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Not a Prophy but not SRP & documenting

I struggle with making the decision between labeling the treatment plan as prophy or SRP. The obvious SRP patient with 5+mm pockets and the obvious healthy patient are not what I’m talking about.

The patient with mostly 3mm maybe a few 4mm pockets, BOP, little to no bone loss, maybe 1+ years since last prophy, mod supra calculus. Why isn’t there a active gingivitis insurance code?!
You put in a lot more effort with these patients.

Different subject: I always feel like I am writing a book with my notes, documenting characteristics of the gingiva, amount of calc, questions the pt had, answers I had. I document everything that was said/done during the appointment. Compared to the other hygienists notes I am writing a lot more. Any suggestions are greatly appreciated.



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3 Answers

There used to be a “difficult prophy” code for situations like the one you mention. I believe it got abused and overused by offices trying to make a bit more money, so the insurance companies no longer accept it. This makes things very frustrating. If the calculus is so heavy you cannot perio chart, then a debridement might be in order, but normally what I choose to do is split the prophy into two appointments. I explain to the patient the amount of calculus and how it will take more time than a “regular prophy”. The insurance will cover the first appointment and then they are responsible for the second one. You are basically charging out two prophies with the patient responsible for one. This often will lead the patient to have better home care and to be more timely about their appointments.
As far as charting, state boards always say it is better to overchart than underchart.

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Depending on how much calculus is present, how long it has been since their last hygiene visit, tissue health, and BOP I will usually perform a debridement first. This way I can accurately take perio measurements and such at the next visit. I can also determine how well the pt has healed along with how well they are doing on their homecare.
As with the charting I feel like sometimes I write a novel but I also know that I have less of a chance of being part of a lawsuit because I have it all down in the chart. I feel like more is better than less. I took a defensive charting CE course and it helped a lot. I recommend looking for such CE courses.

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I would split this patient into a debrisment charge and then return for exam and prophy…

on the note taking I totally understand…I too am the charter/note taker in my office…trust me , its noticed and appreciated…I now have some Dr’s send patients to me specifically…why dont they insist all are doing what we SHOULD be doing?..dont know!!…but I just keep doing it my way…I figure it protects me better legally and is the right thing for patients. ..cant control the rest 🙂

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