The following are guidelines and policies for benefit determinations for D4355, D4346, D4341 and D4342.
D4355: full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit
Full mouth debridement involves the preliminary removal of plaque and calculus that interferes with the ability of the dentist to perform a comprehensive oral evaluation. Not to be completed on the same day as D0150, D0160, or D0180.
Benefit determination: D4355 will not be benefited if performed on the same date of service or 30 days following D0150, D0160, or D0180. A comprehensive oral evaluation is considered the most important service provided to a patient in this situation. Therefore, by definition, a D4355 is not recognized as an appropriate service on the same date as a comprehensive oral evaluation. The same holds true if D4355 is billed 30 days following a comprehensive oral evaluation by the same dentist. In these situations, the D4355 will not be benefited and will not be billable to the patient.
D4346: scaling in the presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation
The removal of plaque, calculus and stains from supra- and sub-gingival 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 planning, or debridement procedures.
Benefit determination: D4346 will be benefited in the absence of periodontitis determined by the absence of horizontal or vertical bone loss. Submission of a claim for D4341 or D4342 for a patient with a history of D4346 within the past 6 months will result in a review of both claims by a dental consultant to determine the appropriate service to benefit.
D4341: periodontal scaling and root planing – Four or more teeth per quadrant
D4342: Periodontal scaling and root planing – one to three teeth per quadrant
These procedures involve instrumentation of the crown and tooth surfaces of the teeth to remove plaque and calculus from these surfaces. It is indicated for patients with periodontal disease and is therapeutic, not prophylactic, in nature. Root planing is the definitive procedure designed for the removal of cementum and dentin that is rough, and/or permeated with toxins or microorganisms. Some soft tissue removal occurs. This procedure may be used as a definitive treatment in some stages of periodontal disease and/or as a part of pre-surgical procedures in others.
Benefit determination: D4341/D4342 will be benefited in the presence of periodontitis determined by the visible presence of horizontal or vertical bone loss around teeth in a quadrant. The absence of bone loss and the presence of suprabony pockets may result in a benefit of D4346.
