How to Implement the code D4346- Scaling of generalized moderate-severe gingivitis.
Hi there, my name is Shelly brown, and I’m one of the dental hygienists that runs hygiene edge, and I wanted to discuss with you today the D4346 code. I wondered if you’re using it yet, if you’re not, you need to start implementing this into your practice.
So, what it is, it’s scaling in the presence of generalized, moderate or severe gingival inflammation, and it is a newer code that was given to us a few years ago now. But I’m finding that a lot of hygienists don’t know how to implement it into their private practice. So, this is what that video is all about.
Just explaining it, reviewing it um so that you can have the information to be able to have maybe an office meeting where you discuss how to implement it into the practice because it needs to be a team effort to be able to use this code.
So, the description from the adt code guide is the removal of plaque, calculus and stain 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 super bony pockets and moderate to severe bleeding on probing.
This should not be reported in conjunction with prophylaxis, scaling and root, planing or debridement procedures. It is a procedure all by itself, so some of the descriptions continued on about this code is that it’s a therapeutic code, meaning it starts with a four versus our preventive codes. That start with a one and usually insurance wise.
Those preventive codes are covered at a greater percentage like at a 100 percent, so sometimes like this code because it’s starting with a four sometimes insurances might cover it like they would periodontal therapy.
So keep that in mind that we do need to give possibly little information to the patient if they’re going to have a deductible or not, it’ll probably depend on insurance with this code. But that is a possibility. It is not aged age or dentition, based, meaning it can be done on children. Think of those children who have ortho, and they have they’re their gums are.
The gingiva is over those braces brackets, and they’re bleeding, and that would be a great um time to do. This uh presents this four three four six code: um because we’re, we’re spending a little more time with the patient in a lot of different ways: oral hygiene, education and work in their mouth, and so we should be compensated more. So, it’s not age-based, so keep that in mind.
It’s also a full mouth code, meaning that it’s not built in quadrants like our d4341 and four three four twos are it’s like a profi prophylaxis code where it’s full mouth. The price uh is usually similar to you, what you’re charging for period maintenance.
So, that’s going to vary uh greatly across different states and so keep that in mind that it’s usually an around there depending on what your office chooses. So, that’s something that you should discuss as an office, and then your office should determine the re-care frequency on a patient who is diagnosed with moderate to severe gingivitis.
So, every office is doing it a little bit different. I feel like, so you can choose a two to six-week interval like a re-evaluation type interval. Let’s get you back real, quick and see how everything’s healing, or you can choose like a three to four-month interval where we’re just seeing you, you know, keeping the patient on a little bit of a tighter leash, but not taking it too far long to You know maybe let it progress, so that’s a possibility and or six months you could just say you know what we’re just gonna see you six months later and at that time we’ll determine if you need this type of scaling or this type of treatment again Or if you need the preventive treatment, if you’ve gone back to healthy, so you’re gonna have to determine as an office what you want.
Your recur frequency to be, and it’s going to vary per office and that’s okay. But you have to do what’s going to be best for your own practice, so those are some options that we see um. When do we build this? When is it that I’m actually going to tell the patient? This?
Is your treatment plan versus a prophylaxis or versus periodontal therapy? When is it that I’m actually going to be doing this on a patient? So, if I have generalized, if I do my assessment and I see that there’s generalized – which is thirty percent in the mouth – thirty percent of the dentition – so if you have a full dentition of about 28 teeth, that’s eight teeth in the mouth. So, keep that in mind, that’s eight teeth in the mouth will be. Give you a generalized condition, um.
If you see moderate or severe gingivitis generalized, then you’re going to be billing. This code, it’s not based on calculus, it’s not based on the amount of calculus that there is. Usually, though, if there is calculus deposit, then you might see gingivitis along with that. So keep that in mind that that is possibility. But it is not based on how much calculus is present in the mouth.
It’s based on how the tissue is looking actually and one way to determine if something is mild, moderate or severe, as you can use that low and stillness gingival index, so normal gingival gingiva looks pink and there’s no edema.
There’s no erythema, there’s no bleeding on probing. Everything looks good. We would do a prophy in that case right if there’s mild inflammation, which is categorized as slight change in color, there’s slight edema, but there’s still no bleeding on probing moderate inflammation.
So if we have localized, if we have localized moderate inflammation, we’re not doing the D4346 code, if we have localized severe inflammation, we’re not doing this local, this four three four six code, if it’s localized, we would still do a profi.
But if it’s generalized, if it’s that eight teeth in a 28 mouth dentition, then we need to move it to this for three, four to six codes. So, we have moderate information. What we would see here is, we would see redness we’d, see, edema we’d, see glazing, and we would see bleeding on probing on eight teeth. Now. That’s just not you know, one tooth, eight.
You know, six bleeding points around one tooth: that’s there are eight teeth in the mouth and when I did my probing, I have eight bleeding points. While I probed, that is considered moderate inflammation, and then we have severe inflammation marked redness edema ulceration tendency towards spontaneously bleeding. We look at it, and it bleeds, that’s severe. We’ve seen those patients before, that’s an easy one. To tell, I need to do a different code, sometimes between moderate to mild.
You might have to really base it on those probe depths to determine. Is this a case where I would need to charge the 4346 code instead? So, keep that in mind? Those are some of the ways that I tell I differentiate between mild, moderate or severe inflammation. So, when do we not build this when one of those times, if you have localized moderate to severe gingivitis, you’re still going to be using that 1110 code?
If you have generalized slight gingivitis you’re going to be using that 1110 prophylaxis code and then if you find that there’s periodontitis, if we see all this inflammation, and then we look at our radiographs, and we’re like.
Ah, you know what I see, bone loss. Then we need to be doing periodontal therapy versus this um therapeutic gingivitis code. So keep that in mind, insurance coverage. Always you know, unfortunately, that’s the world we live in.
We have to be thinking a little bit about insurance coverage for the patient because they’ll be asking us. Of course, you can always refer that information to the front desk person to help the patient get that determined, but it’s good to have some ideas in mind so that you can help the patient in accepting their treatment plan.
So, we should never base treatment on insurance coverage. If the patient has generalized moderate to severe gingivitis, then this coach should be billed it. It’s that’s just a fact as simple as that we’re not like.
Oh man, now I have to like charge more. It’s going to be so annoying to have to explain it to the patient. I know that there are barriers like that. I have been there. I get it, but keep in mind that if it’s there, if it’s present, it should be the treatment plan for the patient.
The best care, it’s available for them to be able to have that treatment. You’re doing that treatment. You should be compensated for that treatment, so um, do it. Insurance very coverage will vary like I mentioned briefly before they may have. The patient may have a deductible plus, generally.
80 percent is usually covered on those therapeutic codes, sometimes offices or insurances. If you’re contracted with them, they might downgrade it to a profit fee, but they might still pay 100, and then it’s covered generally twice per year. So, an example of that is, let’s say we see them at this initial treatment, we’d bill, four, three, four six and then the next time we see them.
They look good in everything, looks pretty healthy because we talk them into their oral hygiene, education and doing better, and now they get an 11 10 prophylaxis. That’s their two per year, that’s their two per year that they would get covered at 100.
So if it, though, at that next six month checkup, it was a four three four six code again, and then you’re like I wanna, see you in three months that three month visit might still be within that year of their insurance, and it wouldn’t be covered. So, generally, there’s only two covered per year versus covering any more than that.
So keep that in mind. If you have like three or four of these per year that you see on that same patient, maybe they just never brush their teeth or whatever the issue is, and you want to see them every two months or maybe every three months, so you’re seeing them four Times per year, two of those possibly per year, if you saw them four times that year, would not be covered. So keep that in mind.
It is a great idea to have your front desk person. Add this to their benefit questionnaire, so generally they’re calling insurances, and they’re asking oh how what are crowns covered at what is a profit covered at? What are the waiting periods, things like that? They need to add this 4346 to the questionnaire so that you can know if what will be covered for the patient and let them know that information when and if you diagnose this treatment plan to be done. Um.
Also, it’s a great idea to identify patients who might need it before, so you can look it up before they arrive because they’ll be asking you what’s the difference in price um, if it’s the, if it’s on a child, you can let the parents know like this. Is what the price will be um because you have asked the front desk person, so maybe you could identify in the morning or the day before, maybe some of those patients who it’s been a really long time – hey, let’s just double-check with their insurance beforehand, to See and if that is the case, that they need it, then we’ll have the information or, if you have a patient who’s been coming in for years and years and years, and you know every time you come in, that it’s going to be a blood, but it’s Going to be a bloodbath, maybe that’s the patient that you need to see a little bit, keep them on a little bit of a shorter leash and then also maybe you need to transfer them to this 4346 code, so maybe identifying some of those patients before they arrive, or new patients might be really helpful for the patient to be able to accept that treatment plan. You want to ensure insurance coverage, so it’s really important if you’re working with patients who have insurance that we help them out just a little bit get coverage on these.
So, you can tell the front desk person to submit your documentation when we document it. We document our diagnosis right.
The patient presents with generalized severe gingivitis needs. Therapy needs gingivitis therapy, periodontal therapy. You could word it, however, you want, but the documentation should be submitted to insurance. You also need to probably provide your probed ups as well with bleeding points. So even on children – and it might not be your policy to probe on children – maybe age, 18 and up every office will vary on when they probe to start probing on children.
But if you find that there is a child who you think that it’s going to take a little bit longer, and you think that they need this treatment, then you should stop and do an assessment and document those probe depths and then maybe even reappoint them back. For the visit, if those probed ups do take a little bit longer, so probed ups will be helpful. The radiographs and any intraoral photos that you can take to show the insurance that this gingiva are overgrown or red or inflamed will help get coverage as well.
So, you can encourage the front desk person over insurance to help you place those in for insurance coverage. Now the verbiage with the patient.
How do we talk with our patients about getting this treatment plan accepted? Because, if it’s not accepted, it benefits neither party, right? Let that sink in if it’s not accepted treatment that is necessary benefits neither party, the patient doesn’t get the treatment done and then, as an office, you don’t make production.
So, it’s beneficial to both parties that we word this perfectly not perfectly, but well, so that our patients will accept the treatment plan. So, of course, when do we want to discuss this?
You have to set an office policy on if the dentist wants to come in before or after, depending on the state and legalities there on when to diagnose this with on the patient. Does the dentist want to come in and confirm everything before or after or during, or how you want to work that? But once the diagnosis is determined um that you find that the patient does have a need for this gingivitis scaling, then you can say it to the patient or to the parent.
We found today that you have what’s called generalized moderate gingivitis. It is an infection in your gums, causing them to swell and bleed, but the good news is that gingivitis is reversible, but we need to treat it with a therapy on your gums to prevent it from progressing into the bone.
That holds your tooth in and then i always personally show educational, material and images on what all of that information means. What we don’t want it to do is progress to the bone where health looks and where gingivitis is and where they are at today, then the patient’s going to ask us a little bit about the cost as usual, so you’ll want to set an office policy on How to handle the cost, so sometimes that means let’s go see the front desk person and see you know, get the financials all worked out beforehand.
Let’s get a full treatment plan worked up and then reappoint you, and that’s usually something of 4346 that I feel like. I can do within the timeframe that I have, then I will try to do it that day. So, that’s why it is nice to have a little chat, maybe beginning of the day, to identify some of those patients who this might be a possible treatment plan for and identify that beforehand, but generally, I’ll word it like this.
The good news is that you have an insurance benefit for the procedure. Here’s the cost. Once I have that available, we can get started on that for you today, and then they can determine yes, okay, that looks good or no, that’s not going to work. For me, whatever it is, but it’s always important to let them know that there is a cost of course, and then um. I always like to say that you do have an insurance benefit, um.
The next visit, I’m always educating the patients on next visit, and I’m pre-scheduling that in advance either whatever that recurring interval is, I can set that recur interval, so it could be the two weeks or two to four weeks or one month, two months, three months, four Months six months, however, your office wants to work that, but you’ll just pre-schedule it just like a recare and complete an assessment again, the next time, and you’ll just do whatever code is there next time it could be an 11 10. It could be a four, three.
Four, six or things might have advanced to the period for three four one or four, three, four, two, possibly, so that’s what they’re trying to prevent. That’s where I hit the oral hygiene education really hard when I’m showing them the educational images and saying we don’t want it to move to here. This is even more expensive treatment, so if we can get this taken care of and reversed, hopefully we can put you back down on the preventive maintenance care procedure again for next time, but this time we need to do something more in depth because you have this Infection going on, so that helps get them thinking.
Okay, I need to come back more often or whatever the interval is that you want, I usually say something like because you have this severe gingivitis. We want to keep a closer eye on your gum. Health. Therefore, I want to see you in how many months or however many weeks it is that you want, and then you get them scheduled back um treatment planning for this. You know once you determine the code after you’ve, probed, then of course performing oral hygiene education.
You might also want to consider some type of rinse, sometimes there’s chlorhexidine, some offices use other things, but a rinse that helps to kill off the bacteria that causes gingivitis can be very helpful as well for the patient, and then, of course, you can do fluoride. After that and radiographs and the exam like usual as well, so I would encourage you to sit down with your office and make some policies for this procedure. Ask the dentist: when would they like to confirm the diagnosis of the 4346 interval care? When do we want to see the patients back, has the fee been set? We need to put the fee into the computer and be adding that to our insurance benefit questionnaire.
Billing. Do we need a treatment plan and financial decisions prior to beginning treatment? What’s what would the office policy like to be on that? Would you like every patient to have a take-home rinse? You know if you work with multiple hygienists in your practice.
Maybe you want everyone to be calibrated and everybody to be recommending the same type of rinse. That’s sent home the same type of you know: re-care interval that right here interval can be flexible based on the patient’s needs, of course, and then, of course, you need to make a note template if you use digital or if you have multiple hygienists in your office And you are still handwriting chart notes.
Make sure that everybody is writing this out the same so that you can send it to insurance and have better coverage, and so that the next time the patient comes in, if they’re being treated by another clinician.
The clinician can see easily that we did four three four six last times and be able to um talk with the patient about that and see how things are looking today and possibly do it again if it’s needed, and so someone will in your office will need To make a note template for the procedure um, i usually just to shorten this four three four six code. You know, you usually say, do a profi, or I’m doing perio, I usually say a gingivitis scaling or gingivitis cleaning or gingivitis therapy.
So, your office as well can set whatever terminology short terminology you want just so that you all know what um has been discussed with the patient. So, hopefully, that helps.
You understand a little bit more about that d4346 code so that you can start implementing it into your practice. Let us know if you have any further questions.
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