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SRP and FMX

I just started at a new office and they require a FMX before any SRP, my first day I saw another hygienists patient to preform SRP after she did full mouth debridement , I didn’t even think to take the FMX because I figured she would have taken what was needed but now when I look back she only took four bitewings , now I am very nervous this patients insurance is not going to cover it because I didn’t take an FMX. I feel terrible. Is it required by insurance to have an FMX to cover SRP?



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3 Answers

To help answer your question, I reached out to Patti DiGanigi the insurance coding queen because I don’t recall the offices I’ve worked for “requiring” a FMX before SRP for insurance reasons. An FMX is required for diagnostic reasons. Patti said:
 
The office requiring a FMX before SRP has merit but what is skewed here is the order and why. Let’s not even start with what insurance wants. Let’s just talk about how treatment is determined. The treatment plan should be based on the dental-medical necessity which is the risk assessment and diagnosis. The problem is the lack of diagnosis. What pieces and parts of needed to make a periodontal diagnosis? AAP has this list:
1. Health status/medical consultation
2. Periodontal examination
3. Diagnostic radiographs
4. Further testing
5. Establishing a diagnosis
6. Periodontist co-management
7. Determining a treatment plan
8. Prognosis estimation
9. Informed consent
10. Treatment
11. Evaluation of therapy
 
As can be seen, the diagnosis is #5 AFTER the health status, perio exam, diagnostic radiographs and further testing. So is a FMX required? No it doesn’t say that, it says diagnostic radiographs. If this new office is requiring an FMX, the RDH needs to ask them, “Help me to understand why?”
 
Now to the insurance carrier part, there is no way a practice can know why might or might not be required by the carrier without getting that information from the carrier. Good luck there, not as easy at it might sound. My experience is the person dictating the FMX also doesn’t have that information. Most dental professionals, business or clinical, don’t have any idea of how insurance works, they just go by what they have seen be successful… or at least not caught.
——-
 
What I interpret Patti as saying is that a FMX is part of the diagnostics to determine treatment, but whether a certain insurance carrier requires it, is up to that particular insurance carrier. The offices I have worked in complete an insurance breakdown for each individual patient before they even walk through the door – instead of a cookie cutter protocol that isn’t individualized or as a way to solely increase the offices bottom line.

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I have not come across any instances where an insurance denied SRP’s because of not having an FMX. If the insurance denies SRP’s its usually due to frequency, such as having had the tx already in within a period of time. I wouldn’t stress too much.

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None of the offices I work in take FMX because THATS what the insurance won’t pay for. They’ll cover SRP with bitewings and a pan.

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