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Short Commentary: Fees for Prophy vs. Perio Maintenance?

Fees for Prophy vs. Perio Maintenance?

Prophylaxis code 1110 is specific for healthy patients to maintain health. This code is for people with no loss of attachment, no pocketing and no bleeding. Periodontal maintenance code 4910 is specific for patients following SRP and/or periodontal surgery. The 4910 fee is higher than the 1110 fee. Townie “scottingham” voices her opinion on the controversy over when it is proper to use these two codes.

It is very logical that a 4910 should have a higher fee than a 1110. That appointment requires attention to details both above and below the gum line. If the patient is in every three months, a complete periodontal charting should be second nature. Some would say probing every visit is overkill; however, most perio patients are immune-challenged in some way (high blood pressure, diabetes or heart disease) and with these circumstances the perio situation can dramatically change in as little as three months.

Case in point: I had a faithful three-month perio maintenance patient who I had seen for several recare visits. Each time he came in, the probing scores and radiographic bone levels were consistent. Quite suddenly, I saw changes. During my routine three-month probing I found a large perio abscess on tooth #19. A periapical radiograph revealed an advanced periodontal lesion with poor prognosis. Checking back, no radiographic evidence was present on the previous vertical bitewing X-rays. I asked myself, “Why?”

This patient was a diabetic. These cases require much more skill and attention to the “big picture,” as well as “the details.” Any office that makes these fees the same is asking for a future of headaches in explaining the difference between the two services and ultimately diminishing the importance of the appointment by setting a low fee.

I have seen many offices that will alternate the two codes to “get more” benefit coverage. The use of the 1110 on an involved periodontal patient is a blatant misuse of the code. The code specifically states health.

As with any rule, there are exceptions. If a patient had localized treatment of one-to-two teeth in only one quadrant, I use judgment there and continue to use the 1110 in that case if all perio activity was eliminated and patient shows no longer shows signs of active disease in those areas.

What are we telling the patient when we alternate these codes? First off, the message is that insurance fraud is okay and it will get the patient more benefits. Or, do we tell the patient that he/she is healthy at one recare visit and not healthy at the next visit? What is the difference between these appointments? I continue to ask the question, “Why do we, as hygienists, have a hard time discussing what it is we do for our perio patients and educating them to a degree that they have no questions that a perio maintenance recare appointment is miles apart from a 1110, and that it is worth every penny more than what they pay compared to the 1110?”

We’re bumping up against office traditions. In the past, patients have been treated for perio without calling it that and now they think that it should all be the same. Disease is just that – infection that destroys tissue and bone and now “publicly” (meaning in the media) related to complete wellness, it takes a higher standard of care to maintain these patients. I think some hygienists have more of an issue with the disease than the patients. They are at “dis-ease” with talking about it.

I believe it is time to leave the insurance to the patient, have those discussions that insurance is an assistance to the patient to help with the cost of dental treatment. The benefit maximum for dental treatment has not increased during the last 25+ years, and the cost of dental treatment has most certainly gone up. For that reason, we need to become great communicators about the phenomenal dental hygiene services that we provide, helping people save teeth and have complete whole body wellness. After all, the mouth is the barometer for the entire body. Your 4910 treatment is worth every red cent that you charge!
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