A Game Changer: 2017 Will Bring a New CDT Code for Gingivitis

Your patient presents with inflamed, hemorrhagic gingiva, light to moderate subgingival calculus, light supragingival calculus on the mandibular lingual anteriors, and generalized pseudo-pocketing. For all of the history of Current Dental Terminology (CDT) coding, there have been no truly accurate codes that can be used for the treatment this patient needs. In 2017, that story will change. Yet, we must guard against misuse of this new code and not miss the disease present.

No Great Options

No clinical attachment loss, from the CDT coding perspective, means non-surgical periodontal codes (D4341/D4342) don’t fit. Coding for a full mouth debridement (D4355) isn’t appropriate either, as a full mouth debridement is indicated when a comprehensive evaluation cannot be completed due to excessive plaque, calculus, and debris. However, coding for an adult prophylaxis (D1110) doesn’t seem appropriate. There is D4999 unspecified periodontal procedure, by report but that doesn’t seem right either. The only choice has been D1110 because there simply isn’t a CDT code that satisfies the treatment needed for their oral condition.

Big News!

But alas, January 2017 will bring us a new CDT code for patients who present with moderate-severe gingivitis! While this code has passed through the ADA Code Maintenance Committee (CMC), it has of yet been given a CDT Code number and can’t be used until after 1/1/17. Insurance companies may take a few months to recognize this new code or that it will covered under their policy. The existence of code does not mean a patient has coverage under a policy. Yet without a code, no coverage could be offered.

The code passed the CMC reading this way:

Nomenclature (Name): Scaling in presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation.

Description: 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.”

Minor tweaks in this verbiage may still happen. Let it be noted: YOU CAN’T USE THIS CODE YET BECAUSE IT DOES NOT YET EXIST! (Yes, we are yelling to be sure everyone hears that part.)

Why do we need this CDT code?

This probably doesn’t need much explanation, but in the interest of being thorough, there are gaps in CDT codes especially in the area of the care provided by hygienists. We have a code for healthy periodontium (D1110), codes for non-surgical periodontal therapy (D4341/D4342), a code for the maintenance of periodontally-involved patients who have undergone non-surgical periodontal therapy (D4910), and a code for gross-debridement (D4355), but nothing for the in-between. The CMC has typically decided that gingival disease treatment should be coded using D1110 yet for many this has never made much sense.

Concerns about Misuse

Some of the insurance carriers and other members of the CMC voiced concerns about misuse. There is validity behind these concerns. DentalCodeology: More than Pocket Change says 2 simple words, diagnosis and documentation, are the answer to nearly every periodontal coding question. Often we want to jump to treatment without a diagnosis. All treatment needs a diagnosis before it is rendered including a preventive prophylaxis or a prophylaxis that is treating gingival disease. If hygienists completed the dental hygiene diagnosis as we were all taught in school, a lot of coding issues would be solved. (Think you can’t perform a diagnosis? Follow the link above.)

Bone height/loss is the parameter used most often to differentiate between gingival and periodontal diseases. Yet, few practitioners’ measure and document bone height. Healthy tissue should measure approximately 1.5-2mm when measured from the aveolar crest to the CEJ. This can only be measured with radiographic images, not a probe. Just because there will be a new code doesn’t mean this has been accurately measured. Without this measurement, misuse of this new code could be rampant. AND more importantly, a lot of disease may not be treated appropriately.

Why has it taken so long to get a proper CDT Code for gingivitis?

While some like to blame the ADHA, as hygienists we all have a duty to participate in the process of updating current CDT Codes if we feel there needs to be a change or update. The CMC meets once per year and it’s an open hearing. Anyone can sit-in, express their opinions, and even submit changes in absentia they would like to see to the CDT code itself. You won’t have a direct vote unless you are representing one of the 21 organizations or members that have voting capacity, but your voice and input can still be heard.

 

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