The newest research indicates if we proactively treat this area now you will have a better chance of stopping the bone loss and managing your condition more successfully in the future.” Talk to the patient’s heart more than their head by discussing relevant outcomes more than you talk about the data or the steps you need to take.
Keep in mind that in this five-step sequence, often the hygienist is having this conversation. We are not asking hygienists to diagnose periodontal disease just to relay the data that they’re gathering.
The next step is to express how common this condition is to the patient. “Honestly, over 50% of adults have the same condition at various levels of severity.” This helps your patient not to feel blamed, many people have this same thing, and a variety of factors contribute to it.
Then talk about the prognosis. Let them know the results you expect based on your experience. Sample verbiage could sound like this, “I recommend we take the most conservative approach first, which is periodontal therapy right here in our practice. If that’s successful, I would expect a very good chance we can manage this condition together, right here. If it’s not successful, we work closely with specialists who offer surgical approaches to treat this type of condition.” In general dentistry, it can be easy to lose sight of the fact SRP is actually the most conservative treatment option available.
Lastly, you want to discuss future care. Set the patient up to understand what to expect in the future. This may or may not involve more frequent cleanings, as an example.
How do you handle a new patient, and what order of treatment is best?
A new patient can receive their comprehensive exam with the prophy on the same day if it’s indicated and the patient is healthy. If there are one or more quadrants that need SRP, it is still recommended that you complete the prophy on the first visit and schedule the patient back for the quadrant scaling. This gives your front office time to stop, prepare a treatment plan, let the patient know any out-of-pocket expenses, set up the right amount of time for that patient, and avoid surprises. It can be problematic from an insurance reimbursement perspective to do quadrant scaling first, followed by a trophy.
What about patients who refuse SRP?
We are also asked about how to handle this frequently. It’s a mistake to indefinitely offer a prophy that doesn’t provide the service the patient needs. You determine the direction of treatment, and the patient determines the speed.
Perhaps you need to space quadrant therapy out more to meet their needs. Maybe the patient needs more time to consider this recommendation. So, you agree to review their condition again at their next hygiene visit. This gives the patient time to process the information, giving you another chance to be influential as you discuss the recommendations.
A continued patient refusal that you are not comfortable treating based on your periodontal philosophy of care, so we’re not usually talking one 5mm pocket we’re talking about a patient well beyond the level of care needed to make sure that they remain stable. And you are not comfortable with a prophy in this situation. You can simply refer that patient and let them know that you aren’t able to meet their hygiene needs. But you can continue to see them for their restorative needs.
Sometimes a patient refuses treatment because they consider SRP to be an aggressive approach.
You can change that perception by letting them know that you would like to provide the most conservative option first, which is to remove the toxins from the root surface here in your office.
If it’s not effective, you work closely with a specialist that offers surgical approaches for their condition.
It helps them to know you are trying to offer the most conservative option first and put it in perspective for the patient.
Lastly, I need to acknowledge that change is uncomfortable for all of us. It requires learning new habits and new ways to communicate. Be patient with yourselves. Redesigning a periodontal program doesn’t take place overnight, it’s more of a journey than a race. You won’t be disappointed with your final results.
As I shared at the outset, Burkhart and Burkhart’s Practice Support Team are passionate about providing you with the expertise necessary for you to enhance your team and your practice’s success. We encourage you to reach out to us should you have questions or need additional information. Our support and services come at no charge to Burkhart’s clients. We hope to hear from you soon.
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