Did your dental hygienist or dentist tell you that you need more than one appointment to have your teeth thoroughly cleaned? Are you upset about this because your insurance only covers two cleanings a year? This article will explain the reason for the additional cleaning and the insurance codes than can be used to get your insurance to cover it!
Bring your insurance card with you to the dental office. Also, bring your insurance booklet about coverage to the dental office and/or the phone number of the insurance company. If the office does not know about your dental coverage or refuses to call the insurance company, then call the insurance company yourself. There should be a toll-free number on the back of your card.
Ask the dentist or hygienist for their diagnosis of the condition of your gums and insist on a copy of their complete periodontal pocket charting. (Some offices don't really check the gums, so if you insist on a copy of the periodontal charting, they will be forced to do so.) You can keep this chart for your reference so that you know where your problem areas are. You will also be able to see in the future if problem areas are getting better or worse. There is a space between the gum and tooth called a "pocket." Pockets 3 millimeters or less are within normal limits. Pockets deeper than that indicate gum disease. However, even pockets 3 millimeters or less can have early gum disease (gingivitis).
Have the dental hygienist show you the best way for you to brush and floss your teeth. There are many different ways to brush. Your brushing needs change over time. The way you were shown to brush as a child is probably not the way you should brush now. Brushing only cleans the front, back, and top of your teeth. You ABSOLUTELY need to clean the bacteria from in-between the teeth with floss. I know, we all hate this, but it is very important. Be sure you are not just flipping the food out from between your teeth with the floss. You must floss CORRECTLY to remove the damaging bacteria!
Have the hygienist or dentist explain the gum disease process to you. Plaque is the soft film that forms on everyone's teeth daily. It contains a lot of bacteria that can destroy the tooth (causing cavities). When you do not remove it all, it eventually mixes with the minerals in your saliva and hardens up into what people call tartar (or calculus). Plaque under the gumline has more damaging bacteria. In addition to destroying the tooth, it causes the gums to become inflamed and bleed and also destroys the bone that holds your teeth in!
Eventually you form gaps (pockets) between your teeth and gums that even your brush and floss cannot clean. In that case, the hygienist needs to do deep periodontal cleaning to reach those areas. Over time, when enough bone is destroyed, the teeth become loose, and then it is time for dentures! This process can occur more rapidly in some people, and much more slowly in others.
Some people do not even get the bleeding, but still lose the bone support around their teeth. Genetics is involved somewhat, but no matter how susceptible you are to gum (periodontal) disease, you will not lose your teeth if you remove the damaging plaque daily with your brush and floss. I am explaining this process as simply as possible. Please ask your dentist or hygienist to explain your unique situation to you. Also, ask the hygienist or dentist to explain the relationship between gum problems and the rest of your body.
Gum disease is an infection, and your head is not a little machine that sits on top or your body all by itself! The bacteria in your mouth get into your blood stream and flows throughout all your body! In the last several years, researchers have been finding relationships between gum problems and diabetes, coronary artery disase, respiratory, liver, kidney, and pancreatic disease, as well as miscarriages and preterm, low birth-weight babies.
Request the diagnosis code that the dentist intends to use to submit charges to the insurance company. There are other codes for cleaning teeth besides the ones used for the two preventive cleanings every year. Most people don't even know about these additional codes for gum problems. If the dentist recommends additional cleanings, then different codes should be used.
Request the dental office to "prior authorize" the dental procedures to the insurance company BEFORE any work begins--and also prior authorize any follow-up cleanings to the insurance company. Regular preventive dental cleanings are submitted to your insurance company as code 1110. If you need just one additional cleaning because you have gingivitis, then the first cleaning should be submitted as code 4355 (initial cleaning/bridge removal) due to gingivitis), and the second cleaning a couple weeks later after the gums are somewhat healed should be submitted as code 1110 (preventive cleaning).
You may have a co-pay. If the dentist or hygienist tell you that you need more than one additional cleaning (deep cleaning/periodontal scaling and root planing), then those cleanings to treat the gum disease should be submitted as code 4341. When that code is used, the dentist charges a fee for each quadrant/quarter of the mouth. That is the way the insurance companies want it, and it is the way all dentists charge it. It is charged that way because it takes a lot of time to do the deep cleaning, and sometimes not all quarters of the mouth need to be cleaned that way.
The name of that treatment sounds scary, but it is totally nonsurgical, and usually the hygienist or dentist give you anesthetic to make the area numb when they are working on it. The anesthetic makes you more comfortable so that someone isn't poking around in your inflamed, sore gums for an hour, and the anesthetic also helps reduce the amount of bleeding so that it is easier for the hygienist to do a good job for you. The fee for deep cleaning (also called periodontal scaling and root planing) can be quite high--often up to $250 per quarter of the mouth ($1000 for the whole mouth), so insist that your dental office send in a prior authorization before you begin the procedure, so that you will know how much your insurance company will pay, and how much is your responsibility. Some insurance companies pay 80% of this; some pay 50%; some don't pay. The insurance is a contract between your employer and the insurance company, so if your insurance doesn't pay anything, then it is because your employer contracted for it that way. Many dental insurances do pay these additional cleanings.
Your employer can always pick up better insurance for you, but it will cost you more.Do not let the dental office begin extra dental cleanings until you FULLY understand the complete cost and what portion your insurance company will NOT cover. Also, after periodontal treatment, the dentist may want to see you every three or four months for cleanings until YOU have your gum disease under good control. These cleaning should be submitted as code 4910 to the insurance company (periodontal maintenance cleanings). Many insurances cover up to 4 "periodontal maintenance cleanings" a year after periodontal scaling/root planing. Most people do not about this coverage. This is because after 3 or 4 months, different types of damaging bacteria start accumulating in your pockets, and if the pockets can be professionally cleaned out every 3 or 4 months, the dentist can HELP you keep the gum problems under control so that you do not reach the point where you need surgery.
However, you must understand that only YOU can bring the problem under control by brushing and floss the plaque off your teeth DAILY. (The extra cleanings help, but what YOU do daily at home determines if your periodontal disease gets better or worse.) Think of your brush and floss as an antibiotic--it is removing the bacteria that causes the gum disease and is possibly causing problems in your body as a whole. The dentist may also recommend other gadgets to clean your teeth. Each situation is unique, and he may possibly recommend medications. If your gum problem is advanced, he may recommend that you see a periodontist (a dental specialist in gum disease).
OR--if you just plain are not happy with the cleanings you receive from your dentist or cannot seem to get your gum problems under control no matter what your dentist or hygienist recommend, you might want to seek a second opinion from a periodontist. (I will warn you that there are many general dentists/hygienists who just do not treat gum disease. It is sad, but it takes a lot of experience and good skills to treat gum disease well, and some dentists/hygienists just are not interested in doing these procedures. It does not matter if the dentist is in a beautiful office or is the President of his local dental society. He just may not be into treating gum disease. He may not even tell you about it, because he does not have the skills to detect it. On the other hand, a dentist in a tiny office in a basement may have a hygienist who does highly skilled cleanings!
