{1 - 24} GreyGrey
{25 - 49} GreenGreen
{50 - 499} BlueBlue
{500 - 4999} OrangeOrange
{5000 - 24999} RedRed
{25000+} BlackBlack

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Alternating Periomaintenance and Prophys

My office manager wants the hygienists to consider billing alternating periomaintenance and prophys in order to get insurance companies to pay for the patient to come in every 3 months. My problem with this is 1)I am basically doing a pm and only charging a prophy 2)how do you explain to a patient why they are paying more out of pocket at a pm appt for the “same” cleaning 3)some insurances are allowing this but likely not all and is this even an option? I don’t want to get paid a prophy but working my butt off on a pm. What ate your thoughts/opinions



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2 Answers

It’s not appropriate to alternate between code D1110 and D4910, as the former is reserved for patients who do not exhibit signs of periodontal disease. How can a person be disease-free one visit, then need periodontal maintenance three months later, then be disease-free in another three months? Keep in mind the nature of the procedures as stated previously — one is preventive, one is therapeutic. Do not alternate codes because you do not want to be guilty of unbundling this procedure by billing only an adult prophy in order to receive benefits. Unbundling is considered an act of insurance fraud.

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I agree with Kara. Most insurance companies are changing and are paying for 4910 either two and sometimes four times a year now. The front desk must forget the mindset of only billing what an insurance company will pay for. Patients must demand better coverage from their employers/insurance/HR. The front office must be trained to support you and the dentist and not feel sorry for the pt having to pay out of pocket for procedures that are necessary with preventing or maintaining dental diseases.

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