Let’s imagine that you have a patient who presents with inflamed and hemorrhagic gingiva, light to moderate subgingival calculus, and generalized pseudo-pocketing. For all of the history of Current Dental Terminology* (CDT) coding, there have been no truly accurate codes for the treatment that this patient would need. There has been a gap; however, there is good news on the horizon! In 2017, this situation will change with the creation of a new CDT code. The tough question is this: How will it fit with our existing system? It could lead to higher levels of frustration, or it could push dentistry to fully embrace the oral-systemic scientific evidence leading to cleaning the over-full dental hygiene “closet” and to improving health and profitability.
CREATION OF A NEW CODE
The Code Maintenance Committee (CMC) is the body that meets annually to evaluate and create new codes to embrace new technologies, materials, and procedures that can lead to earlier arrest and prevention of oral disease and positively influence systemic health. I have attended this open meeting for the last 5-plus years. Year after year, dental professionals wish and submit for more treatment codes between prophylaxis and scaling/root planing. In 2015, the CMC decided that, because this has come up so often, they would form an ad-hoc workgroup to bring recommendations.
In CDT 2017, a new code will appear that reads as follows:
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 subgingival 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. [It] should not be reported in conjunction with prophylaxis, scaling and root planing, or debridement procedures.
How This New Code Fits Into the Existing System
You already have a well-honed system developed and perfected throughout time, and yet there are always cases like the following one that do not quite fit.
Dominic was a cute, slightly overweight, 6-year-old boy whose mom brought him into the dental office due to significant problems found during a health screening done at his school. As is standard in many dental practices, Dominic was scheduled with the hygienist for a 30-minute appointment. Usually, the hygienist will take a couple of bite-wing radiographs, complete a tooth chart, perform a child prophy and fluoride treatment, and then call the dentist into the operatory for the exam. When the hygienist looked in Dominic’s mouth, multiple problems were immediately evident. Using only a mirror, she immediately observed that Dominic had active caries, black-line subgingival calculus, and his gingival tissues were red and swollen with bleeding upon touch. With the clock ticking in the practice schedule, should the hygienist move forward with the standard and generally expected routine that has produced a consistent production level?
What's In Your Hygiene Closet?
These are the challenges when new products, technologies, or in this case, a new code comes along. How does it fit? New success occurs when we stop, step back a moment, and re-evaluate the entire system. It’s like our clothes closet. We buy new clothes and shoes because there is a change of the season, changes in styles or, for many of us, a change in size. We can keep shoving clothes and shoes in the closet, but eventually we just have to reorganize the closet and purge some of the contents. You take everything out to decide what still fits. Is it worn out? Was it a gift you never really liked? Why did you ever buy it in the first place? And so on. It takes time and can be messy and emotional along the way. Even when you are done, it can be frustrating because then you can’t find that favorite accessory. Get the idea?
Similarly, to successfully use this new code, we can try to shove it in with all the other clutter or we can take the opportunity to reorganize the over-full dental hygiene “closet.”
Let’s start with our current system for diagnosing and treating periodontal disease. Should a new patient be scheduled in hygiene first? Should that first appointment include treatment? Should it be a data collection process only? Why does the dentist come in for the examination at the end of the appointment? What if it is a patient of record? Codes can help us evaluate this order.
There are no exam codes. Shocking though that might sound, the name of the CDT category is Clinical Oral Evaluations. Part of the definition for that section states, “the collection and recording of some data and components of the dental examination may be delegated; however, the evaluation, which includes diagnosis and treatment planning, is the responsibility of the dentist.” (The italicized text is the author’s emphasis.) A specific diagnosis is required and becomes particularly important with this new code. Oral evaluations are not age-based, and the data gathered for the dentist to make an accurate diagnosis should be consistent for every patient.
The problem I see repeated over and over again is that many practitioners seem to think only of providing treatment while jumping over the diagnosis step. This problem will continue despite the new code, unless we stop and reorganize the “closet” and routinely document the patient’s diagnosis. Dominic’s diagnosis was early childhood caries and gingival disease modified by systemic factors—malnutrition. He was observed to be slightly overweight and yet he suffered from malnutrition, contributing to his oral diseases. Providing only a prophy, or simply providing him with some fillings, would not have been the correct and complete treatment protocol based upon his systemic findings/needs.
Dominic and the New Code
In order to understand how this new code fits a patient like Dominic, we need to break it into pieces.
D4346 does not appear in the Preventive category with D1110/D1120 prophylaxis; it is in D4000-4999 Periodontics. This difference is important because this procedure is therapeutic, not preventive. What’s more, unlike the prophy codes, it is not age- or dentition-based.
Full-mouth means this treatment is not site specific, quadrant, or any other way divided. The treatment is for the entire mouth. The name specifically states after oral evaluation. This means that the hygienist should not provide this care for Dominic before the dentist completes the evaluation with a written diagnosis and treatment plan.
Absence of periodontitis is a significant part to accurately use this new code. It would be easy to assume that of course Dominic doesn’t have periodontitis; he is a 6-year-old. Not so fast. How is periodontitis diagnosed? In 2015, a special American Academy of Periodontology (AAP) Task Force (joponline.org) suggested that a diagnosis include documenting inﬂammation and bleeding on probing, radiographic bone loss, and probing depths and clinical attachment loss. Clinical attachment loss is the pocket depth plus recession and/or bone loss with 6 readings for each. For this 6-year-old? That age-based thinking doesn’t seem to want to leave the closet. This definition clearly again shows a specific diagnosis is needed and is crucial to using this new code correctly.
The words moderate or severe gingival inflammation are tricky and not quantified by most practitioners. The ADA and AAP suggest documenting using the Löe and Silness gingival inflammation index, as follows:
0 = normal inflammation
1 = mild inflammation—slight change in color and slight edema but no bleeding on probing
2 = moderate inflammation—redness, edema, and glazing, bleeding on probing
3 = severe inflammation—marked redness and edema, ulceration with tendency to spontaneous bleeding.
We also must determine if it is localized or generalized. This is where it can feel more daunting, like when all the clothes and shoes are out of the closet, making the room a bigger mess.
The ADA mapped the AAP Classification system definition for Chronic and Aggressive Periodontitis to a new D4346 code. This definition is:
• Localized < 30% of sites
• Generalized > 30% of sites.
If < 30%, then the treatment code is D1110/1120. If > 30%, then the treatment code is the new D4346.
Then what about the next visit—is Dominic considered a perio maintenance case? What if it’s a difficult case that takes more than one appointment? Isn’t Dominic just the usual gingivitis case? There are more pieces and parts to finish organizing the “closet” that cannot all be answered in a single article. This sounds like frustration. So where is the opportunity?
Our body of oral-systemic scientific research continues to grow with 2016 article titles such as “Certain Oral Bacteria May Be Associated with Increased Pancreatic Cancer Risk,” “The Oral Microbiome and the Risk of Lung Infection,” “Reviewing the Links Between the Oral Microbiome,” and “Aging and Alzheimer’s Disease,” just to name a few. The question becomes: what are you doing differently for your patients like Dominic based on this information?
The following question was asked by Casey Hein, BSDH, RDH, MBA (International Center for Oral-Systemic Health, University of Manitoba; caseyhein.com):
“If we knew 20 to 30 years ago what we know today about the role periodontal disease plays in systemic inflammation and increasing the risk for cardiovascular disease, respiratory diseases, complications with diabetes and pregnancy, would it make a difference in the lives of our patients? What could we have done about the relationship between obesity and periodontal disease? These questions haunt me.”
Think again of Dominic, a 6-year-old, slightly overweight child, with active oral infections. How can a code help? Part of the Affordable Care Act is aimed at improving the quality, efficiency, and overall value of healthcare. Reimbursements will be tied to outcomes in the future. Having a code provides us with the opportunity to measure outcome data. What is our success in treating periodontal disease, whether it is gingival disease or periodontitis? I hear you screaming already, It’s up to the patient! Yes, and no. Are we sure that we diagnosed and properly treated what was there?
This code can lead to earlier recognition and treatment before there is bone loss. Waiting for bone loss is like waiting to treat a patient with high blood pressure after a heart attack. This new code could create frustration if we attempt to shove it into an already-full closet. Or, it can push dentistry into reorganizing the closet to embrace the oral-systemic scientific evidence and improve health and profitability. That choice is up to each and every one of us.
*License to use ADA CDT codes granted to Patti DiGangi, RDH, BS. The dental procedures codes (“Code”) are owned and published by the ADA in its reference manual Current Dental Terminology (“CDT”). The ADA is the exclusive owner and copyright holder of the CDT, including the Code, as well as of the ADA Claim Form.
Disclosure: Ms. DiGangi reports no disclosures.
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