Understanding and applying the new 2017 gingivitis code 4346.
I have received many questions about this new code, When is it appropriate to use it? What will insurance cover? What are the limitations we have when billing with this code? All important questions, that I will cover in this video blog. What I find interesting about this code is that it is in the periodontal category, but many insurance companies are not treating it as a periodontal code. This is causing a lot of confusion about this code, and a lot of questions about how we actually apply this new code in practice.
We teach Hygienists to use 3 levels in regards to periodontal therapy, this would fit into the Therapeutic scaling and root planing category. This new code, 4346, is designed for the patient who’s not quite healthy, but not quite periodontal disease. When we have a generalized gingivitis (patients without bone loss evident on an x-ray), some programs would call that a type 1B code, that’s when this new code would apply. There may be pocketing, but often we see pseudo-pocketing. Often there’s a lot of bleeding and general inflammation caused by excess plaque. The excess plaque can be caused by poor oral hygiene, systemic conditions, and physical disabilities. The key is no bone loss.
When we take a look at the information the ADA put on their website about how to use this code, the definition of the code is, ‘Scaling in presence of generalized moderate or severe gingival inflammation – full-mouth, after oral evaluation.’ In this resource they published, they stated that if there’s generalized, severe inflammation and general knowledge typically states 30% or more of the bleeding sites need to be experiencing inflammation for it to be considered generalized inflammation.
So if 30% of the mouth or more is inflamed, then we can call that generalized inflammation. If we have patients with swollen, inflamed gingiva, supra-bony pockets, moderate to severe bleeding on probing, without bone loss, then this code is applicable.
It has to be done the same day as the oral evaluation. The diagnosis needs to occur first. Practices that are familiar with the our perio program, know that we often teach a perio-alert status for a Gingivitis patient. On that first appointment, in the past, we’ve taught you to utilize the full mouth debridement code – 4355 (in the United States, codes for Canada are in the video training.) I wish I could tell you we could go away from this code completely, because this is one of the most confusing codes that we deal with.
I don’t think that this code (4355) is going to completely go away, we now we have an additional code to consider. Now we also have 4346, (which is scaling in the presence of generalized moderate or severe gingival inflammation full mouth.) Basically, what they are saying is this code is indicated for patients who are swollen, have supra-gingival deposits, generalized inflammation in the mouth. This code should not be reported in conjunction with a prophy, or a scaling and root planing, or a debridement procedures.
So how does it really compare to prior codes? There was a code that we had prior to 1995 (4345) and the definition of that code was pretty much the same. Gingivitis code, no loss of attachment or bone loss. ‘The scaling procedure is more precise in describing therapy for generalized gingivitis, not meant to be performed on a routine basis.’
So here we are bringing back a code that went away almost, 20 years ago. My question was, “Why did we get rid of that code and then create a new code that is so similar?” I think the main reason is that this earlier code was too vague. It was not clear enough. After my research, I’m sorry to say that this new code is exactly the same. There are a lot of challenges with these codes, because they’re not as clear as we would like them to be. I think the only way we’re going to see this code succeed in our practices, is documentation. To get payment on this code, we must be very clear in our diagnosis and provide a LOT of documentation. We must be carefully documenting exactly what level of gingivitis we’re dealing with, what the mouth looks like and if we can assign ICD-10 diagnostic codes to it, fantastic.
Some insurance companies are switching to the ICD-10 codes so we need to be familiar with how to use these diagnostic codes in our practices. If you are not currently using the ICD-10 codes I encourage you to start utilizing them as a part of your protocol – so that you have it when it’s required from insurance companies.
The real significant factor here is that gingivitis does not have resorption of the underlying bone. (IDC-10 Reference)
- Gingivitis – Inflammation of the gingiva as a response to bacterial plaque on adjacent teeth; characterized by erythema, edema, and fibrous enlargement of the gingiva without resorption of the underlying alveolar bone.
- Gingivitis is classified in ICD-10
- K05.00 acute, plaque induced
- K05.01 acute, non-plaque induced
- K05.10 chronic, plaque induced
- K05.11 chronic, non-plaque induced
Let’s take a look at the ICD-10 Periodontal Diagnostic Codes:
- Periodontitis – Inflammatory disease of the periodontium occurring in response to bacterial plaque on adjacent teeth; characterized by gingivitis, destruction of alveolar bone and periodontal ligament, apical migration of the epithelial attachment resulting in formation of periodontal pockets, and ultimate loosening and exfoliation of teeth.
- Periodontitis is classified in ICD-10
- K05.20 aggressive, unspecified
- K05.21 aggressive, localized
- K05.22 aggressive, generalized
- K05.30 chronic, unspecified
- K05.31 chronic, localized
- K05.32 chronic, generalized
So the most common question I’ve gotten up until now is, what will insurance pay?
Unfortunately, most benefit plan administrators and insurance companies are preparing to pay 4346 as if it were merely a prophy. I am seeing in many cases the same reimbursement tables, the same contract limitations and exclusions as the prophy. I’ve even seen some that are paying less than they will pay for a prophy. I’ve also talked with a lot of dental experts, the dental directors of these insurance companies, and more than one of them has informed me that their intention is to decline any and all benefits for 4346, unless we have clinical documentation and diagnostic specifics. So without any documentation, it will not be paid. If the claim comes with documentation and a narrative, then they will consider reimbursement.
So far, the reimbursement is poor, in my opinion. We are seeing some paying a relative value between one and a half to two times the prophy. We must be aware that using this code also simultaneously eliminates any scaling and root planing coding or perio maintenance benefits for 12-24 months.
So here’s my word of caution to you
That’s why I don’t think we can eliminate 4355 or full mouth debridement completely. For some patients, if we use the 4346 code and they develop periodontal disease after the fact, we have a two-year window where we cannot get payment for scaling and root planing. This is incredibly frustrating. The payment criteria will also eliminate patient benefits for full mouth debridement, as well as any potential immediate surgical interventions. This code may address the treatment of generalized gingivitis, but if this initial inflammation progresses into periodontitis, the patient may find themselves without a benefit.
Some plans are going to consider this code as a contractual exclusion, and simply not acknowledge the validity of the procedures, especially as a stand-alone treatment entity. The sad thing is that we are seeing the clinical examples within the ADA document are self-contradictoring and generally misleading.
Sadly, this brings me to expect, that this code will likely become as irrelevant as the former code. I hope that this isn’t true. I don’t have a lot of hope and trust in the insurance companies, I am doubtful they will pay this code fairly and utilize this code. Many experts are in agreement that this is going to be another way for them to down code scaling and root planing, and not pay for it all.
In the ADHA Impact article about this new code, it says in the conclusion that assessment and diagnosis will determine the plan, and whether the gingivitis code is the applicable procedure code. However, equally important in the initial implementation stage of the code will be ‘awareness of a period of adoption by dental benefit plans, and that plans may vary widely in their coverage. We, as dental hygienists, appreciate being able to use a code that accurately reflects the therapy provided and explanations to patients, but acceptance of the new code often takes time.’ Predetermination of benefits is what they recommend, but again, we haven’t recommended predetermining benefits in years. That is an outdated philosophy, and an admitted stall tactic for the benefit of the insurance company alone.
I wanted to see if I could find any information for you from specific insurance companies. When we look at Delta Dental of Kansas, they listed a few bullet points.
- Benefits include a prophy, so fees for a prophy or a full mouth debridement are disallowed when submitted with 4346. So obviously, we can’t submit those the same day
- 4346 is included in the frequency limitation. If they are limited to two per year, 4346 would count as one of their cleanings for the year.
- Fees for 4346 are disallowed when submitted with 4910 by the same dentist. So you cannot use this the same day as Perio maintenance.
- This code can only be used after an examination and a documented diagnosis. This is vague… Does that mean it needs to be a subsequent appointment? Or can those both be coded and submitted the same day? We don’t know. This is something that we are going to have to learn as we implement these new codes.
Now, I’ve included a couple other companies for you (in the video). In another Delta Dental plan, they said scaling on 4346 is standardly covered the same coverage as 4910, the same category as 4910. A cleaning is usually considered a preventive code, which is often covered at 100%. In this plan, it’s the same category as 4910. If the patient has a deductible, it will be applied for this plan. It also will be paid at a different percentage. They may only get 80% reimbursement on perio, if so, the patient will only get 80% coverage on 4346. If they get 50% reimbursement on perio codes, the patient would only get 50% reimbursement. We’ve got to be aware and look at each plan. We always try and help the patient at least know what to expect with their plan, because this is a new code and every company is handling it differently.
In another example, NorthEast Delta Dental – Scaling will be paid under the diagnostic and preventive benefits. Usually at 100% with no deductible and included in the frequency for prophy. Again, the key here is to realize that even with the same company, (Delta) the benefit varies dramatically. We don’t want to train our patients to be insurance focused, but in reality must have a balance. We need to learn about coverage to help patients know what they will be responsible for.
My point in sharing this information from some insurance companies, is that there is no standard. There’s no set reimbursement right now. Every single policy is going to need to be looked at. So that’s why I say, at the first appointment, what we need to be doing is what we have taught for many years…
The first thing that needs to happen is our Hygiene assessment. IF the patient is not in a state of health, we need to plan carefully the next steps. We may still need to utilize the full mouth debridement, especially if we are concerned that the gingival condition may continue to deteriorate into periodontal disease. In some circumstances, we often use a gingivitis protocol to determine next steps. “This patient has generalize inflammation. They are not quite healthy, not quite perio. Let’s do a debridement and see how they respond.” At that first appointment, if they are not quite healthy, not quite perio, you’ve got to be very careful to determine now which code is a better fit. Is a 4355, a debridement appropriate? Or are we going to use the new code, 4346?
We should only use the new code if we are confident the patient will not be needing other treatment, and can follow up with a prophy only.
It’s important for us to be able to make that determination because some insurance plans will not have a benefit for 4355, 4341, 4342, 4910 for sometimes up to two years for this patient.
That makes the decision of how we handle our Perio Alert patients important. Is it a full mouth debridement, or is it the 4346? This code, the full mouth debridement, would certainly be applicable for the patient who may need scaling and root planing after the initial phase of therapy.
Remember, the old definition of 4355 was, Full mouth debridement to enable comprehensive evaluation and diagnosis. It was about obstructive deposits. Today’s definition is different. “To enable comprehensive evaluation and diagnosis. This procedure does not preclude the need for additional procedures. “
We often teach utilizing 4355 or full mouth debridement to aid us in providing assessments regarding patient health. Was this initial catch-up cleaning enough? Or, due to other circumstances and other situations that we see, other areas of inflammation or deposit, we may need to go ahead and move towards periodontal treatment.
The ADHA position on 4355 provides some clarity. ‘In the presence of periodontal disease, periodontal debridement is indicated. These procedures can be the definitive treatment for gingivitis or early periodontal disease, or can be a pre-surgical treatment when the disease is more advanced.”
If you are looking for a definitive treatment for gingivitis only, 4346 will now be the code you’re looking for. If you are trying to do a definitive treatment for early periodontal disease, I would strongly recommend you still utilize 4355.
I recognize this is just the tip of the iceberg. Whenever we have new codes and changes in our industry, it can be a little bit challenging to adapt. If you would like help with implementation of Periodontal Coding, or growing your practice don’t hesitate to contact me directly.