Periodontal Maintenance (PM) vs Prophylaxis (PX) by Dr. Travis Campbell

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Periodontal Maintenance (PM) vs Prophylaxis (PX)Can one alternate these codes?

by Dr. Travis Campbell

This debate has raged for decades among dentists. Some will say “once perio always perio” and others will state “it depends on the current health of the tissue.” At the heart of it are two codes: D1110 (prophylaxis, or PX) and D4910 (periodontal maintenance, or PM).

The ADA code descriptions in the past were more weighted towards the once-perio-always-perio crowd, but in recent years have been modified to be less so. The 2023 ADA coding guide specifically states that the codes are not mutually exclusive and that a prophylaxis can be done between periodontal maintenance visits. This aligns with the ADA’s overall stance that codes should allow for as much clinical decision-making as possible.

For this discussion, let’s avoid the clinical debate. Today, we are going to focus on the more practical side of the question, as that is what we can determine.


What is the best method to manage coding for periodontal patients?
First, let’s return to the original thought about what codes are designed to do in the first place. Codes are primarily for insurance billing; they did not exist before insurance companies entered the arena. So, we do need to factor in how insurance companies treat these codes.

Many insurance companies have systems in place that say a PM must follow an SRP (scaling and root planing) or another PM. Often, one finds that once you use a D1110, the benefits of future D4910s are removed. This is a major concern, as it means alternating codes can cause the patient to lose benefits for the future. The insurance companies do this because of the stance taken by many: “Once perio always perio.” Of course, lowering future costs helps them too.

So, from an insurance company perspective, alternating codes may be a problem with many insurance companies and policies.

If this is the case with insurance, why would an office ever alternate the codes? The main reason is the patient’s desire to pay less. “I want my free cleaning” is the bane of every dentist and hygienist when it comes to routine patient care. And rarely one may come across a policy that specifically pays for two D1110 and two separate D4910. These policies make up less than 1% of the plans sold in the country, but they do exist.

The simple solution to a policy like this is to ask for an alternative benefit. Most recognize the alternative benefit concept when one does a composite filling and gets an alternative benefit of an amalgam. These are typically automated by the insurance company’s computer-driven EOB. However, a D1110 is not always seen or processed as an alternative benefit of a D4910. One would want to specify the request for an alternative benefit in the remarks section of the claim: “Please provide alternative benefit of a D1110 for this patient if D4910 is not available.”

This will allow you to access all the patient’s benefits without having to change your coding at every visit.

The other concern with alternating D1110 and D4910 is with the financials themselves. A D4910 is always more expensive than a D1110. So, by alternating the codes, the office is intentionally receiving less income for the work being done. In the current situation, with offices across the country facing challenges with the profitability of hygiene in general, intentionally dropping one’s fees would just exacerbate this profitability concern.

Finally, we come to the patient’s perception. It can be hard enough to get a patient to accept that they will need to pay more instead of getting their “free cleaning” visit when they have a diagnosis of periodontal disease. If you show the patient the codes can be alternated, this can show the patient the codes are rather fluid, and therefore, why can you not just always use the lower-priced service code?


Summary
While there may be some clinical debate about swapping between a D4910 and a D1110, from an insurance and patient perspective, it can be far easier to stick with the D4910 and avoid switching. One can always ask for alternative benefits for the rare policies that provide them. Sticking with D4910 helps patient understanding, helps prevent loss of insurance benefits, can be easier organizationally, and can help maintain profitability so that hygiene departments don’t incur losses.
Author Bio
Dr. Travis Campbell Dr. Travis Campbell is a practicing dentist and multiple-practice owner who lives in Prosper, Texas, with his wife and two young children. Having gained a reputation as an expert in the complex area of dental insurance, Campbell is commonly known as “The Dental Insurance Guy!” He dispels many myths and misperceptions about today’s dental insurance policies and explains how to navigate the complexities of being an exceptional dentist, business owner, and leader while still maintaining a life outside of work. His most recent textbook, Understanding Dental Insurance, has become a bestseller in dentistry and has already sold out twice. He has also launched the most comprehensive online resource for dental insurance: dentalinsuranceguy.com.
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