Insurance Connection
In June , PDA ’ s Dental Benefits Committee ( DBC ) met with representatives of United Concordia Dental ( UCD ) to discuss some of its in-house claims processing policies . Our guests from UCD included Dr . Clayton Pesillo , Mr . James Shade , Ms . Karen Whitesel and Dr . Jerome Blum . The committee ’ s intent was to obtain answers to members ’ questions and to exchange ideas for UCD ’ s consideration in regards to some of its policies .
NOTE : The Q & A section of this article reflects PDA ’ s understanding of UCCI ’ s policies as of June 25 . For legal reasons , the italicized portions of the following article represent commentary from the committee . This commentary is necessary , in order to put some of the responses in more dentist-friendly terms . The commentary , however , is not intended to define UCD policy or to suggest submission procedures . Please be sure to consult with your UCCI representative for clarification on these issues or to verify for accuracy its policies and claims submission processes . If you have any questions regarding UCD ’ s policies in regards to the issues discussed in this article , please contact UCD ’ s provider relations department .
Question : What is the clinical rationale to justify UCD ’ s policy that a dentist cannot perform scaling and root planing 45 days before or after ( or the same day ) the dentist performs a prophy ? The committee requested that UCD consider shortening the 45-day timeframe to 14 days based on widely accepted periodontal studies indicating that periodontal tissues recuperate 2 weeks post S / RP . Therefore , the committee believes that 14 days is an appropriate interval to re-evaluate a patient ’ s response to scaling and root planing , and a dental prophylaxis should not be disallowed for any longer than industry approved 14 days .
Answer : UCD ’ s policy is to deny a claim if a prophy falls within 45 days of scaling and root planing . Prophys are not typically completed within a short time following S / RP . UCD agrees that 14 days is an appropriate interval to re-evaluate post operatively the patient ’ s response to scaling and root planing as recommended by the committee . However , UCD considers a re-evaluation following S / RP , which may include limited scaling and polishing of the teeth integral to the S / RP procedure . In regards to a non-periodontal patient who has a foreign body in the gingiva or has a gingival abscess , UCD ’ s representatives noted that debriding the pocket in the abscess area is more properly considered a palliative treatment ( D9110 ). Also note that UCD will deny a benefit for S / RP ( 1-3 teeth per quad ( D4342 ) or 4 or more contiguous teeth ( D4341 ) if there is no radiographic evidence of bone loss . UCD ’ s original answer to the time limitation of 45 days was that its system could only accommodate a 45-day time frame and that it would look into changing that time frame . After UCD ’ s review of this article to be printed , that portion of the answer was left out . Also , the portion of the answer that suggested it would be appropriate for dentists to do limited scaling and polishing after a twoweek interval , at no charge , was added .
In regards to the foreign body in the gingiva , some practitioners ( periodontists , non-periodontal specialists and general dentists ) have commented that they have been successful at billing the debridement of a non-periodontal pocket ( gingival abscess ) as an I & D ( D7510 ). During the meeting , UCD ’ s representatives did not say that coding it in such a manner would be inappropriate , but did delete it from the rough draft sent to them for corroboration . Some members of the committee objected to this kind of treatment being considered a palliative treatment ( D9110 ) because palliation by definition is merely alleviation of symptoms , not therapeutic treatment of disease . Unfortunately , most major insurance companies use this code despite the inconsistency in the definition of palliation and the actual treatment of a clinically definable and diagnosable condition ( gingival abscess ).
Question : Please explain the new policy that requires general dentists to have to supply more documentation than periodontists in order to have scaling and root planing preauthorized . Also , does this apply to participating general dentists only ?
Answer : The policy applies to all general dentists , not just participating providers . The original letter sent to providers included a misprint that said the policy would only apply to participating providers . According to the president of the American Academy of Periodontology ( AAP ), as well as AAP ’ s insurance consultant , evidence of radiographic bone loss is essential to the diagnosis of periodontitis . According to CDT , periodontal scaling and root planing is therapeutic for periodontitis . UCD will not benefit from D4341 or D4342 in the absence of periodontitis .
During the meeting , UCD suggested that the impetus for this policy change
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November / December 2010 • Pennsylvania Dental Journal
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