April 2008
Patients | Web Exclusive

Make insurance codes work

You educate patients every day—now it’s time to educate the people handling claims. by Patti DiGangi, RDH, BS

A very timely issue in this election season is the future of healthcare in the U.S. Though this should be of interest and concern for dental professionals on a macro-level, what most dental professionals want to know is how to make insurance codes work now. Making insurance work is a matter of understanding one’s role.

Research on the biology and biomechanics of periodontal disease has shown full mouth disinfection (FMD) as a viable option for the treatment of active periodontal infections. In the book Demystifying Smiles: Strategies for the Dental Team, Kristy Menage Bernie, RDH, BS, states FMD requires full mouth scaling and root planning (debridement) with antiseptic irrigation completed within 24 hours to create an environment conducive to healing and eradication of infection.¹ The distinction must be made that the term FMD is not the same as CDT 2007-2008 code D4355 Full Mouth Debridement to Enable Comprehensive Evaluation and Diagnosis. The language for D4355 is very specific stating, “The gross removal of plaque and calculus that interfere with the ability of the dentist to perform a comprehensive oral evaluation. This preliminary procedure does not preclude the need for additional procedures.”² Is there an evidence-based way to support FMD to insurance carriers?

ALL ABOUT EVIDENCE

Insurance carries understand evidence-based dentistry. The American Dental Association defines evidence-based dentistry (EBD) as, “. . . an approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patient’s oral and medical condition and history, with the dentist’s clinical expertise and the patient’s treatment needs and preferences.”³ EBD is not a cookbook of research findings dictating care, BUT a major part of EBD is the research.

FMD is well-supported by a body of research. The Cochrane Collaboration is an international, not-for-profit, independent organization disseminating systematic reviews of evidence from clinical trials and other studies. The conclusion of a 2007 Cochrane Collaboration summary of research stated, “In patients with chronic periodontitis in moderately deep pockets slightly more favorable outcomes for pocket reduction and gain in probing attachment were found following FMD compared to control.”⁴ FMD may be recognized and covered under policies if properly documented.

WORKING INDIVIDUAL SUBMISSIONS

Dental benefit carriers sell and administer policies via a business arrangement between the carrier and an employer. It makes sense then, that policies are not necessarily purchased based on best evidence even when offered by carriers. Individual submissions are processed to the best knowledge of the person handling the claim, which again, is not necessarily based on the best evidence. Does this mean insurance carriers do not understand evidence? No, this is not the case. It does mean the persons in the dental practice responsible for submitting claims must include all the data needed for appropriate processing.

The role of the hygienist is to provide the business staff the information needed for a narrative to support the procedure completed. Narratives should be short, to the point and fit into Box 35 Remarks on the paper/electronic insurance form. The code for FMD is D4341, a quadrant code which is listed for each quadrant. In the Remarks box, the narrative should include the reason, time spent, anesthesia required, pre-medication, apprehensiveness, medical conditions, travel time, other appropriate data and include research references justifying the FMD approach.⁵ (see sidebar) The carrier then has the information needed to adjudicate the claim. Does this mean that there will be coverage? That answer always must go back to the policy purchased by the employer, over which dental professionals have no control.
Whether it comes to having a say in the future of health care in this country or making insurance work in the office, each person can make a difference. In the elections, the role of each individual is to vote. With dental benefits, the role of the professional is to provide the data needed for complete documentation of claims. Are you fulfilling your role?

Patti DiGangi, RDH, BS, is a speaker, author and still practicing dental hygiene clinician. Patti is a certified presenter through Academy of General Dentistry National Speaker’s Bureau for Periodontal Disease, a member of GC America Key Opinion Leaders, Zila Pharmaceuticals National Speaker’s Bureau, Hu-Friedy Thought Leaders Program and the Proctor & Gamble Whole Health Lecture Board.  She is also a member of the Linda Miles Speaking & Consulting Network, on the Advisory Board for the National Museum of Dentistry and Director for  CareerFusion.  Patti’s articles appear regularly in RDH Magazine, Modern Hygienist, and other professional journals. Patti is currently co-writing a book on minimal intervention philosophy and a novel.

Research articles on Full Mouth Disinfection
•    Eberhard J, Jepsen S, Jervøe-Storm P-M, Needleman I, Worthington HV. Full-mouth disinfection for the treatment of adult chronic periodontitis. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD004622. DOI: 10.1002/14651858.CD004622.pub2
•    Schara R, Medvescek M, Skaleric U. Periodontal disease and diabetes metabolic control: a full-mouth disinfection approach. J Int Acad Periodontol. 2006 Apr;8(2):61-6
•    Greenstein G. Efficacy of full-mouth disinfection vs quadrant root planing. Compend Contin Educ Dent. 2004 May;25(5):380-2, 384-6, 388 passim
•    Apatzidou DA, Kinane DF. Quadrant root planing versus same-day full-mouth root planing. I. Clinical findings. J Clin Periodontol. 2004 Feb;31(2):132-40.
•    De Soete M, Mongardini C, Peuwels M, Haffajee A, Socransky S, van Steenberghe D, Quirynen M. One-stage full-mouth disinfection. Long-term microbiological results analyzed by checkerboard DNA-DNA hybridization. J Periodontol. 2001 Mar;72(3):374-82
•    Quirynen M, Mongardini C, de Soete M, Pauwels M, Coucke W, van Eldere J, van Steenberghe D. The role of chlorhexidine in the one-stage full-mouth disinfection treatment of patients with advanced adult periodontitis. Long-term clinical and microbiological observations. J Clin Periodontol. 2000 Aug;27(8):578-8
•    Mongardini C, van Steenberghe D, Dekeyser C, Quirynen M. One stage full- versus partial-mouth disinfection in the treatment of chronic adult or generalized early-onset periodontitis. I. Long-term clinical observations. J Periodontol. 1999 Jun;70(6):632-45

1. What we do for our users. WebMD Available at: http://www.webmd.com/policies/about-what-we-do-for-our-users Accessed 1/31/08.
2. Hodson, K., Anthony, B. Demystifying Smiles: Strategies for the Dental Team. Tulsa, OK: PennWell. 2003. P. 96-99.
3. CDT 2007-2008. American Dental Association. 2006. P.26.
4. Eberhard J, Jepsen S, Jervøe-Storm P-M, Needleman I, Worthington HV. Full-mouth disinfection for the treatment of adult chronic periodontitis. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD004622. DOI: 10.1002/14651858.CD004622.pub2. Available at: http://www.cochrane.org/reviews/en/ab004622.html Accessed 1/31/08.
5. ADA Policy on Evidence-Based Dentistry. April 4, 2003. American Dental Association. Available at: http://www.ada.org/prof/resources/positions/statements/evidencebased.asp#definition Accessed 1/31/08.
6. Blair, C. Coding with Confidence: The “Go to Guide for CDT 2007-2008. Mt. Holly, NC: Blair. 2006. P. 111.