Coding Coach

Based on feedback from past complaint resolutions, as well as questions that are asked at the AAP’s insurance workshops, certain issues with carriers arise frequently. Offices can avoid some of these issues, reducing frustrations by making sure claims are sent correctly with adequate documentation. Let’s review these common mistakes so that claims can be submitted more effectively, resulting in more efficient payments and fewer frustrations. 

One of the most frequent mistakes made involves soft tissue grafts. There seems to be confusion related to which codes to use when multiple teeth or implants are grafted, regardless of the type of graft. It does not matter how many teeth or implants are grafted; each should have its own code for the soft tissue graft. The key in the use of these codes is the word “contiguous.” The first tooth or implant in the area should have the correct code used depending on the type of graft place: 

If multiple teeth or implants are grafted, are these the next tooth or implant sequentially in the arch? If so, then the codes for each additional contiguous tooth or implant should be used:

For example, if teeth #3, #4, and #5 are grafted, then D4275 would be used one time and D4285 would be used twice. However, if it includes teeth #3, #4, and #6 then the correct codes would be D4275, D4285, and another D4275 since teeth #4 and #6 are not contiguous.  

These soft tissue graft codes also apply to edentulous areas that have soft tissue grafting. In the case of an edentulous area, grafts are considered by site, which is the equivalent of two tooth areas. It may be contiguous with teeth or implants if the graft is placed at the same time.  

Also related to soft tissue grafting are denials based on the prognosis of a tooth or implant. Carriers request a radiograph to verify the prognosis of the tooth or implant being treated. Make sure that the radiograph is of diagnostic quality to prevent delays in processing. Although carriers in most cases do not require a photograph, the AAP highly recommends a photo of areas to be grafted. Photos can aid in justification of the soft tissue graft either during the initial claim or a later appeal.  

The most common complaints are related to scaling and root planing (SRP). Although most offices understand the need for charting and radiographs for claims involving SRP, the quality of the documentation is a factor. Periodontal charting always needs to be legible, but radiographs are more often the issue. Carriers want to see radiographic bone loss in the areas of SRP. This can be difficult with panoramic radiographs, which do not show enough detail, or even with horizontal bitewings, which may not show enough root surface. Periapical radiographs are the gold standard for viewing bone loss. If an isolated area is being treated, provide at least a periapical radiograph of that area. Diagnostic quality vertical bitewings may be acceptable under certain circumstances. The key is to provide evidence of bone loss, which is considered objective, rather than pocket depths alone, which can be subjective.  

There has also been confusion regarding D4355, full mouth debridement. Previously, no evaluation could be performed at the same appointment after a full mouth debridement was completed. The criteria have changed, and at this time some evaluations, including a comprehensive oral evaluation, a periodic evaluation, or a problem-focused evaluation can be completed the same day. A comprehensive periodontal evaluation, however, still cannot be completed on the same day, since it is necessary for soft tissues to heal to clinically examine and evaluate the periodontal conditions for a diagnosis.  

Lastly, let’s discuss the difference between D6011 and D4245. D6011 is surgical access to an implant body (second stage implant surgery). This is the typical procedure for exposure of an implant when it is to be restored. It can be a punch technique or the use of an instrument to create access through the tissue. D4245 is an apically positioned flap. This can also be used for implant exposure, or at times, it can be used in conjunction with the D6011. In these cases, two separate procedures must be done: one to expose the implant and the second to retain the keratinized gingiva by repositioning it. Again, photographs might be of benefit for a claim.  

In all of these situations, a pre-treatment estimate is strongly recommended. And most importantly, make sure claims are correctly submitted and all documentation is of diagnostic quality.