How many D1110/D4346 can we bill?

A reader asked Patti: 

I just read your article on Understanding Gingival Inflammation Code D4346. My question is can you use this code interchangeably with D1110? We have a large population base already coming for additional cleanings due to gingivitis. Are we allowed to bill out two D1110 and one or two D4346 in a year? Also in your experience have you noticed if insurance is covering the D4346 at all?

Patti responded:

As far as billing, your codes should reflect the treatment provided based on the diagnosis. There isn’t a ‘sequence’ per se. If one time they have < 30% inflammation in the absence of periodontitis then they qualify for D1110. If they then present with >30% inflammation in the absence of periodontitis and your records reflect this then they qualify for D4346. That is the simple response.

Your coverage question is more difficult because of 2 factors. One is when there is a newer code, though the D4346 is 2 years old, policies don’t often catch up for a year or two. The 2nd reason is policies are so very different. I have definitely heard it reported by many that when they document properly, there is coverage under D4346. Sometimes the same as D1110.

Which brings me to my final point and that is coding, as I mentioned, must be based on the condition diagnosed and treatment selected. And the office must use the code that most accurately describes that treatment. To choose codes based on payment by using a greater or lesser code is called remapping-most of us know it as downcoding. We have seen 3rd party carriers do this so we think it is okay. A carrier can and a practice can’t. Why? When a carrier changes the code, it is based on a contract and $$. When a practice does, it can be considered fraud because we are saying we did something different than we actually performed. Many of us understand the problem with upcoding which is charging for a higher level than performed. We sometimes don’t realize it is just as problematic when we downcode. Using D1110 instead of D4346 is exactly that.

As far as any office being late to the party of change, it is my experience that often it takes 5-10 years for things to really change in dentistry. 😊

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