These TIPisodes keep getting better and better! Teresa gives us another round of great advice and in this tip, she tackles the 4355 code
Teresa Duncan, MS is such a wealth of knowledge. Please visit her website and enjoy her awesome resources! For more info from Teresa, see below!
Teresa Duncan: Speaker on insurance and management, Podcaster, Author of a book and contributes to several magazines and the ADA’s publications!
use code TALE for $3 courtesy (offsets shipping)
For your viewing pleasure this TIPisode has been transcribed:
Michelle Strange: A Tale of Two Hygienists presents this week’s TIPisode: Quick and easy tips to keep you up to date, and presented by the experts in the profession. Now, get ready for your unofficial TIPisode.
Teresa Duncan: Hi, this is Teresa Duncan with Odyssey Management and also the host of the Nobody Told Me That! podcast. I’m back here on A Tale of Two Hygienists because I really want to talk to you about issues that effect hygienists and that have to do with management and coding. What I’m going to discuss today is 4355, which is the debridement code. 4355 is one of those that we love the code, it makes a lot of sense, and then we hate the code because it’s tough to deal with as far as administratively. And patients really don’t understand why we can’t clean their teeth the day of.
So what you should know from an admin point of view is that 4355 is a code that is meant to get rid of — and I’m not going to use the coding language. I’m going to use the layman’s terms, really — is the code to get rid of all the gunk and the junk on the teeth so that we can do an evaluation. So the scenario is the patient comes in, they’ve scheduled for either a cleaning with you or they schedule for a new patient comprehensive evaluation on the doctor’s side. I’m not sure how it works in your office. Many offices do either or. So, depending on who sees them, you take a look at their teeth and you realize, “Okay. Even if I take x-rays, it’s not going to tell me a lot. Even if I probe, I can’t even get the probe in there. I can’t even really scale. It’s just going to be a bloody mess.” And the reason is they have just so much stuff on their teeth.
Now, the code is written so that 4355 is to enable a comprehensive evaluation. So that actually means that you’re not doing an evaluation on that day. The billing error that I run into is that many offices do the comprehensive evaluation at the same time they do the debridement. If you think about it, you can’t do a comprehensive evaluation — a good evaluation of the soft tissue, the gums — and you really can’t even get down to where the true bone level is, so there’s the hard tissue we’re really not taking a look at. So how can you do a comprehensive evaluation?
So the getting rid of the surface gunk, what we do then is we allow a healing period. Now, the healing period can be anywhere from 10 and 14 days. That’s a clinical decision that you and your doctor are going to have to discuss and set a guideline for. Then, after that, we get them in for the comprehensive evaluation. Now, I’ve heard two schools of thoughts [sic] here. You may do a full set of radiographs at the time of the new evaluation, or maybe you did one when they first came in. It is, again, your clinical decision on how you’re going to do it, but you need to be consistent in it.
So, then, when the patient comes in, hopefully the bleeding has stopped, the inflammation has gone down, all that junk that was sitting on their teeth has gone away so now the gums aren’t as irritated, and you have a better view of what’s going on. At that point, it’s appropriate and, of course, recommended that we do a comprehensive oral evaluation because, at that point, you can actually do the evaluation.
So that’s the administrative part. It was a little clinical but, really, from an admin point of view, the biggest issue that we run into is you cannot do an evaluation, the comprehensive evaluation, at the same time of the debridement. It is actually in the debridement code. It says, “to enable a comprehensive evaluation.” And, so, other offices, what they’ll do is they will bill for a limited evaluation, and that’s fine. I really have no issue with that. It’s a problem focused [sic]. We’re focusing in on getting all of that tartar and junk off of there, plaque even, right? So all of it, like cement — I know you call it cementum, but it’s just cement sometimes [laughs] — So maybe you’ll do a limited evaluation. I urge you, if you’re planning on doing that, to read the code book with your doctor and see if it actually fits the bill.
Moving on. When you brought them in for the debridement — I’m sorry, when you brought them in for the evaluation, at that point, you decide what’s the pathway. And that’s when you listen to the rest of Tale of Two Hygienists podcast and find out what your clinical pathway is, especially with regards to the new perio guidelines. And I know that they’re — recently, they’ve been talking a lot about that, so go back and take a look. Listen to those podcast episodes.
Let’s talk about the conversations you have to have with the patient. Unfortunately, sometimes the hygienist is the one that has to break the news to the patient that “Look. I can’t do a regular cleaning for you, or a regular preventive visit for you, because there’s just too much there.” So the verbiage is delicate because patients do expect to come in. They don’t have a lot of time. Sometimes it actually costs them money to take time off work to come in, so we have to be really, really delicate.
My verbiage for you is, “Mrs. Jones, I wish that I could do a complete cleaning for you. I was looking forward to it. But I just can’t.” And be very honest with them. They don’t know any differently. You’re the one who’s clinically trained. Own that. Let them know “Look. That you have –” and bring out your camera. My goodness, the camera is where it’s really going to help you here. Bring out the camera and say, “I would love to, but look at this here and look at this here. If the doctor does an evaluation today, it’s going to give us false readings. We really can’t do that. It’s almost like if you were to go into your doctor, your physician, and you were looking to get an x-ray of your ribs — maybe you thought your ribs were broken — but somebody just put a big lead weight on top of your ribs. The x-rays wouldn’t tell you what it needed to because there’s too much blocking it.” I would use an analogy.
I would let them know I intended to. “We had you scheduled, but when I take a look at what’s going on health-wise with you, I just can’t. So here’s what we’re going to do. I’m going to remove as much as I can.” And trust me. Your patients are completely aware of the fact that their mouth is not normal, right? If they need a debridement, there is nobody out there that is proudly wearing all that junk. They know something’s wrong. That’s why they’re coming in for you, right? So you say to them, “What I’d really love to do is take care of this right now. We’ll send you home because you’re probably going to be a little bit sore. To be quite honest, you’re going to be a little bit sore. Let’s send you home. Let’s let all of that puffiness go away. And, then, when you come in, we’ll be able to really take a good look at things. It’s just a little bump in the road. It’s okay.” And I would say, “This happens often. Many people have this issue.”
Patients don’t want to feel, especially if their mouth is just jacked up, to be clinical, right? There’s your clinical term. If their mouth is just really jacked up, patients don’t want to feel like they’re the only ones out there that are like that or that you’ve seen them and it’s an anomaly and “Oh, my gosh.” It’s like going [gasp] “I’ve never seen that before!” You don’t want to do that. So you let the patient know this happens a lot. “Many patients have to go through this preliminary step. It’s okay. Do you have any questions for me?”
At that point, they probably have questions about finances. That’s not your purview. You kick it up front. You tell your office manager or your insurance coordinator, “Hey, you may want to come back and talk to this guy and let them know that there’s probably going to be an additional cost.” That really is the one thing that you need to know. There probably will be an additional cost.
Usually, the debridement is covered at 80 percent, whatever the basic percentage is, and then it sometimes is subject to the deductible. So there’s a really big chance that your patient is going to walk out with a co-payment or a cost-of-care share at that appointment. And, honestly, that’s okay. The patient has let their teeth go this long. It is okay for them to participate in the cost of their care. We have to remember that. Yes, we’re healthcare providers, but it’s not a non-profit. For the most part, it’s not a non-profit organization. We have to be able to not lose money when working on a patient.
Hopefully, I have given you a little bit of insight into code 4355, which is a very interesting code but, again, very problematic. Not very much a beloved code, but it is a necessary code because we do see those people come in, and they’re not eligible for their evaluation.
Share this information with your team and with your doctor and let me know if you have any questions. Until then, you can visit my website. I’ve got a lot of information. I’ve got a lot of articles and webinars on my website, odessymgnt.com. And check out my podcast if you’re so inclined. It’s called Nobody Told Me That! Thank you.
Michelle Strange: We hope you enjoyed this week’s TIPisode. Be sure to reach out to our guest experts and let them know how helpful their tips were. Follow A Tale of Two Hygienists on Facebook, Instagram, and head over to ataleoftwohygienists.com and subscribe to our newsletter. You can also email us at firstname.lastname@example.org, and keep listening for more awesome content from your unofficial dental hygiene podcast.