I Got Hos in Different Dental Codes

Posted March 5th, 2023

Fellow hygienists! I need your thoughts... But first, a little context:

When the 4346 code came out in 2017, I was thrilled that an intermediary code was finally available for patients who were way more work and had significantly more gingival disease than a 1110 prophy but didn't have the bone loss required for a 4341/4342 NSPT. At the time, I thought the 4346 was going to be THE answer to underbilled prophys and denied NSPT's and would allow hygienists to code and bill for how much additional work we were doing and the actual therapy we were providing to our affected patient. Fabulous! Great! Easy peasy, right?

Oh, how wrong I was.

Although the ADA was excited to offer a solution to their revelation that hygienists were busting their asses on patients who had sub-g calculus (but not radiographic), 4-5mm pockets, and appeared as though you were killing them slowly with how much their gums were bleeding but could only be billed for a 1110 prophy, many offices I worked in were either reluctant to use the code or totally against its use. I couldn't figure this out. Why not use the correct code for the correct procedure? The code was there! ...again (but I'll get to that later). We had the answer! Hygienists unite! All hail the mighty ADA! 🎶We're not gonna take it! NO! We ain't gonna take it! We're not gonna take it anymo—🎶

[knock knock knock]

*record screech*

"...Uh, who's there?"

"We're the insurance companies and we exist to suck reason and logic out of every room we enter and replace it with unintelligible word salad, confusing legalese, and contradictory qualifications all while stealing your profits and convincing you you're stupid. We heard you hygienists were having a party! We're here to shit on your parade in our cheap suits and be a total buzzkill with our insufferable know-it-all attitude without any education in dentistry or any comprehension of the plight of overworked and underpaid dental hygienists. Got any beer?"

UGH!!

As it turns out, insurance companies will cover a 1110 prophy at 100% (meaning the office will receive the $100+ for a prophy) but will only cover a fraction of a 4346 (at my office, this comes out to about $67 for a procedure that costs $250+). An office can't charge the patient the difference because that would be considered insurance fraud (so say the rules THEY made up). And quite often, they deny to pay anything at all, regardless of how well me and the other hygienists document our findings. We can't code for an NSPT without documented bone loss and we can't resubmit the claim for a 1110 or 4341/4342 because that, too, is considered fraud. Our poor insurance coordinator is pulling her hair out doing appeal after appeal trying to do right by the patients and the office to little avail. So the insurance companies are paying less on a procedure indicated for patients with more significant disease symptoms than they would on a "regular cleaning?" (I HATE that phrase). Make it make sense?!

Even worse, if a 4346 is completed, it may bar the patient from having an NSPT covered if their disease progresses for one to three years! It's labeled as a perio code, despite the criteria that there is no attachment loss, then eliminates the option to perform treatment for perio that the 4346 doesn't treat. A 4346 has different protocols from a 1110 prophy and NSPT (no polishing, required perio chart showing bleeding and psudopocketing in over 30% off the mouth, use of a cavitron, recommended chlorhexidine rinse after treatment, done in a single office visit with an exam, etc) which further separates the code from a 1110 prophy or NSPT. The code is clearly defined, yet the insurance companies went and mislabeled it thereby punishing anyone who dares to properly label the actual treatment rendered.

The ADA got rid of an old code, the 4345, in 1995 due to insurance companies not covering it and the language of the code being too vague. They essentially brought back the old code with a tiny upgrade and clearer rules but the same old baggage, and insurance companies are treating the new code with the same illogical disdain as its predecessor. I see a lot of patients who qualify for the 4346 in my office, but I feel like I can't keep using the code if the insurance companies won't pay for it. It's maddening and I am beyond frustrated with this clusterfuck the insurance companies have created in my office and others.

Besides putting a hex on every insurance company that ever existed, I'm struggling to come up with a solution. So my question to all you lovely people is what the hell do we do about this? Do you use the code in your office? Are you having the same issues? Have you found a way to make the 4346 profitable when it is properly indicated? Do we have any other legal options? What are the coding protocols in your office? If you've abandoned the 4346 code, what do you do instead?

Looking forward to your replies!

*hums twisted sister*