Your patient's best smile is worth more than their dental maximum! Discover how to prioritize oral health while learning how to ensure your treatment plan focuses on patient needs, not just the possibility of insurance reimbursement.

Plan Stipulations vs. Patient Needs: D4341 & D4342

You know the drill. From the moment you clock in until the moment the last patient leaves for the day, diagnosing treatment and the seemingly never-ending task of presenting financial estimates are just par for the course in any dental practice. Think about it – does a single day go by without a brand new financial estimate landing in a patient’s hands?

But here is the big question:

Are We Treatment Planning Based on Patient Need or Based on the Potential for Insurance Reimbursement?

Suppose a patient is diagnosed with periodontal disease requiring scaling and root planing (D4341). Two quadrants were completed in one visit, and one week later, the other two quadrants were completed. Then you sit back, relax, and wait for the insurance check in the mail. But it never comes. Instead, you receive two denied explanations of benefits (EOBs) stating that the services do not meet the benefit guidelines. Now you’re left wondering – what went wrong?

Just because a case meets the diagnostic criteria for needing treatment does not mean that it meets the criteria outlined in the insurance plan design for reimbursement.

While the diagnostic criteria for periodontal disease has not changed, the actual plan criteria for reimbursement has gotten more stringent among many payors. Pocket depths alone are no longer sufficient with all plans for reimbursement, a noticeable change from years ago. This has led to an increase in D4341 denials with offices nationwide. At the end of the day, dental insurance is a defined benefit plan with specific criteria outlined by the designers of the plan as to when they will reimburse claims.

This Does Not Mean the Payor Does Not Recognize the Need For Care.

What this means is that the employer – or the designer of the plan – chose to limit reimbursement to certain circumstances as a way to reduce the plan cost to them. That being said, the following is a sample of the plan criteria some plans may require before reimbursing scaling and root planing (D4341). Note that each payor may define these criteria differently:

• The teeth must be permanent.
• Crestal bone level must be greater than 2mm below the CEJ on bitewing radiographs for 4+ teeth.
• There must be radiographic evidence of vertical and/or horizontal bone loss.
• Calculus deposits must be visible on the cementum or root surface.

If these four criteria are not all met, this plan most likely will not reimburse for D4341.

Pro tip: Most plans are now requiring clinical documentation of start and stop times for the treatment visit, types and amounts of anesthesia given, as well as active bleeding points and radiographically visible bone loss. All of these should be clearly documented in the patient record.

However, try not to stress over a D4341 claim denial. Rather than throwing in the towel (or the gauze, for that matter) try resubmitting the claim with a more appropriate code – keeping in mind the golden rule of always coding for what you do! For example, if one to three teeth in the quadrant qualify, simply resubmit your claim using the scaling and root planing code of D4342 in its place. Where D4341 demands at least four teeth per quadrant be involved, D4342 only requires treating one to three teeth per quadrant, instead. This small difference could be the key to unlocking insurance funds.

All things considered, a healthy mouth comes first. The next time you’re wondering what the perfect treatment planning path is, remember that patient needs always take priority over the confusing rules of an insurance plan. Remember, the potential for insurance payor reimbursement should never dictate clinical decisions.

Patient needs come before plan stipulations – always.