This procedure is instituted following periodontal therapy and continues at varying intervals, determined by the clinical evaluation of the dentist, for the life of the dentition or any implant replacements. It includes removal of the bacterial plaque and calculus from supragingival and subgingival regions, site specific scaling and root planing where indicated, and polishing the teeth. If new or recurring periodontal disease appears, additional diagnostic and treatment procedures must be considered.
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Ongoing periodontal maintenance (D4910) does not include a periodic oral evaluation (D0120) or comprehensive periodontal evaluation (D0180). The periodic evaluation (D0120) or D0180 is submitted as a separate procedure on the same date of service. The oral evaluation (D0120 or D0180) is generally provided twice per year, and is subject to the typical “one evaluation per six months” or “two evaluations per year” limitation. For a comprehensive periodontal evaluation of an established periodontal patient provided on a periodic basis consider reporting D0180. Note: The reimbursement for D0180 might be re-mapped as D0120. If the more extensive and time consuming D0180 is performed, report what you do.
Some offices report one D0180 and one D0120 per year for periodontal recall patients. Some offices have two consistent, but different, fee levels for D0180, depending on whether the procedure is provided for the new (entering the practice) or established (recall) D4910 patient. See D0180 for details.
- Periodontal maintenance (D4910) follows active periodontal therapy: scaling and root planing procedures (D4341/ D4342), gingival flap surgery (D4240/D4241) or osseous surgery (D4260/D4261). The periodontal maintenance patient (D4910) must have undergone either SRP or periodontal surgery (gingival flap or osseous surgery) prior to periodontal maintenance (D4910). Periodontal maintenance (D4910) is ongoing and therapeutic in nature, not preventive. Typically there is a ninety day exclusion period following active treatment. Active periodontal treatment may be reported as D4341, D4342, D4240, D4241, D4260, or D4261.
The ongoing periodontal maintenance (D4910) interval is typically ninety days but the frequency is determined by individual need. Some authorities deem it improper for the same practitioner to alternate D4910 with a prophylaxis (D1110). However, a patient alternating between the GP and periodontist might receive alternating D1110s and D4910s. The periodontist could provide ongoing periodontal maintenance (D4910) while the GP office provides prophylaxis. Be advised, however, that some payers terminate D4910 coverage if prophylaxis (D1110) is provided in the periodontal treatment sequence. Some payers assert that the patient cannot be a periodontal patient one visit, and a prophy visit the next, alternating between a diseased and healthy state.
- Once the patient is in ongoing periodontal maintenance (D4910) following active periodontal therapy, they could remain in D4910 status. Periodontal disease is episodic. If the patient’s periodontal status improves (to good health), then prophylaxis (D1110) could be appropriate. This change may occur; however it may take one year or more for the issue to resolve following root planing and scaling (D4341) therapy. This change from periodontal disease to health is not the rule, but the exception. When the patient moves from periodontal disease to a condition of health and prophylaxis (D1110) is provided, then a subsequent sequence of SRP (D4341/D4342) would be required before D4910 would be reimbursed again. SRP (D4341 or D4342) typically has a twenty four or thirty six month frequency limitation with most plans.
- Although most periodontal patients will require periodontal maintenance for a lifetime, the American Dental Association gives dentists some discretion when reporting D1110 and D4910. See page 157 of CDT 2009/2010: “Follow-up patients who have received active periodontal therapy (surgical or non-surgical) are appropriately reported using the periodontal maintenance code, D4910. However, if the treating dentist determines that a patient’s oral condition can be maintained with a routine prophylaxis, delivery of this service and reporting with code D1110 may be appropriate.”
Patients who need periodontal maintenance have periodontal disease and have been treated non-surgically (D4341/ D4342) and/or surgically (D4240/D4241 or D4260/ D4261). Periodontal maintenance is performed in the presence of disease whereas a prophylaxis (D1110) or scaling in presence of generalized moderate or severe gingival inflammation (D4346) is performed to prevent disease. D4910 is performed to maintain the periodontal condition of the patient as a result of nonsurgical and/or surgical periodontal treatment. Periodontal maintenance includes removing any new plaque and calculus that may have formed since the patient’s last periodontal therapy appointment as well as site specific scaling and root planing where indicated, and polishing the teeth. The descriptor clearly states D4910 does not preclude the need for additional diagnostic and treatment procedures if new or recurring periodontal disease develops. Additional scaling and root planing, locally delivered antimicrobials (D4381), or periodontal surgery may be necessary when there is evidence of new disease
- Reimbursement for ongoing periodontal maintenance D4910 is highly variable. Some payers may not reimburse D4910 at all or some may reimburse D4910 two to four times during a 12-month period. Some policies provide reimbursements for two D4910 and two prophylaxes (D1110) during a 12-month period. Even though the contract reimburses certain procedures at a frequency greater than every six months, you are bound to report what you do. Since plan limitations are highly variable when providing D4910, request an alternate benefit of a prophylaxis (D1110) in the event D4910 is not a covered benefit. Benefits are highly variable. Some plans will provide reimbursement more frequently for diabetic or pregnant patients.
- Some payers (i.e., some Deltas) will pay D4910 indefinitely. Other payers may only pay 24 or 36 months and then the patient must requalify for SRP.
- D4910 may be reimbursed at a 50-80% fee (unlike the typical 100% reimbursement for a prophylaxis), and may also be subject to a deductible. Payers may reimburse D4910 as preventive, basic or major. Reimbursement for D4910 is highly variable.
- A prophylaxis (D1110) is considered a part of D4910 by payers in the ongoing periodontal maintenance regime. The clinical record should reflect the fact that a prophylaxis was completed as part of the overall D4910 procedure.
- Some payers require that osseous surgery (D4260/D4261) be completed to qualify for D4910 reimbursement. However, in general SRP treatment will justify ongoing periodontal maintenance (D4910).
- D4921 reports periodontal pocket irrigation using medicinal agents, e.g., chlorhexidine. Payers typically consider gingival irrigation a part of D4910. PPO contracts may limit reimbursement for the use of gingival irrigation in periodontal maintenance. See D4921 for comments.
- D9910 describes desensitizing medicaments applied to a single tooth or up to the entire mouth. Payers typically consider the application of desensitizing medicaments to the entire mouth a part of D4910. PPO contracts may limit reimbursement for the use of D9910 with periodontal treatments.
- Consider filing a manual claim when reporting D4910 with the following narrative: “If periodontal maintenance (D4910) is denied, please provide the alternate benefit of a prophylaxis (D1110). The ongoing periodontal maintenance (D4910) visit included a prophylaxis (D1110).” The clinical notes should reflect the fact that a prophylaxis was provided as a part of D4910. Because payers consider D1110 a part of periodontal maintenance, expect reimbursement of the alternate benefit of a prophylaxis. Instruct the patient that you are bound by law to report D4910. Per HIPAA requirements, the government mandates it.
- When submitting D4910 identify the date that active treatment SRP or osseous surgery was performed. Include a current periodontal chart with a claim of D4910. Consider a narrative: “This patient underwent SRP on mm/dd/yy” or “This patient underwent osseous surgery on mm/dd/yy at Dr. Smith’s office.” State which quadrants had SRP and on what date. “See attached periodontal chart.”
- If benefit plans change or there is change in employment, it is important to provide the new payer a narrative for the first D4910 claim (to turn the periodontal coverage switch “on”) describing a history of scaling and root planing (SRP) or osseous surgery. Provide the same information from the patient’s history when the patient returns from the periodontal office. When previous periodontal treatment history is not noted in the “remarks” section, D4910 may be denied by the subsequent plan. For documentation, submit current periodontal charting and a narrative stating that the patient is in ongoing periodontal maintenance therapy.
- “SRP performed in the ____ quad(s) on MM/DD/YYYY and ____ quad(s) on MM/DD/YYYY. See attached perio chart.”