Understanding gingival inflammation code D4346

Foggy weather is common in the spring. You wake up, look out the window and know that traffic will be a mess. Your hope is for the fog to lift and the sunshine to break through before you have to get in your car.

For the dental industry, a fog seems to have settled around the new D4346 gingival inflammation code. For many, it’s a code we hoped for and knew was needed for a long time. Yet there is a lot confusion and our understanding is foggy.

I want to clear up some of the fog surrounding this code. Breaking through the fog will reveal specific reasons for patients to return to your practice, thus escalating its profitability.

Related reading: 5 important facts about new code D4346

Eight points to understand

As an invited author in the CDT 2017 Companion book, I learned the details of D4346 back in March 2016. I was excited by the opportunities, yet knew it would take shifts in our traditional thinking about treating gingival disease.

To set the table, the new code including the description reads:

"D4346 scaling in presence of generalized moderate or severe gingival inflammation-full mouth, after oral evaluation. The removal of plaque, calculus and stains from supra- and subgingival tooth surfaces when there is generalized moderate or severe gingival inflammation in the absence of periodontitis. It is indicated for patients who have swollen, inflamed gingiva, generalized suprabony pockets, and moderate to severe bleeding on probing. Should not be reported in conjunction with prophylaxis, scaling and root planing, or debridement procedures."

The ADA created a Guide to Reporting D4346. However, I saw this would only be a starting point for a major shift.

My book, A Gingivitis Code Finally! came out in September 2016. I broke D4346 down into digestible pieces, using mini-quizzes, case histories and more to give you what you need to successfully and profitability implement this new code.

As I have traveled the country speaking, I determined there are eight major points to grasp to blow away the fog surrounding the D4346 code:

1.    Care is therapeutic not preventive.

2.    An oral evaluation must be completed before care.

3.    This code is not age-based.

4.    All patients must have a periodontal chart and current radiographs (including children) to show the absence of periodontitis.

5.    Documented type 2-3 on the Löe and Silness gingival inflammation index must be > 30 percent of the teeth (e.g. 30 teeth then >10 teeth.)

6.    A specific periodontal diagnosis must be documented. (Every case qualifying for D4346 is not plaque-induced gingivitis.)

7.    Care is for the full mouth. No other scaling codes can be submitted on the same date.

8.    D4910 does not follow this care

A quick D4346 FAQ

Those eight points make D4346 easy, right? Not so fast! Many questions have arisen, and thanks to readers and course participants, I’ve heard them all. Here are some of the most common ones I hear:

Q: The way D4346 is written states that the dentist needs to do the evaluation first. Can the evaluation be the same day? A week before? What if the evaluation was seven months prior to the appointment?

A: The after oral evaluation part of the nomenclature (name) changes our appointment flow. The code does not state how long prior to care. Traditionally, the hygienist gathered data, performed care and the dentist came in after the fact, to check most often depending on the assessments of the hygienist. Can the evaluation be that same day? Yes. Could it be seven days before? Yes. Could it be seven months prior? No. Health and disease are dynamic, not static. A diagnosis rendered seven months prior may or may not be accurate. Treating disease that may or may not exist is like an unethical auto technician telling me I need repairs that are not really needed, just to extract more money from me. A guideline might be no more than 30 days, though there no specific research behind this suggestion.

Q: Can we use the 4346 code more than once a year?

A: From a coding perspective, there are no limitations. D4346 was placed in the therapeutic D4000 Periodontics section was based on the science of biofilm infections. If we have a patient this level of inflammation to qualify under this code, it would be my expectation that we see them again in 7-14 days to see if the inflammation has cleared or needs more treatment. If the person once continues to have >30% teeth with inflammation Type 2-3 in the absence of periodontitis, they again qualify under this code. So, how many times can it used? As many times as it needs to be. Again, that is from a coding perspective. There is nothing in either the nomenclature/name description with limitations.

Inflammation is the body's attempt at self-protection and to begin the healing process. Current science believes inflammation is the oral-systemic connection. Using this code accurately has the power to finally bring the medical relevance to gingivitis treatment which presents a great opportunity.

Q: What is the usual fee that can be used for D4346?

A: Fees should be based on the cost of doing business plus a reasonable profit and not based on insurance carrier payments. Different practices across the hall from one another can charge different fees because their cost of doing business is different. With that said, I have suggested that the fee for D4346 might be half between your prophy fee and one quad fee. But that is arbitrary and has no science, accounting or economics behind it. There no reason the fee must be different than for other care. Just because there is a different code, it does not require a different fee.

Opportunities blow away some fog

This code finally assists in clearly identifying and treating gingivitis after decades of merely dumping gingival inflammation into the same category as health. We have been providing the care anyway, and this code provides a reason for patients to return to your practice, improve their health and boost your bottom line.

The D4346 fog will clear the more it is implemented over time. If you have a question yourself, simply ask me at Patti@DentalCodeology.com