Prior to the D4346 code for gingival inflammation, many dentists and hygienists were performing a dental service that had no code.
For reimbursement purposes, dental professionals were over-coding patients who presented with bleeding gums and inflammation as D4341/D4342: Scaling & Root Planing (resulting in many denied claims) or under-coding as D1110 Prophylaxis. Both are inappropriate because they are not codes that accurately describe the service actually rendered.
Many patients presenting with gingivitis were coded for insurance reimbursement as D1110, and we used a periodic exam code—D1120—when, in fact, these patients received more than just a cleaning.
The prophylaxis code provides the nonverbal message to patients and their insurance providers that until there is bone loss, their health implications are not serious. This is akin to having a patient with high cholesterol but not identifying and treating it until a heart attack or something worse occurs.
Keep the health of your patients at the forefront of why you do what you do. The new gingivitis code should serve as our purpose, answering why we do what we do as dental professionals.
Massive amounts of research confirm that inflammation anywhere in the body is a significant factor in many chronic diseases, such as heart disease, diabetes, rheumatoid arthritis, Alzheimer’s disease, and various cancers. Patients with inflammation in their mouth can be affected by inflammatory diseases. Our research shows that inflammation in the mouth causes inflammation in the body. Recognizing and identifying oral inflammation is the first step in preventing systemic diseases.
How to Use the Code
This new gingivitis code is defined as:
“D4346: scaling in presence of generalized moderate or severe gingival inflammation—full mouth, after oral evaluation. The removal of plaque, calculus and stains from supra- and sub-gingival tooth surfaces when there is generalized moderate or severe gingival inflammation in the absence of periodontitis. It is indicated for patients who have swollen, inflamed gingiva, generalized suprabony pockets, and moderate to severe bleeding on probing. Should not be reported in conjunction with prophylaxis, scaling and root planing, or debridement procedures.”
This new code will help dental professionals effectively treat inflammation. Now we can take the appropriate time with our patients for them to understand the difference between preventive and therapeutic care.
When you determine which code to use (D1110 or D4346), you also must determine if inflammation is localized or generalized. Plus, D4346 is only accurate if greater than 30% of the sites affected have inflammation. You should use D4346 when:
- The exam has already been performed.
- The patient is diagnosed with moderate or severe gingivitis.
- Moderate to severe bleeding on probing is present.
- Radiographs show that there is no bone loss.
Do not use this code when:
- The patient is diagnosed with any classification of periodontitis versus gingivitis.
- The patient is diagnosed with localized gingivitis versus generalized gingivitis (less than 30% of the periodontium).
- The patient is diagnosed with slight gingivitis versus moderate or severe gingivitis.
- Bleeding on probing is localized versus generalized.
- Attachment loss is present.
- Radiographs show bone loss.
- There is too much plaque and calculus for an exam to be done.
The insurance claim submission should include:
- Comprehensive periodontal charting, showing pocket depths, recession, mobility (if present), etc;
- The most recent radiographs;
- A narrative (or copy of patient notes) stating the diagnosis;
- A narrative describing bleeding on probing status if not included on the perio chart;
- A narrative stating when the last prophylaxis was done;
- A narrative describing other contributing factors such as plaque deposits, calculus deposits, gingiva appearance, pain, or malodor;
- Intraoral photographs if they help illustrate the gingival condition.
Example: Case Presentation
Here’s one possible scenario for this situation. A 24-year-old female patient comes into the dental office for a routine cleaning. Her medical history states she has no risk factors. She has not been seen by the hygienist for 3 years. The oral examination reveals heavy plaque and calculus due to very poor oral hygiene. Perio charting shows 4 mm and 5 mm pockets around many teeth. Gingiva has generalized bleeding during probing.
Also, interproximal papillae appear edematous, with loss of stippling on the attached gingiva. Intraoral x-rays show many areas of supra- and subgingival calculus. The bone levels appear normal, and no bone loss is noted. There is no loss of gingival attachment. Only pseudopockets are present, rather than an apical migration of the gingival attachment. The dentist diagnoses it as generalized plaque-induced gingivitis.
Not too bad, right? Hold on. What is the recommended treatment?
Most dentists and hygienists intuitively know that she needs her mouth cleaned up, and she must get her oral hygiene back on track. It will most likely take a significantly longer appointment versus a routine prophylaxis appointment. More instrumentation will be required.
Prior to January 2017, you may have scheduled 2 prophylaxis appointments. You may decide to at least use topical anesthetic, or maybe local anesthetic. You also intend to, at some point when you can find the time, spend time on oral hygiene instruction. But how would you code and bill the patient’s insurance for these services?
D4346 now provides a way to schedule enough time to do what you really need to do, serve your patients at the very highest level of care. It provides time not only to scale and polish but also a time to discuss the oral-systemic link and oral hygiene with post-op instructions.
In this scenario, you would complete the previously mentioned services and have the patient return in approximately 2 to 6 weeks for a prophylaxis appointment.
When treating inflammation, according to the American Academy of Periodontology, we need to establish an “end point” of therapy. Thus, you will need to see patients with inflammation approximately 2 to 6 weeks later to establish healing and their end-point balance. A positive end-point means there is a lack of gingival inflammation and, most importantly, no bleeding upon probing.
What You Will Do with the New Code
Gingivitis code D4346 is closing the gap in our treatment of inflammation. It provides an insurance code for billing purposes in the hope of reimbursement to your patients for services rendered.
For many years, we were only diagnosing inflammation (gingivitis). Now, we have a code to use for documentation and reimbursement to insurance that shows we are treating inflammation without the presence of alveolar bone loss. It allows us to put some focus on the important topic of the oral and systemic disease link.
Coding patients correctly sends a message that treating early disease is important in preventing other types of systemic diseases. It gives your patients a very important reason to return routinely. You must tailor your message differently to each patient. It is important that you, as the clinician, understand what is valuable to your patient and then speak to the benefits of your treatment plan as it pertains to each of your individual patients.
Using the new gingivitis code is about delivering the right message to the right person. It means using all-encompassing therapy. This includes digital photographs, radiographs, curettes, ultrasonics, and lasers as appropriate, as well as education on the best homecare for each individual patient.
Always diagnose and treat what you know exists in your patients’ oral condition. If your patients have insurance benefits, then you must code and bill exactly what you completed the day services are rendered.
These are the exact steps that will answer what to do with the new gingivitis code.
Ms. Seidel-Bittke is a registered dential hygienist and the CEO of Dental Practice Solutions, which she founded in 2000. Since that time, she has continued to support the optimization of hygiene departments globally. Through her proven systems to communicate with dental patients about oral disease, she creates highly profitable dental practices around the world. You can reach her at email@example.com or (888) 816-1511. Also, check out her no-cost hygiene department training at dentalhygiene.solutions.
Disclosure: Ms. Seidel-Bittke does not have any conflicts of interest.