Decoding Dental Benefits: Scaling and root planing
Periodontal scaling and root planing claims tend to have a higher frequency for denial than other procedures, prompting many calls from frustrated dentists to the ADA asking why certain claims were denied.
Dental claims can be denied or delayed for myriad reasons, and procedures for periodontal scaling and root planing are often followed by requests for additional information from many carriers. The ADA has resources to help dentists and their dental office staff guide them through the claim process regarding scaling and root planing —including when claims are denied.
“It is appropriate to appeal the benefit decision if you think the scaling and root planing claim has not been properly adjudicated,” said Dr. Christopher Bulnes, vice chair of the ADA Council on Dental Benefit Programs. “A proper appeal involves sending information to facilitate payment of the benefit for the patient.”
The ADA Council on Dental Benefit Programs recommends these tips for minimizing claim denials or delays for scaling and root planing:
- Before submitting a claim for scaling and root planing, check the company’s guidelines on their website or in the provider’s office reference guide.
- When submitting scaling and root planing for more than two quadrants within a single visit, a best practice would be to send documentation, including full-mouth periodontal charting, FMX, periodontal diagnosis and the treatment plan.
One recurring question from dentists is that they don’t understand why claims for periodontal scaling and root planing are denied when the patient has abnormal pocket depths, said Dr. Bulnes. A claim may be paid on a patient with 4mm pockets while at other times the same payer may deny the same procedure for another patient who had the same depths.
A carrier may have a specific processing policy that states there must be documentation of at least 4mm pocket depth on the diseased teeth, Dr. Bulnes said. If there is not 4mm pocket depth, the procedure could be interpreted by the third-party payer as a D1110 (prophylaxis – adult).
Dr. Bulnes said the addition of code D4342 (periodontal scaling and root planing – one to three teeth per quadrant) has been helpful in determining appropriate benefit reimbursements. Before 2003, when code D4341 was the only scaling and root planing code, it was more difficult to determine coverage when scaling and root planing were performed for a small number of teeth in a quadrant.
The ADA has created a new landing page for dental benefits information that can help dentists address and resolve even their thorniest questions, ADA.org/dentalbenefits, part of the Center for Professional Success.
A good place to start is a 20-page manual titled Responding to Claim Rejections, located at Success.ADA.org/en/dental-benefits/responding-to-claims-rejection. An entire section is devoted to scaling and root planing.
Staff from the Center for Dental Benefits, Coding and Quality can help dentists with dental benefits-related problems, questions and concerns. Call 1-800-621-8099 or email firstname.lastname@example.org for questions regarding denial of claims.
If dentists have a concern or question they would like addressed in a future issue of ADA News, they can contact email@example.com.