By Cindy Hartwell, Dental Benefits Analyst at CDA Practice Support
CDA Practice Support receives calls from dentists and their staff regarding claim denials for scaling and root planing services from dental benefit plans. In this article, I examine the criteria used 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 see the difference between D4341 and D4346.
In the ADA Guide to Reporting D4346, version 4, published in July 2018, the description code for D4341 (periodontal scaling and root planing – four or more teeth per quadrant) states: “The code should be used to report a procedure involving instruments on the crown and root of the teeth to remove plaque and calculus from these surfaces. It is indicated for patients with periodontal disease and has a therapeutic, not prophylactic, character.”
The describer continues: “Root planing is the definitive procedure designed to remove cementum and dentin that is rough and/or calculus-penetrated or contaminated with toxins or microorganisms. Some soft tissue removal is done. This procedure can be used as a definitive treatment in some stages of periodontal disease and/or as part of pre-surgical procedures in others.
The ADA in 2017 introduced a new code: D4346 (escalation in the presence of generalized moderate or severe gingivitis – full mouth, after oral assessment). This code descriptor says, “this code refers to the removal of plaque, calculus, and stains from the supragingival and subgingival surfaces of teeth when there is generalized moderate or severe gingival inflammation in the absence of periodontitis. Indicated for patients who have swollen, inflamed gums, generalized supraosseous pockets, and moderate to severe bleeding on probing. It should not be mentioned in conjunction with prophylaxis, scaling and root planing or cleaning procedures.
In its guide to reporting D4346, the ADA explains why the code was implemented. The guide states that code D1110 is largely a preventive procedure, but can be curative depending on the overall health of the periodontium. It is applied to patients with a generally healthy periodontium where any deposits are removed to control irritants and also to 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. Equipping the exposed root surface to remove sediment is an integral part of this process.
Prior to the implementation of D4346, no code was available to report the treatment of patients with generalized moderate to severe gingival inflammation with or without pseudosockets but who did not experience bone loss. With the implementation of the D4346 code, this gap was filled.
As a result, dental benefit plans not only focus on submitted periodontal signs, but also look for radiographic evidence of bone loss. Without the radiographic evidence of bone loss, a plan is likely to deny the claim of scaling and root planing.
Note that if radiographic evidence of bone loss is visible in only one to three teeth, 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 current CDT codes, they are not required to pay or provide benefits for the code.
Dental practices are encouraged to log into the program’s online portal and check their patient’s benefit plan for coverage. While logged into the online portal, read the updated program provider manual to keep track of changes to the program’s processing policy. If you cannot access the online portal for a program or cannot locate the above information in the portal, please contact the program for assistance.
For more information on petition D4346, CDA encourages members to refer to ADA Guide to Reference D4346.
CDA Practice Support offers members one-on-one assistance with dental benefits questions. Simply submit your questions online using the dental benefits submission form accessible through your
cda.org account. Hands-on Support will analyze the issue, assess it for possible resolution and communicate clear next steps.
To submit your questions about dental benefits online, visit my account click the link to submit a dental benefits question and follow the instructions.
