Scaling and root planing (SRP) are important services to treat and prevent the progression of periodontitis, also known as gum disease. SRP services are the bread and butter of many dental practices but can also be a common source of denials. No pays are unpleasant for both practices and patients, and even worse, can result in a patient thinking you did an unnecessary procedure.

Part of the challenge is that early-stage periodontitis isn’t always obvious and can be hard to detect, both in an appointment and on a scan.

When possible, a pre-treatment estimation can help predict your reimbursement and avoid denials. However, this isn’t always possible. In case of an infection, a patient’s health is at risk if you wait for a pre-treatment estimate.

Part of the challenge is that early-stage periodontitis isn’t always obvious and can be hard to detect, both in an appointment and on a scan.

So, how can you avoid getting those dreaded no pay messages from insurance companies on SRP claims?

4 Steps To Making Sure SRP Claims Are Paid

1. Choose The Correct CDT Coding

The recent addition of code D4342 has helped determine appropriate benefit reimbursements. D4342 should be used for a periodontal situation with three or fewer teeth per quadrant that require definitive periodontal treatment.

Code D4341 should be used for a periodontal condition with four or more teeth per quadrant that require definitive periodontal treatment.
In the past, when code D4341 was the only SRP code, it was more challenging to decide on coverage when diagnostics supported SRP for a small number of teeth per quadrant. So, plan to use D4342, the more recently added code if three or fewer teeth are involved, to prevent no pays.

In some situations, you may be unable to probe due to calculus. In those situations, use the code D4355 for remove gross calculus to diagnose. It will cover the debridement, and the patient can return in two weeks for probing. If the pockets measure 5mm or above, it is safe to do the SRP. Patients can be frustrated by a change in appointment, but prefer that to a no-pay from the insurance company if the probe depths are not deep enough.

2. Include Diagnostic Quality X-Rays

You will need to submit currently dated and labeled preoperative diagnostic full mouth series x-rays to provide proof of calculus on the root surface, horizontal and vertical bone loss, and any areas of infection.

These x-rays can also help compare the patient’s gum pocket measurements. The initial full-mouth series x-rays also serve as a great baseline and prove the treatment has been effective to the insurance company.

Not all x-rays are created equal, and unfortunately, delays and denials can be caused by incomplete x-rays. The resolution of the x-ray can’t be too low to evaluate or lack sufficient contrast to be read clearly.

Be picky about your x-rays and always send the duplicate since as you likely know, x-rays rarely get returned!  Many offices print off the x-ray and circle bone loss with a red pen.  It draws attention to what the insurance needs to notice, and it can’t be overlooked.

3. Attach Detailed Progressive Charting Of Probing Depths

Insurance carriers can verify disease progression when an office can document that gum pockets have deepened.

Submit periodontal charting and current treatment records that specifically document the SRP service. The periodontal charting should have a patient’s probing history, including six gum tissue measurements.

The chart should indicate at least Case Type II periodontal disease (indicated by 4-6 mm pockets and early bone loss). The pocket depth and loss of periodontal attachment need to be at least 5 mm. Also, take note of any bleeding or gum recession.

It is also good to chart other pre-existing medical conditions the patient might have that play hand in hand with periodontal disease. The insurance company needs to see the complete picture when the claim is submitted. Failure to include pre-existing conditions that impact or cause periodontal disease can result in a denial or a no pay.

It’s also wise to reprobe after each treatment because calculus could have blocked the most actual depth. This will help ensure accurate probe depth charting.

4. Perform One Or Two Quadrants Per Appointment

Even though it will take more time, be sure you only perform one or two quadrants per appointment. A four-quadrant SRP in one day would require the patient to have full mouth local anesthesia, creating a high risk for biting the cheek or tongue. It will also be compensated with a lower benefit. And the amount of time spent matters- most insurance companies want to see at least 45 mins spent on each quadrant.

Also, be sure to factor in healing time and verify the required time in between quadrants with an individual’s insurance policy.

Make sure each quadrant qualifies by planning your services to clean the number of teeth necessary for eligibility at each appointment. You need to make sure the hard work you do with patients is visible to insurance companies to ensure reimbursements.

Troubleshooting Your Mystery Denied Claims

Sometimes claims for patients with similar presentations of disease and equal amounts of charting can be handled differently, even by the same payer.

Payers may establish varying guidelines on pocket depth indicators for SRP, based on differing interpretations of the scientific literature, or have different policies for different employer groups.

In this situation, keeping track of specific payer guidelines or working with dedicated 3rd party dental billing support that can do it for you is essential to consistent reimbursement on SRP claims.

Attention To Detail Can Ensure Reimbursements From Submitted Claims

SRP services are easy to get no payments on but with the appropriate attention to detail in coding, x-rays, and charting you can ensure reimbursements.

Important steps are:

  1. Using the correct CDT code according to the number of teeth per quadrant,
  2. Sending a diagnostic quality x-ray,
  3. Including detailed progressive charting of probing depths, and
  4. Performing one or two quadrants per appointment.

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