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

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Perio Maintenance VS Prophy

Curious how my fellow hygienists would handle this:

We saw a husband and wife last week, both new patients. She was a healthy prophy with no history of perio services. He was alternating with a periodontist every 3 mos with his previous DDS. Surgery was in 2009 and he is perio stable. Oral hygiene is excellent. He uses elec tb and flosses daily and is going to get a water pik also as he would like to move to every 4 mos. He had very light local pinpoint bleeding with probing in a few sites. No bite disease evident. 2 localized 5 mm pockets: one a pseudo pocket on a tipped molar, the other opposite a metal restoration that will be replaced. Health history is very mild BP, no meds. He wants to stop seeing the periodontist. Dr and I agreed that he could continue on a regular basis every 4 mos and we would evaluate his perio at the next 4 mo appt but, since we do laser bacterial reduction and treat more advanced cases, we felt we could keep him ” in house ” for his hygiene appts.
The dilemma: his wife called this morning and stated that they went home and ” compared notes” and felt I did the exact same thing on both of them and since he is stable, she insists that he be a regular prophy and NOT a perio maintenance as they have more out of pocket costs with that code.
What would you say to this patient?? Once a 4910 , always a 4910??

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1 Answer

After periodontal therapy, a patient is periodontal maintenance (4910). To alternate codes (like many offices do) constitutes insurance fraud. I would explain to the patient about the disease process; more specifically about bone loss due to virulent bacteria. “Maintenance” is needed due to the virulent bacteria present. A regular prophy is preventative for a patient with no bone loss (attachment loss), which is the difference between this wife and husband. I would explain the issue of insurance fraud to the patient as well. It’s tough when patients argue about this, but educating the patient is all you can do. It’s your license on the line, so if they don’t “approve” of the treatment they are always free to go elsewhere!
ADHA Position Paper link: http://www.adha.org/resources-docs/7115_Prophylaxis_Postion_Paper.pdf

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