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Treating, Reporting and Managing Periodontal Diseases:

A Dental Hygienist’s Perspective

Presenter: Kathy S. Forbes, RDH, BS

June 23, 2018

12:30-3:30

• Periodontal Disease DiagnosisCase Types I-V andAAP Classifications I-VIII

• Chart Documentation Risk Management Issues

• Dental “Insurance”Not really insurance . . . Really!

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• Treatment Planning for *Non-surgical Dental Hygiene Procedures/Procedure Code Selection

*Evaluations *Adult/Child Prophylaxis*Scaling and Root Planing*”Gingivitis” Procedure*Periodontal Maintenance

Concerns?

There are dental hygienists who provide periodontal procedures (SRP, PM) but document preventive procedures (AP).

There are business staff who bill for adult prophylaxis when the hygienist has provided periodontal procedures.

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Concerns?

Both scenarios cause the practice to lose money.

Both scenarios would be considered risk management issues.

Classification/Case Typesof Periodontal Diseases(Based on 1989 World Workshop in Periodontics)

Formerly AAP Classification System

Case Type I – Early/Chronic GingivitisCase Type II – Established

Gingivitis/Early PeriodontitisCase Type III –

Moderate/Chronic PeriodontitisCase Type IV – Advanced PeriodontitisCase Type V – Refractory Periodontitis

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General GuidelinesExtent Severity

Localized = 30% or less of sites are involved

Slight = LOA/CAL 1-2 mm

Generalized = more than 30% of sites are involved

Moderate = LOA/CAL 3-4 mm

Severe = LOA/CAL 5+ mm

LOA = Loss of Attachment CAL = Clinical Attachment Loss

Case Types I-V (recognized by most “Insurance” Companies)

Case Type Status Defined Loss of Attachment/Clinical Attachment

Loss

Type 0 Clinically healthy No LOA/CAL

Type I Early/Chronic Gingivitis No LOA/CALPseudopocketingpossible

Type II Established Gingivitis/Early Periodontitis

Slight LOA/CAL =1-2 mm

Type III Moderate Periodontitis/Chronic Periodontitis

Moderate LOA/CAL =3-4 mm

Type IV Advanced Periodontitis Severe LOA/CAL =5+ mm

Type V Refractory Periodontitis

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Development of a Classification System for Periodontal Diseases and Conditions

Annals of Periodontology

December, 1999www.perio.org

AAP Classification of Periodontal Diseases and Conditions

(Based on 1999 International Workshop)

Gingival Diseases Chronic Periodontitis Aggressive PeriodontitisPeriodontitis as a Manifestation of

Systemic DiseasesNecrotizing Periodontal DiseasesAbscesses of the PeriodontiumPeriodontitis Associated with

Endodontic LesionsDevelopmental or Acquired

Deformities and Conditions

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Gingival Diseases

A. Plaque induced

1. Associated with dental plaque only2. Modified by systemic factors3. Modified by medications4. Modified by malnutrition

B. Non-plaque induced

1. Bacterial, viral, fungal, allergic, genetic, etc.

ChronicPeriodontitis

A.Localized≤ 30%

1. Modified bysystemic factors

2. Modified by medications

3. Modified by malnutrition

B.Generalized≥ 30%

1. Modified by systemic factors

2. Modified by medications

3. Modified by malnutrition

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Update will commence in 2017to review:• Attachment level• Chronic versus

aggressive periodontitis

• Localized versus generalized periodontitis

AAP Disease Classification/Diagnosis– Use descriptive words:

Generalized chronic periodontitisLocalized plaque-induced gingivitis with generalized slight chronic periodontitisLocalized chronic periodontitis - stable

Billing Class/Case Type/Code– Use Roman numerals (I-IV)– May use description title also:

IV: Moderate chronic periodontitis

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Fee for Service$100 procedure- $60 overhead$40 profit

PPO (20% discount)

$80 procedure- $60 overhead$20 profit

Insurance:

Protection against the occurrence of an infrequent, catastrophic event.

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Dentistry:Involves the frequent occurrence ofnon-catastrophic events.

Dental “Insurance”

Not really insurance but a

Dental Benefitor

Healthcare Financing

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Dental “Insurance” 1972Most plans paid by incentive:– First year: paid 70% of dentist’s fees–Second year: paid 80% of dentist’s fees–Third year: paid 90% of dentist’s fees–Fourth year and beyond: paid 100%

Maximum benefit?

Dental “Insurance” 2018Paid according to negotiated contract between employer and insurance companyVarying rates of reimbursement

– Some based on % of UCR computed by insurance company

– Some rely on “evidence-based” research

– Some based on “who knows what”

Maximum benefit?

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Documentation Top Two Areas of Claim Frequency:#1: Failure to diagnose periodontal

disease.#2: Failure to diagnose oral cancer#3: Legal considerations, poor record

keeping, and a lack of informed consent.

Also note #9:Failure to refer or referring too late.

Avoid personal shorthand that others cannot understand and non-relevant comments that could prove embarrassing if read in court.

Allow adequate time to complete the treatment record to avoid poor documentation and frustration.

Document all data immediately;delays lead to inaccuracies.

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RDH MagazineNovember 2013

Top Reasons Hygienists Are SuedStrategies for Avoiding Malpractice Claims

Author:Dianne Glasscoe Watterson, RDH, BS, MBA

Informed Consent defined:The patient’s agreement that he or she has had a thorough discussion with the doctor (dentist), understanding the recommended treatment or procedure, its alternatives, risks and consequences, and desires the dental procedure to be preformed.

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Informed Consent defined:Informed consent is more than simply getting a patient to sign a written consent form. It is a process of communicationbetween a patient and physician (dentist) that results in the patient’s authorization or agreement to undergo a specific medical (dental) intervention.

Revised Code of WashingtonRCW 7.70.060

Consent form – contents –prima facie evidence – failure to use.

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(1) A description, in language the patient could reasonably be expected to understand, of:

(a) The nature and character of the proposed treatment;

(b) The anticipated results of the proposed treatment;

(c) The recognized possible alternative forms of treatment; and

(d) The recognized serious possible risks, complications, and anticipated benefits involved in the treatment and in the recognized possible alternative forms of treatment, including non-treatment;

INFORMED REFUSAL

Periodontal Scaling and Root PlaningPeriodontal MaintenanceX-ray Consent Withheld

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Examples of Fraud

Billing for services not performed.Altering dates of service.The American Dental Association’s Code of Ethics (5.B.4) states: A dentist who submits a claim form to a third party reporting incorrect treatment dates for the purpose of assisting a patient in obtaining benefits under a dental plan, which benefits would otherwise be disallowed, is engaged in making an unethical, false or misleading representation to such third party.

Examples of Fraud

Misrepresenting patient identities

Not disclosing existence of primary coverage

Not informing dental carrier you’ve billed medical carrier also

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Examples of Fraud

Up coding (now referred to as remapping), for example:Billing Scaling and Root Planing

when you provided Periodontal Maintenance.Billing a night guard or fluoride

trays when you’ve only provided whitening trays.

Example of Fraud

Waiver of co-payments and/or deductiblesThe insurance plan is a contract between the patient’s employer and the insurance company. The dentist is not a party to that contract. As such, dentists cannot accept payments from insurance companies as payment in full when a co-payment is contractually required.

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Example of Fraud

Unbundling Codes – separating dental procedures so the benefits of the component parts total more than the procedures as defined would normally be reimbursed.

Procedure Codes designated for

dental hygiene/periodontal diagnosis and therapy

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How many codes are available to hygienists in Washington

State?

Where do we start?

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Clinical Oral Evaluations

(Not Exams)

Periodic Oral Evaluation –established patient

CDT 2018, p. 5: D0120

An evaluation performed on a patient ofrecord to determine any changes in thepatient’s dental and medical health statussince a previous comprehensive or periodicevaluation. This includes an oral cancerevaluation and periodontal screening whereindicated and may require interpretation ofinformation acquired through additionaldiagnostic procedures.

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What is the definition of a “Periodontal Screening” ?

Many hygienists and dentists consider a periodontal screening to include nothing more than spot probing BUT…The American Academy of Periodontology states that a charting containing only six points per tooth pocket depths is a Periodontal Screening.

Comprehensive Oral Evaluation –New or Established Patient

CDT 2018, p. 6: D0150

Typically used by a general dentist and/or specialist when evaluating a patient comprehensively. This applies to

• new patients;• established patients who have had a

significant change in health conditions or other unusual circumstances, by report, or

• established patients who have been absent from active treatment for three or more years. > > >>>>>

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Comprehensive Oral Evaluation –New or Established Patient

Evaluate and record: An evaluation for oral cancer where

indicated Extra-oral and intra-oral hard and soft

tissues Dental historyMedical history A general health assessment

>>>>>>>

Comprehensive Oral Evaluation –New or Established Patient

Dental caries, missing or unerupted teeth Restorations Existing prostheses Occlusal relationships Periodontal conditions, including

periodontal screening and/or periodontal charting

Hard and soft tissue anomalies

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What is the definition of a “Periodontal Charting” ?

The American Academy of Periodontology states that a complete periodontal charting, including a description of periodontal conditions, includes – six points per tooth pocket depths, – recession, – furcations, – mobilities, – bleeding points, – minimal attached gingiva notations, – AAP diagnosis, etc.

Re-evaluation – post-operative office visit

CDT 2018, p. 7: D0171

No specific definition included in CDT 2016 or 2017 but October 2014 issue of Insurance Solutions Newsletter states:

“May be used to document the re-evaluation of a patient four to six weeksafter periodontal scaling and root planing. However, most payers include follow-upevaluations in the global procedure fee.”

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Comprehensive Periodontal Evaluation – New or Established Patient

CDT 2018, p. 7: D0180

This procedure is indicated for patients showingsigns or symptoms of periodontal disease and forpatients with risk factors such as smoking ordiabetes. It includes evaluation of periodontalconditions, probing and charting, evaluation andrecording of the patient’s dental and medicalhistory and general health assessment. It mayinclude the evaluation and recording of dentalcaries, missing or unerupted teeth, restorations,occlusal relationships and oral cancer evaluation.

What is the difference in the definitions?Comprehensive Oral Evaluation Comprehensive Perio Evaluation

Evaluation of oral cancer Oral cancer evaluation

Extra-oral/intra-oral hard/soft tissues NOT INCLUDED

Dental history Dental history

Medical history Medical history

General health assessment General health assessment

Dental caries, missing or unerupted teeth

Dental caries, missing or unerupted teeth

Restorations Restorations

Existing prosthesis NOT INCLUDED

Occlusal relationships Occlusal relationships

Periodontal conditions including periodontal screening and/or charting

Periodontal conditions including periodontal charting

Hard and soft tissue anomalies NOT INCLUDED

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Oral evaluation for a patient under three years of age and counseling

with primary caregiver CDT 2018, p. 5: D0145

Diagnostic services performed for achild under the age of three,preferably within the firstsix months of the eruption of thefirst primary tooth, includingrecording the . . .

Oral evaluation for a patient under three years of age and counseling

with primary caregiver

• Oral and physical health history, • Evaluation of caries susceptibility,• Development of an appropriate

preventive oral health regime,• Communication with and counseling

of the child’s parent, legal guardian and/or primary caregiver.

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Pre-diagnostic Services

…. and other individuals may report any of the listed CDT Codes as long as they are acting within the scope of their state law.

Screening of a PatientCDT 2018, p. 7: D0190

A screening, including state or federally mandated screenings, to determine an individual’s need to be seen by a dentist for diagnosis

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Assessment of a PatientCDT 2018, p. 7: D0191

A limited clinical inspection that is performed to identify possible signs of oral or systemic disease, malformation, or injury, and the potential need for referral for diagnosis and treatment.

Diagnostic Codes(related to caries risk)

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Caries risk assessment and documentation, with afinding of moderate risk.

Using recognized assessment toolsCDT 2018, p. 11: D0602

Caries risk assessment and documentation, with afinding of high risk.

Using recognized assessment toolsCDT 2018, p. 11: D0603

Caries risk assessment and documentation, with afinding of low risk.

Using recognized assessment toolsCDT 2018, p. 11: D0601

“Evaluation of caries susceptibility”

Caries Risk Assessment Forms for –Age 0 to 6 years and –>6 years

www.ada.orgSearch, enter:

“caries risk assessment forms”

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Preventive ServicesOther than Prophylaxis or Periodontal Procedures

Fluoride Treatment(Office Procedure)

Prescription strength fluoride product designed solely for use in the dental

office, delivered to the dentition under the direct supervision of a dental

professional. Fluoride must be applied separately from

prophylaxis paste.

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*Factors increasing risk for caries may include but are not limited to:

High level of caries experience or demineralizationHistory of recurrent cariesHigh titers of cariogenic bacteriaExisting restoration(s) of poor qualityPoor oral hygieneInadequate fluoride exposureProlonged nursing (bottle or breast)Poor family dental health >>>>>>>

*Factors increasing risk for caries may include but are not limited to:

Developmental or acquired enamel defectsDevelopmental or acquired disabilityXerostomiaGenetic abnormality of teethMany multisurface restorationsChemo/radiation therapyEating disordersDrug/alcohol abuseIrregular dental care

*ADA Guidelines

July 2004

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Topical application of fluoride varnish CDT 2018, p. 15: D1206

Topical application of fluoride –excluding varnish

CDT 2018, p. 15: D1208

Interim caries arresting medicament application – per tooth

CDT 2018, p. 16: D1354

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Documentation for Radiographs

Guidelines for Prescribing Dental Radiographs

From: American Dental Association andU.S. Food & Drug Administration2004, then Updated 2012

www.ada/org/prof/resources/topics/radiography.aspwww.fda.gov/cdrh/radhlth/adaxray.html

Guidelines for Prescribing Dental Radiography, 2012

Page 3 of ReportRadiographic screening for the purpose of detecting disease before clinical examination should not be performed. A thorough clinical examination, consideration of the patient history, review of any prior radiographs, caries risk assessment and consideration of both the dental and the general health needs of the patient should precederadiographic examination.

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ADA Clinical Indicatorsfor Dental Radiographs

A. Positive Historical Findings1. Previous periodontal or

endodontic therapy.2. History of pain or trauma.3. Family history of dental

anomalies.4. Postoperative evaluation of

healing.5. Remineralization monitoring6. Presence of implants or evaluation

of implant placement.

ADA Clinical Indicatorsfor Dental Radiographs

1. Clinical evidence of periodontal disease

2. Large or deep restorations3. Deep carious lesions4. Malposed or clinically impacted

teeth5. Swelling6. Evidence of dental/facial trauma7. Mobility of teeth8. Sinus tract (“fistula”)9. Clinically suspected sinus

pathology10. Growth abnormalities11. Oral involvement in known or

suspected systemic disease12. Positive neurologic findings in

the head and neck

13. Evidence of foreign objects14. Pain and/or dysfunction of the

TMJ15. Facial asymmetry16. Abutment teeth for fixed or

removable partial prosthesis17. Unexplained bleeding18. Unexplained sensitivity of

teeth.19. Unusual eruption, spacing or

migration of teeth20. Unusual tooth morphology,

calcification or color21. Missing teeth with unknown

reason22. Clinical erosion

B. Positive Clinical Signs and Symptoms

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“Cleaning” Codes

Prophylaxis – ChildCDT 2018, p. 15: D1120

Removal of plaque, calculus and stains from the tooth structures in the primaryand transitional dentition. It is intended to control local and irritational factors.

Removal of plaque, calculus and stains from the tooth structures in the permanent and transitional dentition. It is intended to control local and irritational factors.

Prophylaxis – AdultCDT 2018, p. 15: D1110

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Scaling in the presence of generalized moderate or severe

gingival inflammation – full mouth, after oral evaluation.

CDT 2018, p. 39: D4346

The removal of plaque, calculus and stains from supra-and sub-gingival 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. Should not be reported in conjunction with prophylaxis, scaling and root planning, or debridement procedures.

www.ada.org

CDT 2018pp. 288-298

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Full mouth debridement to enable comprehensive evaluation

and diagnosis on a subsequent visitCDT 2018, p. 39: D4355

Full mouth debridement involves the preliminary removal of plaque and calculus that interferes with the ability of the dentist to perform a comprehensive oral evaluation. Not to be completed on the same day as D0150, D0160,or D0180.

Full mouth debridement to enable comprehensive evaluation

and diagnosis

Narrative needed describing:● why debridement necessary● description of tissues, bleeding,

amounts of plaque and calculus, etc.● length of time since last “cleaning”● x-rays and/or photos showing calculus

deposits and degree of gum infection

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When is Initial Periodontal Therapy (Scaling and Root Planing) Indicated?

When there is evidence of active disease

bleeding on probing

Increased pocket depthContinued attachment loss (i.e. recession)Increased tooth mobilityPurulent (pus) discharge/suppurationSequential radiographic change of crestal bone

Comprehensive Periodontal Therapy: A Statement by the American Academy

of Periodontology

• Health Professionals• Clinical/Scientific Resources• Scroll to Academy

Statements• Comp Perio Therapy

(from jop, July 2011)

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Report sets forth the scope, objective and procedures that constitute periodontal

therapy:

Scope of Periodontal TherapyPeriodontal EvaluationEstablishing a Diagnosis, Prognosis and Treatment PlanInformed Consent and Patient RecordsTreatment ProceduresEvaluation of TherapyFactors Modifying ResultsPeriodontal Maintenance Therapy

Our responsibility to our patients:

We inform.We document.We all share the same culture in the office.We all have the same “Standard of Care”.We have a team on board serving the patients’ perio and restorative treatment needs.

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Scaling and Root PlaningCDT 2016, p. 36-37: D4341/D4342

This procedure involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. It is indicated for patients with periodontal diseaseand is therapeutic, not prophylactic, in nature. Root planing is the definitive procedure designed for the removal of cementum and dentin that is rough, and/or permeated by calculus or contaminated with toxins or microorganisms. Some soft tissue removal occurs. This procedure may be used as a definitive treatment in some stages of periodontal disease and/or as a part of pre-surgical procedures in others.

Periodontal Scaling and Root Planing –four or more teeth, per quadrant CDT 2018, p. 39: D4341

Periodontal Scaling and Root Planing –one to three teeth, per quadrantCDT 2018, p. 39: D4342

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Periodontal Maintenance ProceduresCDT 2016, p. 37: D4910

This procedure is instituted following periodontal therapy and continues at varying intervals determined by the clinical evaluation of the dentist,for the life of the dentition or any implant replacements. It includes removal of bacterial plaque and calculus from supragingival and subgingival regions, site specific scaling and root planing where indicated, and polishing the teeth. If new or recurring periodontal disease appears, additional diagnostic and treatment procedures must be considered.

Example:

“If benefits unavailable or exhausted for Periodontal Maintenance, please consider an alternate benefit for Adult Prophylaxis.”

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RDH MagazineFebruary, 2014

Site Specific Scaling & Root Planing

What code to use?

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RDH MagazineNovember,

2014

After active periodontal therapy and a period of maintenance, is it ever appropriate to report code D1110 (prophylaxis) for recall visits?

What does the American Dental Association say?

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Response . . .“This is a matter of clinical judgment by the treating dentist. Follow-up patients who have received active periodontal therapy (surgical or non-surgical) are appropriately reported using the periodontal maintenance code D4910. However, if the treating dentist determines that a patient’s oral conditions can be treated with a routine prophylaxis, delivery of this service and reporting with code D1110 may be appropriate.”

From CDT 2016, p. 103

Other ProceduresWhich may be necessary for

patients requiring periodontal therapy

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Implant maintenance procedure when prostheses are removed and reinserted, including cleansing of prostheses and

abutments.CDT 2018, p. 63: D6080

This procedure includes active debriding of theimplant(s) and examination of all aspect of theimplant system(s), including occlusion and stabilityof the superstructure. The patient is alsoinstructed in thorough daily cleansing of theimplant(s). This is not a per implant code and isindicated for implant supported fixed prostheses.

Scaling and debridement in the presence of inflammation or mucositis of a single

implant, including cleaning of the implant surfaces, without flap entry and closure

CDT 2018, p. 63: D6081

This procedure is not performed in conjunctionwith D1110, D4910 or D4346.

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Debridement of a peri-implant defect or defects surrounding a single implant, and surface cleaning of the exposed implant

surfaces, including flap entry and closure.CDT 2018, p. 58: D6101

No descriptor; however, at the Code MaintenanceCommittee meeting in March 2018, a submission suggestinga new code for “disruption of subgingival biofilm using airand water pressure combined with a low-abrasive powder onTooth surfaces and implants” was rejected because“The CMC determined that this action request isfor a technique that is appropriately reported withCDT code D6101 ….”

Local Anesthesia Codes

“Local anesthesia is usually considered to be part of Restorative, Endodontic, Periodontal, Removable Prosthodontic, Implant Services, Fixed Prosthodontic and Oral and Maxillofacial Surgical Procedures”

Local anesthesia CDT 2018, p. 87: D9215

Local anesthesia not in conjunction with operative or surgical procedures CDT 2018, p. 87: D9210

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Oraqix™(Lidocaine and Prilocaine)

Kovanaze™(Tetracaine HCl and Oxymetazoline HCl)

• Regional anesthesia (#4 - #13)

• Pre-filled, single-use sprayer

• 2 sprays (0.2 ml per spray) 4-5 minutes apart.

FDA approved as of June 29, 2016

www.st-renatus.com

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OraVerse®(Phentolamine Mesylate)

www.septodontusa.com

• Local Anesthetic reversal agent• Accelerates the reversal of lingering

numbness• Takes ½ the time

Cleaning and Inspection of a removable appliance

CDT 2018, p. 91

This procedure does not include any required adjustments.Cleaning and inspection of removable complete denture, maxillary D9932Cleaning and inspection of removable complete denture, mandibular D9933Cleaning and inspection of removable partial denture, maxillary D9934Cleaning and inspection of removable partial denture, maxillary D9935

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Localized delivery of antimicrobial agents via controlled release vehicle into diseased

crevicular tissue, per toothCDT 2018, p. 40: D4381

FDA approved subgingival delivery devicescontaining antimicrobial medication(s) areinserted into periodontal pockets to suppressThe pathogenic microbiota. These devisesSlowly release the pharmacological agents sothey can remain at the intended site ofaction in a therapeutic concentration for asufficient length of time.

Gingival irrigation – per quadrantCDT 2018, p. 40: D4921

Irrigation of gingival pockets withmedicinal agent. Not to be used toreport use of mouth rinses or non-invasive chemical debridement.

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Fluoride gel carrierCDT 2018, p. 56: D5986

Synonymous terminology: fluoride applicator

A prosthesis, which covers the teeth ineither dental arch and is used to applytopical fluoride in close proximity to toothenamel and dentin for several minutes daily.

Periodontal medicament carrier with peripheral seal – laboratory processed

CDT 2018, p. 56: D5994

A custom fabricated, laboratory processedcarrier that covers the teeth and alveolarmucosa. Used as a vehicle to deliverprescribed medicaments for sustainedcontact with the gingiva, alveolar mucosa,and into the periodontal sulcus or pocket.

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Adjunctive General ServicesApplication of desensitizing medicament CDT 2018, p. 90: D9910

Includes in-office treatment for root sensitivity. Typically reported on a “per visit” basis for application of topical fluoride. This code is not to be used for bases, liners or adhesives used under restorations.

Application of desensitizing resin for cervicaland/or root surface, per tooth CDT 2018, p. 90: D9911

Typically reported on a “per tooth” basis for application of adhesive resins. This code is not to be used for bases, liners or adhesives under restorations.

Contact Information:

Kathy S. Forbes, RDH, BSPhone: 253-670-3704FAX: 866-669-9308Email: prodentseminars@gmail.com

Professional Dental Seminars, Inc.1702 Valley Oak CtCastle Rock, CO 80104