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4342 Question

Hi! Today I saw a patient for a comprehensive exam. He was missing the last two molars and one premolar on every quadrant, giving him 5 teeth per quad. I performed my perio chart and found every tooth had at least 4-9mm pockets, some 2mm but I could tell calculus was in the way and there was obvious severe bone loss on the radiographs around each tooth. The office billed this as a 4342 for all four quadrants as the dentist decided to tx plan extractions 6 total teeth after the cleaning and therefore felt that only a 4342 should be billed instead of a 4341.
The bone loss and subgingival calculus was severe and I felt it should still be billed as a 4341 since I was cleaning the teeth before the extractions and he had 5 teeth per quadrant. Am I wrong in thinking this? Was it correctly billed since he had planned tx for extractions after the cleaning? I thought I understood this insurance code but now I’m questioning what it means!
Also, as a side note, the dentist insisted we try to remove all calculus even though I explained the instruments they had were not deep enough to reach some of his pockets (on teeth he was keeping) and we should refer him out to a specialist. She told me she’d rather clean now and then in 3 months refer out if we find any remaining calculus instead of referring now. How does your office go about giving referrals? Thanks for your time and I hope to hear back soon!

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1 Answer

Perhaps the patient’s insurance carrier had a “minimum tooth” eligibility in order to bill D4341. I would suggest asking who ever does the billing in your office to explain the patient’s benefits so you can better understand why they billed the way they did. If the patient’s insurance doesn’t have a minimum tooth eligibility, it sounds like you are correct, in my opinion. D4341 = 4 or more teeth per quad and D4342 = 1-3 teeth per quad.
As far as referrals, hygiene instruments are only effective up to about 6mm (and sometimes not even that deep), which is why patients need to be referred. Unless you have an endoscope, generally speaking, you are best to refer out. If calculus is left and the tissue heals around it there’s a risk the patient can develop a perio abscess. If this happens, it can set the office up for liability issues. Plus, explaining to the patient they got an abscess, and might need the tooth extracted if it doesn’t respond to antibiotics due to not referring in the first place, wouldn’t be a fun conversation.
It sounds like it’s worth a sit down to get everyone on the same page as far as how the office refers. Remember, you must share the same patient care standard, including when to refer, as the office/doctor, otherwise the office might not be the best fit. You don’t want to put yourself at risk for liability issues.

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