Home Practice ManagementInsurance Understanding and Applying the New Gingivitis Code 4346

Understanding and Applying the New Gingivitis Code 4346

by Wendy Briggs

I have received many questions about this new code. When is it appropriate to use it? What will insurance cover? What are the limitations we have when billing with this code? All of these are important questions, that I will cover in this article.

What I find interesting about this code is that it is in the Periodontal category, but many insurance companies are not treating it as a periodontal code. This is causing a lot of confusion about this code, and a lot of questions about how we actually apply it in practice.

We teach hygienists to use 3 levels in regards to periodontal therapy; this would fit our therapeutic scaling and root planing category. Code 4346 is designed for the patient who’s not quite healthy, but does not yet have periodontal disease. When we have generalized gingivitis (patients without bone loss evident on an x-ray), we can evaluate whether or not this code would be appropriate. There may be pocketing, but it could be pseudo-pocketing. There may be bleeding and general inflammation caused by excess plaque. Excess plaque can be caused by poor oral hygiene, systemic conditions, and physical disabilities. The key is no bone loss.

When we take a look at the information the ADA put on their website about how to use this code, the definition of the code is, "Scaling in presence of generalized moderate or severe gingival inflammation – full-mouth, after oral evaluation." In this resource they stated that if there is generalized, inflammation this code is appropriate. Typically 30% or more of the bleeding sites need to be experiencing inflammation for it to be considered generalized inflammation. If we have patients with swollen, inflamed gingiva, supra-bony pockets, moderate to severe bleeding on probing, without bone loss, then this code is applicable.

It has to be done the same day as the oral evaluation. The diagnosis needs to occur first. Practices that are familiar with the our periodontal protocol, know that we often teach a perio-alert status for a gingivitis patient. One could complete a 4346 when a perio-alert status patient is classified. This code should not be reported in conjunction with a prophy, or a scaling and root planing, or a debridement procedure.

An interesting question is how does this code compare to prior codes? There was a code 4345 that was discontinued in 1995. The definition of that code was pretty much the same as the new 4346. It was primarily a gingivitis code, no loss of attachment or bone loss: "The scaling procedure is more precise in describing therapy for generalized gingivitis, not meant to be performed on a routine basis."

The question then becomes, why are we bringing back a code that went away almost 20 years ago? Which leads to another question, Why did we get rid of that code and find a need to create a new code that is so similar? I think there are several answers to these questions. I think the description is too vague, and the usage was confusing and not consistently covered by insurance. After my research regarding 4346, I’m sorry to say that I fear there will be similar struggles.

I think the only way we’re going to see this code succeed in our practices is documentation. To get payment on this code, we must be very clear in our diagnosis and provide a plethora of documentation. We must be careful documenting exactly what level of gingivitis we’re dealing with and what the mouth looks like in greater detail than we have in the past. It is also strongly suggested that we assign ICD-10 diagnostic codes to any claims as well.

Some insurance companies are switching to ICD-10 Diagnostic codes. We need to be familiar with how to use these diagnostic codes in our practices. If you are not currently using ICD-10 codes, I encourage you to become familiar with them and start utilizing them as a part of your protocol.

Gingivitis – Inflammation of the gingiva as a response to bacterial plaque on adjacent teeth; characterized by erythema, edema, and fibrous enlargement of the gingiva without resorption of the underlying alveolar bone.

Gingivitis is classified in ICD-10 in the following ways:

• K05.00 acute, plaque induced

• K05.01 acute, non-plaque induced

• K05.10 chronic, plaque induced

• K05.11 chronic, non-plaque induced

Let’s also take a look at the iCD-10 Periodontal Diagnostic Codes:

Periodontitis – Inflammatory disease of the periodontium occurring in response to bacterial plaque on adjacent teeth; characterized by gingivitis, destruction of alveolar bone and periodontal ligament, apical migration of the epithelial attachment resulting in formation of periodontal pockets, and ultimate loosening and exfoliation of teeth. Periodontitis is classified in ICD-10:

• K05.20 aggressive, unspecified

• K05.21 aggressive, localized

• K05.22 aggressive, generalized

• K05.30 chronic, unspecified

• K05.31 chronic, localized

• K05.32 chronic, generalized

What are we seeing as insurance re-imbursement for Code 4346?

Unfortunately, most benefit plan administrators and insurance companies are preparing to pay 4346 as if it were merely a prophy. We are seeing in many cases the same reimbursement tables, the same contract limitations and exclusions as the prophy. I’ve even seen some that are paying less than they will pay for a prophy. I have also reached out to other dental experts, and dental directors of these insurance companies. More than one of them has informed me that their intention is to decline any and all benefits for 4346, unless we have clinical documentation and diagnostic specifics. Without substantive documentation, it will not be paid. If the claim comes with documentation and a narrative, then they will consider reimbursement.

The reimbursement rates are poor, in my opinion. We are seeing some companies paying a relative value between one and a half to two times the prophy. We must be aware that with some companies, using this code also simultaneously eliminates any scaling and root planing coding or perio maintenance benefits for 12-24 months.

In some plans, if we use the 4346 code and their symptoms continue to deteriorate, leading to periodontal disease, we may have a two-year window where we cannot get payment for scaling and root planing. This is incredibly frustrating. The payment criteria will also eliminate patient benefits for full mouth debridement, as well as any potential immediate surgical interventions. This code may address the treatment of generalized gingivitis, but if this initial inflammation progresses into periodontitis, the patient may find themselves without a benefit.

Some plans are going to consider this code as a contractual exclusion, and simply not acknowledge the validity of the procedures, especially as a stand-alone treatment entity.

Sadly, this brings me to suspect, that this code may likely become as irrelevant as the former code. I simply don’t have a lot of hope in insurance companies, I am doubtful they will pay this code fairly. Many experts are in agreement that this is going to be another way for them to down code scaling and root planing, and not pay for it all.

We are warned by the ADHA, that in the initial implementation stage of the code there will be ‘awareness of a period of adoption by dental benefit plans, and that plans may vary widely in their coverage. We, as dental hygienists, appreciate being able to use a code that accurately reflects the therapy provided and explanations to patients, but acceptance of the new code often takes time.’

This makes the decision of how we handle our Perio-Alert patients critically important. If you are looking for a definitive treatment for gingivitis only, 4346 will now be the code you’re looking for. If you are trying to do a definitive treatment for early periodontal disease, I would strongly recommend we not utilize this code.

I recorded a video training on this as well. If you would like to watch, you can find it at www. TheTeamTrainingInstitute.com/perio-code-4346.

Wendy Briggs is the author of "The Ultimate Guide to Doubling & Tripling Dental Practice Production" and "The Business of Dental Hygiene." A registered Dental Hygienist with more than 25+ years of experience. For the last 15 years, she has taken her unique skills in doubling hygiene production directly to the practices. She has consulted with more than 3,718 dental practices in 12 countries. Hygiene is her passion … and exploding hygiene productivity, case acceptance, and profits are her areas of expertise.

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