FYI

Claims for periodontal scaling and root planing (D4341 and D4342) are denied more frequently than those for many other procedures, according to the American Dental Association.

Delta Dental defines periodontal scaling and root planing (SRP) as “a definitive non-surgical periodontal treatment involving the judicious and thorough planing of the root surface.” The procedure involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus.

Although you should always refer to the Delta Dental Dentist Handbook for specific processing policies and guidelines, we’ll highlight some common reasons for denials for SRP and associated procedures.
 

Documentation fails to support payment of SRP

Delta Dental considers a quadrant of procedure D4341 to consist of at least four diseased teeth (4-6mm pockets, early bone loss).
 

• When fewer than four diseased teeth are involved, Delta Dental bases its allowances on procedure D4342.
• In addition to qualifying pocketing, radiographs must show loss of alveolar crest height beyond the normal 1-1.5mm distance to the cemento-enamel junction (CEJ).
• Exposure of cemental surfaces of the roots is necessary for root planing.
• Without a reduction in the alveolar crest level, root planing isn’t achievable.

Qualifying: X-rays clearly shows appreciable bone loss and calculus

Non-qualifying: X-rays show no appreciable bone loss and calculus 

Denial code: 5F8. Submitted documentation fails to support payment of benefits for scaling and root planing.
 

Submission of more than two quads of SRP on the same date of service

Without supporting documentation, the fees for more than two quadrants of SRP performed on the same date of service are not billable to the patient. Acceptable supporting documentation includes:
 

• Clinical progress notes
• Evidence of length of appointment (successful scaling typically takes 30-45 minutes per quadrant with local anesthesia)
• Information about the local anesthetic used
• The reason for performing more than two quadrants on the same date of service
   

Four quadrants of SRP may be approved on a pre-authorization when criteria are met. However, you’re expected to know the policy upon payment.

Denial code: 447. No more than two quadrants of scaling and root planing are allowable on the same date of service.
 

Inadequate periodontal charting or x-rays

The D4341 and D4342 procedures require you to submit periodontal charting that indicates at least Case Type II periodontal disease (4-6mm pockets, early bone loss).
 

• Periodontal charting should be dated no more than 12 months before the date of service.
• Full-mouth series or bitewings that clearly show appreciable bone loss are preferred because these images are usually the most accurate determinant of bone loss.
• Submit corresponding images for each submitted quadrant.

Qualifying: Labeled periodontal charting that indicates exam date

Non-qualifying: X-ray is non-diagnostic as interproximal contacts are overlapped and fail to show bone loss

Denial codes:
 

• 5F8. Submitted documentation fails to support payment of benefits for scaling and root planing.
• 574. Benefits could not be determined because of missing periodontal charting.
• 570. Benefits could not be determined because of missing pre-operative radiographic images.
• 573. Benefits could not be determined because of missing full mouth radiographic images.
• 569. Benefits could not be determined because of the non-diagnostic nature of the radiographic images submitted.
• 426. Benefits could not be determined because of missing radiographic images, periodontal charting, and treatment record.
• 5GB/5GC. Submit current periodontal chart, dated pre-operative diagnostic radiographs, and a copy of the patient treatment record.
   

Associated denials related to SRP

Gingival irrigation (D4921)

Gingival irrigation isn’t a separately payable procedure when provided in conjunction with SRP or any other periodontal procedures. You can’t charge a separate fee for the procedure to Delta Dental or the patient.

Denial code: 449. The fee for gingival irrigation is included in the fee for any periodontal services performed on the same date of service.
 

Localized delivery of antimicrobial agents (D4381)

This procedure isn’t a benefit under some plans and requires you to submit periodontal charting indicating pockets of at least 5mm. When submitted with nonqualifying SRP, these procedures will be denied due to conflict with the denied SRP.

Denial codes:
 

• 7BB. This service is not a covered benefit of the enrollee’s program.
• 7C2. The submitted procedure is not payable due to the absence or conflict of a related service.
   

Unspecified periodontal procedure (D4999)

These are most commonly submitted as bacterial decontamination, laser or irrigation.

Delta Dental considers specialized techniques, such as those that use lasers or antibacterial medicaments, to be included in the fee for any SRP or surgical procedure. You can’t charge a separate fee for the procedure to Delta Dental or the patient.

Don’t forget:
 

• Delta Dental pays for completed procedures, not tools used for treatment.
• Please provide a narrative report with a complete description of the procedure and its rationale.
   

Denial codes:
 

• 440. The fee for this procedure is considered part of and included in the fee for periodontal services.
• 9WA. The fee for this procedure is considered to be part of, and included in the fee for, a completed service.
• 564. Submit clinical treatment narrative.
   

Delta Dental’s periodontal processing policies described above should be considered guidelines. Whenever an exceptional case is involved, please provide a full narrative description and any available supporting documentation to help our staff determine benefits.

And remember, to ensure timely benefit determination, always submit the appropriate supporting documentation on your initial submission.