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Cracking The Codes, Part I: Scaling and Root Planing by Dr. Dominique Fufidio, FAGD

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Categories: Practice Management, HR and Accounting;
Cracking The Codes, Part I: Scaling and Root Planing 

Visible bone loss is a requirement for SRP insurance claim reimbursement

by Dr. Dominique Fufidio, FAGD

Periodontal disease, a chronic infection of the hard and soft tissues supporting the teeth, is the leading cause of tooth loss in older adults1 and is not uncommon in dentistry. The Journal of Dental Research reports that 47.2% of U.S. adults age 30 and older have some form of periodontal disease,2 and analysis of Egyptian hieroglyphics and medical papyri indicate that nonsurgical periodontal treatment was common 3,000–4,000 years ago. (Now, that would make for some unique office decor!)

Although instruments and techniques have been modified, scaling and root planing (SRP) remains the quintessential step in managing periodontal disease. Clinical trials support consistent responses making SRP the gold standard for management of periodontally diseased tissue,3 but according to a report by the American Dental Association, SRP procedures—including D4341 and D4342 specifically—have a higher frequency of denial, or receive more requests for additional information, than other procedures.4 From experience, I believe dental providers and offices don’t always understand the rationale behind an SRP denial when a patient has signs and symptoms of inflammation and periodontal pathology.

What qualifies as “medically necessary”?
Why is insurance benefit reimbursement for SRP claims so challenging and seemingly complicated?

While periodontology instruction is a foundational component of a dental education, benefit utilization management and “medical necessity” are not. When a claim is submitted to an insurance provider, the services are reviewed to see if they meet what is called medical necessity for treatment. To determine this, a payer will apply its specific criteria and policies, and although this criteria is largely similar across carriers, each payer does differ slightly as to what is considered:
  • the required information to perform a review of the services submitted, and
  • what meets medical necessity criteria resulting in a favorable review.
For SRP reimbursement, root surfaces need to be instrumented.5 Pocketing is a sign of pathology, but variability from provider to provider, and even among team members at the same provider, has been documented, sometimes up to 1 mm.6 As a result, the reliability of periodontal charting becomes limited7 and because the payer’s team is not chairside, insurance carriers are left to rely on the one finding of utmost importance to make a recommendation for benefits: evidence of visible bone loss.

When I sold my practice and transitioned to the payer market, I experienced this confirmation of the medical necessity challenge. I was left to hone in on the presence of radiographic bone loss. But how much bone loss meets criteria? Is slight crestal bone loss enough to say a patient has visible bone loss qualifying for scaling and root planing benefits?

Unfortunately, the answer across the market is “not really.” A study by Hausmann et al. published in the Journal of Periodontology asked, “What alveolar crest level on a bitewing radiograph represents bone loss?” and the study concluded a distance of 0.4–1.9 mm, measured radiographically from the cementoenamel junction (CEJ) to the crest of bone on bitewing radiographs, was consistent with no bone loss.8 Another study by Gargiulo et al. declared measurement of less than 2 mm to be considered normal, 2–4 mm consistent with noticeable disease and 4 mm related to severe periodontal disease.9 And lastly, the American Academy of Periodontology defines periodontitis as 15% bone loss, which equates to a measurement on a periapical when the entire root surface including the apex is captured.10

The struggle is real: A case study
To demonstrate my point, and to empathize with your struggle, I’ll share an example from my private practice. This 42-year-old patient (Figs. 1–3) was seen for a new-patient examination, including six-point periodontal probing and complete soft- and hard-tissue assessment—a true comprehensive periodontal evaluation. The patient had not seen a dentist in more than five years, and preliminary soft-tissue examination revealed all the signs of inflammation, including glossy gingiva, loss of stippling and rolled gingival margins. There was plaque, calculus, periodontal pocketing and multisite bleeding, so I diagnosed this patient with Stage 1, Grade A generalized periodontitis and recommended SRP (D4341) in all four quadrants.
AI insurance claims
AI insurance claims
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Fig. 1: Select images from the patient’s full-mouth radiographs
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Fig. 2: Comprehensive periodontal charting..
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Fig. 3: Soft-tissue examination findings documented, as well as a summary of oral hygiene findings and a radiographic interpretation overview

Despite what I believe was an obvious need for the treatment, I received an adverse determination where the explanation of benefits indicated the services on the claim were denied for “necessity not [being] evident.” I appealed the adverse determination, recounting the bleeding, calculus and pocketing, and received another denial. I appealed a second time, adding to my narrative and circling and highlighting images, but was denied again, so I exercised my right to a peer-to-peer discussion.

This time spent with the claim reviewer was when I realized I wasn’t focusing on the one thing that really mattered to them: visible bone loss of at least 2 mm. Eventually the services on this claim were paid for, because we agreed there was visible bone loss in excess of the criteria requirement for this payer, but it took time to get there. And by “time,” I don’t mean just the appeal and reappeal—during our phone discussion, the claim reviewer and I went tooth by tooth, pocket by pocket, bitewing by bitewing and PA by PA, before eventually agreeing that enough teeth in each quadrant had visible bone loss to meet the criteria.

Using AI to measure bone loss I believe that time-intensive struggles like this one likely won’t continue, because insurance companies have begun to incorporate artificial intelligence to help measure the level of bone loss. However, because the analysis of scaling claims will become less subjective, providers need to understand what’s being evaluated—and it’s not the pocketing or the bleeding but the bone loss, and bone loss of 2 mm or more specifically. (Some carriers may vary.)

Some dental practices have added AI technology to their workflows to measure bone levels on bitewing radiographs and bone loss ratios on periapicals, but even if you’re not ready to add AI to your office workflow, that doesn’t mean you can’t keep up with the times. Developing a keen awareness of the requirements like the ones described in this article will allow you a more predictable claims submission experience and make for a more accurate and precise benefits discussion with your patients.

It’s crucial to understand that the decision from the insurance carrier is a benefit determination based off the guidelines, policies and provisions to establish a consistent and calibrated standard for all claims being reviewed. It is not a clinical treatment recommendation; the treatment recommendation is clinically yours, and yours alone. You must make your best recommendations for your patients and submit information in support of your diagnosis that influenced your treatment planning, getting you paid for what you do and benefiting the patient’s treatment.

References
1. Thornton-Evans G, Eke P, Wei L, Palmer A, Moeti R, Hutchins S, Borrell LN; Centers for Disease Control and Prevention (CDC). “Periodontitis Among Adults Aged 30 Years—United States, 2009–2010.” MMWR Suppl. 2013 Nov 22; 62(3):129–35.
2. Eke PI, Dye B, Wei L, Thornton-Evans G, Genco R. “Prevalence of Periodontitis in Adults in the United States: 2009 and 2010.” J Dent Res. Published online 30 August 2012:1–7.
3. Cobb CM. “Clinical Significance of Non-Surgical Periodontal Therapy: An Evidence-Based Perspective of Scaling and Root Planing.” J Clin Periodontol. 2002 May; 29 Suppl 2:6-16.
4. ADA (2023). “Claims Submission: Scaling and Root Planing (SRP), Long Version.”
5. ADA. “CDT 2023: Current Dental Terminology Application Software.” 2023. Accessed 19 June 2023.
6. Andrade R, Espinoza M, Gómez EM, Espinoza JR, Cruz E. “Intra- and Inter-Examiner Reproducibility of Manual Probing Depth.” Braz Oral Res. 2012 Jan–Feb; 26(1):57–63.
7. Khan S, Cabanilla LL. “Periodontal Probing Depth Measurement: A Review.” Compend Contin Educ Dent. 2009 Jan–Feb; 30(1):12–4, 16, 18–21; quiz 22, 36.
8. Hausmann E, Allen K, Clerehugh V. “What Alveolar Crest Level on a Bite-Wing Radiograph Represents Bone Loss?” J Periodontol 1991; 62(9):570–572.
9. Gargiulo AW, Wentz FM, Orban B. “Dimensions and Relations of the Dentogingival Junction in Humans.” J Periodontol 1961; 32: 261–267.
10. American Academy of Periodontology (n.d.). “2017 Classification of Periodontal and Peri-Implant Diseases and Conditions.” AAP. Retrieved May 2023 from perio.org.

Author Bio
Dr. Dominique Fufidio Dr. Dominique Fufidio, FAGD, is the founder and main coach at Fufidio Consulting Group, where she has pioneered a coaching experience focused on understanding the dental insurance claims review process. She also serves as the director of specialty services for Apex Dental Partners. Previously, Fufidio had been the owner of a successful fee-for-service private practice, a top-performing dental claim reviewer and an artificial intelligence co-creator. She continues to engage with the dental community via writing and speaking. Information: fufidioconsultinggroup.com.
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