Dentaltown December 2019 - 38

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Practice Whisperer
Member Since: 07/22/11
Posts: 20, 21 and 26 of 58

So one of the first things an insurance company or dentist consultant is going to try to deny
on a perio case claim is pseudopocketing, meaning pockets that are there only because tissue is
swollen, so without data they are going to assume up to -2mm GM, which means 5mm pocket
depths, is actually normal bone height (CAL).
This is why you need to mark all GMs, even 0s. But it is also important for your own
diagnosis, because if you have someone with a bunch of 4-5mm pockets and -1 to -2 GMs, they
aren't perio (yet), and likely just need an FMD/GD and better home care.
GM = distance from CEJ to tissue. In a healthy child usually these are -2, meaning tissue
is 2mm above the CEJ.
From a true AAP point of view, the case needs more information to determine appropriate
treatment, regardless of insurance participation. As I have mentioned earlier in the thread, a
patient can have up to 2mm of tissue above the CEJ, especially when swollen due to build-up.
It is possible (not completely likely) that the tissue is swollen above the CEJ and a lot of those
4-5mm pockets are possible to be 2-3mm CAL, which is normal.
Again not likely, but to give a true definitive diagnosis you need all the information, which
includes GMs. This is one of the few things I agree with insurance on, because this is how we
were all originally taught (or should have been). ■
8/16/2019

Herodontist 80111
Member Since: 09/22/17
Post: 27 of 58

Even if this is true, what therapy besides SRP (or other variation that includes SRP-like flap
curettage) is going to deal with subgingival calculus as seen on the radiographs? A prophy? ■
8/16/2019

Practice Whisperer
Member Since: 07/22/11
Post: 28 of 58

The coding for hygiene in America is [a mess], I agree. SRP is also defined as root planing,
so it wouldn't apply on cases with severe gingival overgrowth with subgingival calculus that's
not on roots. The only code available after that is FMD, with an additional code for anesthetic if
needed. I probably see one true case of FMD every couple of years. Most likely, the case the OP
presented does need SRP, but for anyone to truly define that, it needs correct documentation.
Someone claiming a case is pseudopocketing is going to correctly say that if you remove a
bulk of the calculus, the tissue will shrink back and allow you to do a normal prophy in a month.
If you mark GMs, then you remove the ability for someone to claim that, thereby removing a
majority of issues with getting claims paid eventually.
The problem with the concept of just pre-D it, all insurance is going to do is likely deny up
front. 99% of those same cases that are denied on pre-D would be accepted once treatment is
done with correct documentation. Crowns are another great example; we never get true denials
on crowns. ■
8/16/2019

jcr87
Member Since: 04/04/06
Post: 29 of 58

I understand you are stating what the insurance company's rationale is in denying the claim,
but it seems to me that in the case I submitted, an FMD with anesthetic vs. SRP is a distinction
without a difference to the actual work/service provided by our dental office. To me, it's just a
weasel way to shift the cost of treatment to the patient.
I appreciate your response; it was very informative and helpful. ■
8/16/2019

Practice Whisperer
Member Since: 07/22/11
Post: 30 of 58

Oh, absolutely it is-but what do you expect from insurance companies? Start recording
GMs and you won't have nearly the same issues again. A few other things and you should never
have an issue. ■
8/16/2019

DECEMBER 2019 // dentaltown.com

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Dentaltown December 2019

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