Disclaimer: Insurance administration and dental billing recommendations, as well as interpretations of the CDT codes, represent the opinions of our experts. For the latest CDT codes and official interpretations, contact the American Dental Association or visit ADA.org. You are responsible for your own use of the CDT Codes, insurance administration, and dental billing.

Plan Stipulations vs. Patient Needs: Periodontal Maintenance and SRP

We’ve all seen this tension play out. On one side, the insurance coordinator is focused on making sure the practice is reimbursed for the care it provides. On the other, the hygienist is guided by clinical judgment and an ethical commitment to avoid unnecessary treatment.

But what happens when a payor introduces a rigid requirement—such as mandating Scaling and Root Planing (SRP) at fixed intervals (e.g., every two years)—as a condition for continued Periodontal Maintenance (D4910) coverage?

If your office is currently debating whether or not to reset a patient’s clock with a forced SRP, you must understand the reality of the CDT.

• The Eligibility Reset is a Payor Guideline
  • There is no requirement in the CDT that says SRP must be repeated to justify D4910. In fact, the descriptor for D4910 is quite clear: “This procedure is instituted following periodontal therapy and continues at varying intervals, determined by the clinical evaluation of the dentist, for the life of the dentition or any implant replacements.” While some insurance carriers have internal policies designed to reset eligibility – essentially trying to force a patient back into a prophy status – these are payor policies, not clinical standards.

• Treat the Disease

• • Performing SRP just to satisfy a reimbursement requirement is a slippery slope. However, it’s also important to remember that active disease isn’t just about the presence of calculus on a radiograph.

• • Indicators of active periodontal disease include:
    • Probing depths of 4mm or greater 
    • Clinical Attachment Loss (CAL) – indicated on probing and charting, and bone loss visible on radiographs
    • Gingival recession or furcation involvement.
    • Suppuration or tooth mobility.
    • Bleeding On Probing (BOP) – an indicator of active disease that may require treatment

• The Alternating Code Shuffle: D4910 vs. D1110
  • It is a misconception that a history of SRP on a patient excludes all use of D1110 in the future. While bone loss is forever, active disease and inflammation are episodic. The ADA Coding Companion makes it clear that the D4910 and D1110 procedures are not mutually exclusive, but do differ in both the scope of treatment and clinical delivery. Per the descriptor of D4910, periodontal maintenance is a therapeutic (disease-treating) procedure that “includes removal of the bacterial plaque and calculus from supragingival and subgingival regions, site specific scaling and root planing where indicated, and polishing the teeth.” D1110 includes the removal of “local irritational factors,” is not a therapeutic treatment, and does not include significant subgingival debridement or site specific scaling and root planing. Always code for what you actually do!
  • It is a common “hack” to alternate D4910 and D1110 to maximize reimbursements from a patient’s plan. The decision about which procedure to deliver should be based on the patient’s clinical needs, not on insurance reimbursement. 
  • If you’re worried about capturing all of a patient’s available benefits,, submit a narrative with D4910 that states: “Please consider an alternative benefit of D1110 if D4910 is not payable.” Many plans will downgrade the benefit rather than outright denying it, ensuring the patient gets some coverage without you having to misrepresent the clinical service.

• Documentation: Your Best Friend or Worst Enemy
  • At the end of the day, your clinical notes are a legal document. If you are audited or summoned by a dental board, “the insurance lady told me to do it like this to get paid” is not a valid defense for performing SRP unnecessarily or miscoding a procedure. Always code for what you do as indicated in the clinical documentation. If it’s not documented, legally, it did not happen.

Insurance should never dictate care; it should only determine who pays for it.

If there is new or recurrent disease present, SRP is appropriate care.  If the patient is stable, code D4910 or D1110 based on what you actually do, not what the insurance company wants to see. Remember, if it is not documented, it did not happen. If it is documented, it should be what actually happened and not include any fabricated information about the appointment.

Let your clinical findings drive the treatment plan, use thorough narratives to fight for your patient’s benefits, and keep your coding honest. When we prioritize the clinical needs of the patient over the quirks of a payor’s reimbursement guidelines, we protect the practice, the provider, and most importantly, the patient’s health. Log into Code Advisor to learn more details about these codes today!