As an integral part of the treatment team, dental hygienists and support staff must feel comfortable with the language of CDT codes, which correspond with procedure codes. Perhaps surprisingly, many team members lack formal training in this area and are unable to confidently navigate the web of CDT codes. Proper and widespread use of CDT coding within dental offices can deliver dental treatment documentation practices that align with the highest standards of uniformity, consistency and specificity.
Coding must match up with the procedures and services rendered. Because all dental office staff members work closely together, clinicians and nonclinical staff with a grasp of the nomenclature can help ensure dental procedures align with reporting. As an added benefit, this enhances the patient experience. During consultations and when billing questions arise, staff members can better describe and inform patients about procedures and insurance coverage before they move forward with a course of treatment.
As many dental insurance plans focus on preventative care, patients can lose sight of a comprehensive perspective that is more attuned to their individual needs. Coding correctly makes it possible to inform patients that coverage does not always align with the patient’s diagnosis. By simply following the roadmap set forth by dental insurance, patients might face steeper costs and more extensive dental treatment down the road.
Dental specialists and other staff members can be at the forefront of informing patients as early as possible about the next steps, ensuring better treatment outcomes.
Streamlining dental office operations comes naturally when everyone is up to speed on all dental terminology and on the same page with coding. When everyone is equipped with these skills, teams can expect greater consistency, effective dialogue between front and back desks and an overall workflow that has a positive impact on morale and, in turn, patient care.
For staff members who enter treatment plans, here are some highlights on the common restorative codes relating to hygiene therapy they should know about:
D1110: Prophylaxis (adult)
- Preventative and treatment for generalized slight gingivitis
- Procedure scales and polishes all surfaces at the coronal or the cementoenamel junction
- Removal of plaque, stains and calcified dental plaque
- Prophy could be supra based on marginal tissue descriptions
D1120: Prophylaxis (child)
- Removal of stains and calcified dental plaque
- Codes for prophy are dentition-specific, but age is a factor
- Child could be removed from this status upon absence of deciduous teeth
D4346: Scaling, presence of generalized moderate or severe gingival inflammation
- Removal of plaque, stains and calcified dental plaque in patient with swelling, bleeding and inflamed gums and related symptoms
- No age limit; for permanent, primary or transitional dentition
- Based on diagnosis
- Unrelated to level of difficulty
D4355: Full mouth debridement
- Preliminary and superficial removal of plaque and calcified dental plaque
- Used for removal of deposits that interfere with completion of successful comprehensive oral exam
- Second visit typically required
D4910: Periodontal maintenance
- Therapeutic procedure
- Follows scaling, root planning, gingival surgery or osseous surgery
- Re-care intervals
- When insurance limits are met, reporting must be continuous
- Complete documentation can outline steps that follow a denial and show alternate benefit of prophylaxis
- Patients with history of periodontal disease but are not actively showing symptoms, and have no history of scaling and root planning, osseous or flap surgery, can fall under D1110 code
Dental professionals uphold their obligations to ensure medical accuracy and efficiency when they follow proper coding procedures. The benefits are not just about administrative efficiency; it’s also a tool to put patients at ease about their care and how it’s paid for.
With a basic understanding and with the aid of the American Dental Association CDT book, dental professionals can take part in meaningful dialogue in everyday interactions with their teams, promoting office efficiency and enhancing patient care.
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