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2 separate prophy appointments for patient with sensitivity

I have a patient that has extreme thermal and tactile sensitivity but has great probing depths. She qualifies for just a prophy but needs to be anesthetized. Therefore, we do 1/2 mouth one visit and the other half another visit. What insurance code would we use to bill this out as?

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2 Answers

I asked one of my Today’s RDH Advisory Board Members, Andrew Johnston, RDH, to chip in on this answer. I’ll start with Andrew’s thoughts:
First of all, I would suggest using fluoride varnish at the beginning of the appointment; it’s super messy, but effective. While anesthetizing is an option, it’s not always practical and doesn’t satisfy the reason that the patient needs to be anesthetized in the first place, for which is usually dentinal hypersensitivity. Cetacaine and 20% benzocaine do a great job of anesthetizing gingival tissue, but this sounds like it’s something different. I have found a great deal of success in applying fluoride varnish first, at about an 80% success rate. Another suggestion is to make sure that your scaling technique is proper. Using American Eagle XP instruments require a lighter stroke, so I would consider investing in them for that purpose.
Now to address the coding issue. The insurance companies will not reimburse for two of the 1110 codes. They are considered to be ‘complete’ codes; similar to the 4910 PM code. Both codes are considered to be the full-mouth cleaned to completion. So while you might be able to submit both, one will be rejected. One idea is to book the appointment for longer (80 minutes instead of 50), using fluoride varnish prior, and maybe only isolated local anesthesia. This, along with the use of the unspecified perio code for patient management to include additional use of anesthetics and adjunct services at a price that your office has pre-determined. This will not be covered by insurance and the patient should know they will need to pay out-of-pocket ahead of time.
If you really feel you need two appointments, you have a couple of options. You can either tell your patient that due to the complexity of the situation, they can have the insurance pay for the first appointment and then the patient can pay out of pocket for the second appointment, or they can use the unspecified perio code for the second appointment and charge a lesser rate. I would advise that a detailed conversation is had with the dentist/owner to see what they prefer of these two options. Knowing that it is going to take time away from the hygiene production schedule, the dentist will need to be compensated in some way for this so that they aren’t losing money for that hour. Don’t forget the second appointment should not be nearly as long as the first appointment, and the first appointment shouldn’t be nearly as long as your normal recare appointments because you’re only doing half of the mouth. But do try to use fluoride varnish first and see if that works. Of course, document everything you do!
In addition to Andrew’s suggestion of applying fluoride varnish first, you can also try polishing first with a desensitizer like Colgate Sensitive Pro-Relief Desensitizing Paste. If the sensitivity is caused by recession, using a product like Tokuyama Sheild Force Plus (light-cured, resin-based desensitizer) on the exposed areas can relieve the patient’s sensitivity immediately.
Regarding scaling technique, I agree with Andrew in that using AEI XP instruments is a good idea due to less force needed to scale effectively. If you don’t use AEI XP, make sure your instruments aren’t past their prime and dull (depending on many factors, instruments only have a lifespan of 9-18 months). If instruments are worn out and/or dull, it requires you to press harder when scaling and that’s neither comfortable for you or the patient. So make sure you assess your instruments.
The last thing I feel should be addressed is why this patient so sensitive in the first place? Is it due to recession, clenching, or grinding, all of these in combination, something else? I ask because making the patient comfortable while you are scaling is of utmost importance, however, I feel that finding the definitive cause and treating based on that, could provide much-needed relief for this patient. For instance, if clenching is the problem, assessments for airway issues and tongue ties, or occlusal guards, occlusal adjustments, among other treatment modalities could be of great value to this patient.
We kind of went down the rabbit hole on this answer, but I hope it all helps a bit!

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We charge out for a prophy or PM at the first visit and just continue the treatment the next visit.

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