CDT coding in the dental care industry is dynamic and always evolving. In 2024, the ADA (American Dental Association) announced sixteen CDT code changes, including revisions. Hence, it should not come as a surprise that the usage of wrong codes is a typical reason for claim denials.
An SRP procedure, or scaling and root planing, is a procedure that a patient must undergo when diagnosed with a periodontal disease. It has been classified as a periodontal procedure. It is not deemed a specialty treatment since it is non-surgical, and a dental hygienist can perform the task. Hence, no referral is required if the patient has HMO insurance.
As of this date, two CDT codes for scaling and root planing have been introduced by the American Dental Association. The code D4341 should be used by the dental team for any SRP that involves four or more teeth per quadrant, while the code D4342 applies when treating 1–3 teeth per quadrant. The only variance between the two is the number of teeth involved in the treatment. For accurate dental billing, it's crucial that the appropriate code is selected based on the clinical documentation to avoid claim denials or delays.
There are many times when claims made by a dental practice for scaling and root planing are denied for a patient with an abnormal pocket depth. There are also times when a claim has been successfully processed for a patient with 4mm pockets, but the same insurance company might deny processing the claim for a different patient with the same or similar kind of clinical presentation. This can be confusing for dental practices. When the claim is denied, a patient might reckon that the dental practice has recommended an avoidable procedure.
Very often, if a patient or someone from the dental team calls the insurance company regarding benefits that can be accrued under a particular plan, one gets a general response such as a yes or no.
Insurance companies do not offer specific payment advice as may be required. If these were provided, the understanding of the dental team and the reimbursement process would be simpler and more transparent.
It is expected that more transparency could help avoid such unpleasant situations. This needs to become standard practice, and the insurance company must make it clear to both the dental team and the patient why SRP may be necessary, but the plan can offer benefits only when the plan's specific clinical
Indicators are present. If the insurance company revealed the actual payment parameters, the dental practice could convey in advance what the plan can cover to all patients.
About the dental benefit programs, the American Dental Association enables a single insurance company to reimburse multiple patient groups differently. In some situations, the insurance company might act as an insurer. In some situations, the insurance company can administer a policy on behalf of the employer. When a company buys insurance plans that cover many employees, some rates get negotiated, and there can also be changes in reimbursement rates.
The dental team needs to guide patients that, at times, the coverage can be based on employer funding of the policy, based on the clinical need of the specific patient.
Insurance companies create frameworks and standard policies relating to the reimbursement of procedures based on published medical and scientific literature, feedback from their dental experts, analysis of past claims, and dental advisory councils.
As per the situation, an insurance company’s decision on reimbursement for a case regarding scaling and root planning can get altered for certain patients based on their negotiated benefits, analysis of their claim history, or feedback from their benefits experts.
Thus, two claims for SRP submitted to the same insurance organization with a similar patient profile may be considered quite differently. An outcome can be based on the employers' group dental policy under which both the patients are covered.
It must be noted that a pocket depth of 4mm or more is a commonly recognized indicator in SRP literature. There are, however, differences within the industry and dental literature about the specifics of pocket depths as standardized benchmarks.
Hence, an insurance company might set its criteria based on such varying factors. These criteria can vary among insurance companies and even among customers within an insurance company. Almost all insurance companies post their rules and procedures regarding SRP on their websites.
There is no formal minimum pocket depth concerning scaling and root planing. It will be observed that every insurance company has a minimum depth that they
Consider it for any reimbursement. From common observation, one can note that no insurance company will reimburse a pocket depth of less than 4mm. Some have made the limit less than 5 mm.
For code D4341 to be applicable, this would imply that at least 4 teeth must meet this condition. For code D4342, the requirement falls to just one tooth.
Since each insurance organization has varying conditions for SRP, the dental team must confirm the minimum requirement at the time of insurance verification.
Apart from a minimum pocket depth, an insurance company might restrict the number of quadrants that can be done on a single visit. Some companies might permit four, while some might permit only two. If the number of quadrants is crossed for the same date of service, then reimbursement will be denied. Since this rule could vary across insurance companies, the dental team needs to confirm the number of quadrants covered per visit at the time of insurance verification.
The dental team must understand the insurance requirements for billing SRP and ensure that the pocket depths are met, as well as the precise number of quadrants as per the insurance company rules.
X-rays, periodontal charts, and clinical narratives need to be attached at the time of claim submission. A panoramic x-ray, if possible, can increase the chance of the claim getting successfully processed.
When it comes to CDT coding for D4341 and D4342, scaling and root planing is a comprehensive dental procedure that requires careful attention during billing. These Dental Scaling and Root Planing codes are similar in nature, which can often lead to confusion among the dental team. To ensure accurate claims submission, it’s essential for the team to understand the specific insurance requirements outlined in the patient’s plan. This includes verifying that the required pocket depths are documented and that the number of quadrants treated aligns with the insurance company’s guidelines.
