The patient has to have a history of S/RP before perio maintenance can be billed to insurance. I had a new pt that was perio and had S/RP and Osseous Surgeries in 2004 and previous dentist (another state) only charged out Adult Prophy. We contacted the insurance and all they needed was the date of S/RP and I was able to complete a Perio Maintenance instead of S/RP since the previous office was actually doing a perio maintenance, but was being nice and only charging an Adult Prophy.

I agree with hygenius. As long as the pt has had SRP before the insurance will accept perio maintenance even if the arp was done on a different insurance. As long as you have proof of the procedure and charting etc. Your real issue is explaining the difference between a prophy that was covered at a 100% and the perio maintenance which is covered at a percentage usually 80%. That being said if your pts were coming in for 3 month recare and paying out of pocket for a prophy they might be actually happy because now the insurance kicks in more but that is providing that your front office charged them every time they had an additional prophy out side of the two that they get a year. hope this helps

Yes….agree with above…but we have an insurance person that handles each and their insurance….we may bring it up as a need but the office person handles sorting it out…too mant insurance plans, groups, and tiny differences for me to be sorting it out…

This happened to me when I inherited alot of patients when the regular hygienist of 10 years quit. She had a history of charging out perio maintenance appointments every 3-4 months as an 1110 and not 4910 which is a bit of a price difference. We didn’t have a problem with insurance because we had documentation proving srp was done in the past. The harder part was explaining the higher fees to the patients. Once I explained why they are considered perio maintenance I said the ADA recently changed code protocols to explain the different code and price so I avoided having to say the other hygienist had been doing it wrong all this time. Most were fine with it.

As long as you can provide history of SRP and current perio charting you should be ok. The problem you will undoubtedly run into is that some ins policies do not cover PMT at 100%. Patients will most likely question this so be ready to defend and educate! Good Luck!