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