The Dental Billing Podcast

Episode 88: How to Bill D4346 - From Bloody Prophy's to Perio Conversions

• Ericka Aguilar • Season 11 • Episode 8

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Are you leaving money on the table while your patients remain undertreated? After analyzing over 300 dental practices across the country, I discovered a shocking truth: the average dental practice with a full-time hygienist treats only 17% of the periodontal disease they diagnose. That means 83% of diagnosed disease goes completely untreated—a staggering gap between diagnosis and care.

This episode dives deep into the "hidden opportunity" within your hygiene department by exploring D4346: scaling in the presence of generalized moderate to severe gingival inflammation. This often-misunderstood code bridges the critical gap between a standard prophy (D1110) and scaling and root planing (D4341/D4342). For patients showing clear signs of gingivitis without bone loss—bleeding on probing, inflamed tissue, pseudopockets, and plaque that doesn't respond to routine cleaning—continuing to perform prophies isn't prevention; it's undertreatment.

I walk you through a comprehensive, step-by-step process for properly implementing D4346 in your practice, from accurate diagnosis and bulletproof documentation to effective patient education and ethical billing. We cover common challenges including insurance downgrades, particularly when carriers like Delta may pay less for D4346 than for a prophy, and how to handle these situations without compromising ethics or revenue. The key message: this code is based on diagnosis, not difficulty or time spent, and represents therapeutic care designed to heal tissue, not maintain it.

Whether you're a dental biller, office manager, hygienist, or dentist, this episode provides practical guidance for transforming your approach to gingivitis treatment. The benefits extend beyond proper coding—you'll deliver better care, improve patient outcomes, and optimize practice revenue. Pull a few charts this week and see how many of your "prophy patients" actually qualify for D4346. The results might surprise you.

Want to learn Dental Coding and Billing? Join here:

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Would you like to set-up a billing consultation with Ericka? She would love the opportunity to discuss your billing questions and see how Fortune Billing Solutions may help you.

Email Ericka:
ericka@dentalbillingdoneright.com

Schedule a call with Ericka:

https://calendly.com/ericka-dentalbillingdoneright/30min


Perio performance formula:

(D4341+D4342+D4346+D4355+D4910)/(D4341+D4342+D4346+D4355+D4910+D1110)





Speaker 1:

Hey friends, welcome back to another episode of the Dental Billing Podcast. I'm your host, Erika Aguilar. Before we dive into today's episode, I wanna tell you a little backstory. Before I started Fortune Billing Solutions, I worked with offices across the country to analyze their billing departments. I wasn't just logging into fixed claims or post payments like we do today. I was actually studying patterns. What I noticed over and over again was that most billing opportunities were hiding right inside the hygiene department. I started documenting everything. I created a methodology to measure perio performance percentage, meaning how much diagnosed perio is actually being treated in the practice. After about 300 practice analysis that I performed, I found that the average dental practice with at least one full-time hygienist was treating only 17% of the perio that they diagnosed. Let that sink in. Benchmarks for perio performance vary from. I found it to vary from 60 to 80%, but honestly, that doesn't even matter when you're only treating 17%. That number shocked me and it led me to ask a bigger question why are we treating so little of the disease we diagnose? And the answers were endless. I found that hygienists aren't given enough time to properly diagnose or reclassify a patient, and we're going to talk about that here in this episode. Most teams aren't even aware of the full range of codes, like 4346 or 4342. The default is typically to bounce between D1110 and D4341, missing the nuance in between Low fee schedules that are discouraging, scheduling longer or additional hygiene visits, and a lot of providers are just simply backed up and have no margin to slow down and reassess. And, honestly, friends, this list can go on and on. That is why this episode matters. It might sound clinical, but I want you to know up front. I'm speaking about this from a biller's perspective, from someone who has analyzed literally hundreds of billing departments, from someone who knows where the money is missed and from someone who has seen the impact that accurate coding and proper perio conversion can have. Today we're going to talk about 4346, scaling in the presence of gingival inflammation, and how you can ethically and confidently reclassify prophy patients when there is active disease.

Speaker 1:

Now let's go back to the basics, because here's where the confusion usually begins. What is the difference between prophylactic and therapeutic? When you think of D1110, your standard adult prophy, it's prophylactic in nature. This means it's designed to prevent disease. It's intended for patients with generally healthy periodontium Maybe a little localized inflammation here and there, but nothing major. Your hygienist is most likely removing minor deposits, maybe a little bit of staining, and polishing up that patient to get them back in good shape. But what happens when the patient is already in a diseased state? What happens when there's generalized inflammation, bleeding on probing, two to four millimeter pseudopockets rolled or bulbous tissue and plaque accumulation? That is just not responding to a routine cleaning. That is not prevention anymore, my friends, that is treatment. Prevention anymore, my friends, that is treatment. And when we keep doing a prophy on a patient with active disease, we're not helping. We're just polishing inflamed tissue. It's like waxing a dirty floor. That's not standard of care. That is under treatment. And that's when we need to shift from preventive to therapeutic.

Speaker 1:

D4346 is a therapeutic code that bridges that gap. It was created for this exact gray area, for patients who don't necessarily have bone loss so they don't qualify for SRP but they also don't have a healthy periodontium. There's a place that we call limbo of disease between generalized, moderate to severe gingivitis, and what they need isn't just a cleaning. They need scaling that addresses inflammation. This is where D-43-46 comes into play. This is a therapeutic service, it's a treatment plan and it's performed after a full evaluation designed to heal tissue, not to maintain it, and I'm going to say that again for all of you in the back, because I want everybody to hear this loud and clear 4346 is a therapeutic service designed to heal tissue, not to maintain it like a prophy. So if you've been using how much time you've spent with the patient or how hard the cleaning was as the indicator friend, you're missing the point. This code is based on diagnosis, not difficulty.

Speaker 1:

Now that we have set the foundation, let's get into the step-by-step process to identify, document, bill and deliver 4346 the right way. Okay, so let's get into step one. We need to call out the problem. Let's set the stage. You've got patients with bleeding on probing, inflamed bulbous tissue, plaque sitting on the margins, two to four millimeter pockets, but no bone loss on the x-rays. You're doing pro-fees on these patients every six months and it's not working. These patients are not healthy, they're in a disease state and what we're really doing is ignoring the diagnosis and under treating. It's time to stop calling it a hard prophy, a bloody prophy, and start calling it what it is scaling in the presence of generalized, moderate to severe gingival inflammation. That's 43-46. So that's step one.

Speaker 1:

We first need to call that problem out and stop ignoring the fact that we are treating gingivitis patients as prophy patients, treating them with a preventive treatment as opposed to a therapeutic one that restores and heals heals. Step two is they are the experts, and I clicked up with them because I wanted to understand these patterns that I was seeing in these practices and understand why there is such a low perioperformance percentage in terms of utilizing all of the codes that we have available to us. I've also noticed that a lot of hygienists I've surveyed literally hundreds of hygienists and asked them you know, do they go subgingival during a prophy and do you document moderate bleeding during a prophy? And a lot of times it's a yes, and a lot of times a hygienist is unaware that there's even a code that more accurately describes what they're doing. So, before I get into the diagnosis of the disease, I want you to understand there's still a lot of mystery around this code and the procedure that bridges the gap. As Jen usually says, she says this code bridges the gap between a prophy and a periopatient. Says she says this code bridges the gap between a prophy and a periopatient.

Speaker 1:

Before we can reclassify our prophy patients, we need to be absolutely clear about the diagnosis. This is not SRP territory yet, right, Because we know that gingivitis is a reversible disease. But when they move up the ranks into perio, that's no longer reversible. So there's no bone loss, there's no attachment loss. What we do have is generalized gingival inflammation in 30% or more of the mouth, bleeding on probing in multiple sites, two to four millimeter pseudopockets, rolled or bulbous margins, redness, edema and inflammation all need to be present with no bone loss, no attachment loss. According to the ADA guide to reporting 4346,. This code is for full mouth therapeutic scaling after an oral evaluation. When there is no bone loss but generalized inflammation present, you gotta stage it and grade it. For gingivitis that's usually stage one, grade A, slow rate, no risk factors. So now that we know how to diagnose it, step three is to chart it. Chart it like you mean it.

Speaker 1:

Let's talk about documentation. If you're going to shift patients from prophy to perio, your notes, your clinical notes, specifically need to be bulletproof. That means that full periodontal charting needs to be present with pocket depths bleeding on probing, listing recession. Our x-rays need to confirm the absence of bone loss, right? So that's the key term there, because when we're talking about periopatients and we're submitting a claim. For SRPs it's the opposite. We have to have x-rays that confirm bone loss, but in this case for 4346, we want to make sure that we have x-rays proving that there was no bone loss. We also want to be smart and take some intraoral photos and capture the inflammation, the redness of the gums. That all is supporting documentation proving the necessity of this procedure. We also want to include gingival descriptions, like the color, the consistency, the margin shape, and note any pseudopockets or plaque levels. Remember that 4346 is not billed alongside a prophy or SRPs. This is a standalone therapeutic code, so we want to make sure that we understand that.

Speaker 1:

Step four is probably in my opinion, because I've worked with and coached many offices on what we refer to as perio conversions I think when we get to the stage that now we need to educate and empower our patients so that they understand that they no longer qualify for a regular cleaning. We can't just spring this on them at checkout. This is a conversation that has to happen. It can't be a surprise charge to them. So we have to be very intentional around how we introduce the fact that they are showing signs and symptoms of active disease right. So one of the ways that we do that is by showing the patient and talking to them about the fact that they're showing the signs of active gum disease in more than 30% of their mouth and that this disease is called gingivitis.

Speaker 1:

We hear about it in all of those toothpaste commercials and everybody's talking about preventing gingivitis and gingivitis is always mentioned. So you know that your patients are aware, or at least they've heard, of gingivitis. So if we keep doing a standard cleaning, we need to let them know that we're just polishing on top of inflammation and it's going to continue under the surface. And today we are going to recommend a more therapeutic cleaning and one that's going to treat the inflammation and help you heal. We want to emphasize that this treatment is therapeutic in nature and we are going to try to reverse this disease so that we can go back to that regular cleaning. However, if it continues to progress, we want the patients to understand that next level is going to be periodontal disease and once you are in the perio stage, it's very, very difficult, if at all, to reverse perio. We are putting the patients in the light of taking responsibility for what's going on in their mouth because they need to participate in the healing phase, so that cleaning is just the beginning and the home care is going to make or break how they proceed. So are we going to go into perio phase? Are we going to go back to regular cleanings and then explaining to them that there could be some out of pocket if insurance does not cover it at 100? But patients will care more about getting healthy than you think if you educate them. Education is everything and I find that this area of perio conversions, this is the hardest area for teams when we're talking about implementing 43-46. Hardest area for teams when we're talking about implementing 4346.

Speaker 1:

We also want to, moving into step five, execute in the treatment protocol. We have an ideal flow based on a standard periodontal protocol and I know a lot of offices don't have this, so it's more of a if this, then that type of perio protocol, and the first thing that we're going to do in our treatment protocol is to confirm the absence of bone loss in the x-rays. Then we're going to perform a full perio chart. Then we're going to perform a full perio chart. We're going to then do 43-46, assuming this patient needs that, We've done your standard protocol. Whether you irrigate or use the laser, whatever your protocol is. We are going to then provide OHI to the patient in detail, because we really want to emphasize that home care is really going to be the make or break. And then we want to set the patients up for a six-week re-evaluation. And this is the moment of truth have they improved or is this progressing into periodontitis? Okay, so, moving into step six, we need to know when to escalate from a 43-46 into SRPs. And so now we're getting into more of what we refer to as perio protocols and establishing what we do if the patient progresses, Because not all gingivitis cases resolve.

Speaker 1:

Some patients come back with bleeding, 5 millimeter pockets and now bone loss. This is where your 43-46 protocol ends and scaling and root planning begin. 46 protocol ends and scaling and root planning begin. You only use 43-41 and 43-42 once there's clinical attachment loss. That's when the tissue has detached and migrated apically, confirmed with probing and x-ray. Don't bounce back and forth between prophy and SRPs. Follow the disease, not the benefit plan, and I'm going to talk about that in a second Step.

Speaker 1:

Seven, we're going to talk about billing and documentation tips. So this is where we're going80 as your evaluation for 4346. If the patient is diagnosed with gingivitis or perio, that's when you want to use D0180. A lot of people will ask me you know what's the difference between 150 and 180? The difference is that, though you're doing pretty much the same thing, 1-5-0 does not require the patient to be diagnosed with disease. If you bill 1-8-0, the requirement is that the patient has to be diagnosed with disease, specifically perio gingivitis. If you are billing 1-8-0 and the patient is not showing signs and symptoms of perio, you are using the wrong code. So you want to be careful with that and knowing that, although they look very similar, when you're reading the descriptor of these codes, there is a difference with requirements. So when you are doing 4346, 4341, 4342, you want to use the 180 evaluation code. When they're diagnosed with those treatments with that disease, Document everything periocharting, your x-rays, tissue descriptions.

Speaker 1:

We want everything to support dental necessity. If you take intraoral photos, I always send those with the claim. And then we also want to have clear clinical notes. Patient presents with generalized moderate gingivitis with more than 30% bleeding on probing and pseudopocketing, no bone loss visible. Radiographically scaling in the presence of gingivitis is medically necessary. We want to make sure that our documentation is super clear and make sure that that is noted in your clinical documents, your clinical documentation, so that we can prove once again dental necessity and finally know your fees billers.

Speaker 1:

This is not a discount prophy. Your 43-46 should reflect the time, skill and value of therapeutic care. It's not a discount. It is not a difficult pro fee. It is a more invasive procedure and we want to make sure that our fees are reflecting that. Now let's talk about some real-world scenarios and payment challenges and downgrades that are associated with 4346.

Speaker 1:

With 4346. I want to talk to you about something that comes up in most every live coding and billing workshop that I teach. What happens when Delta pays less for 4346 than they do for 1110? So what happens when any insurance company, for that matter, but Delta always comes up in my workshops, which is why I use Delta often what happens when 4346 actually pays less than 1110? I have a few answers to that. Offices tell me that they're tempted. I've even had doctors themselves stand up and openly admit to billing a prophy, billing for a prophy, when they know 4346 was performed, and they do that to get paid more. And honestly, I get it. It feels like the insurance company is undervaluing what you're doing. But here's the thing you can't misrepresent what you actually did. The ADA code of ethics is crystal clear. Right, you must bill for the service provided.

Speaker 1:

D-4346 is a therapeutic treatment, not a preventive polish. If you document and perform 4346, then bill for 1110 just to get higher fees becomes an ethical violation and this not only turns into insurance frustration, it can even turn into insurance fraud. So always code and bill for what you do, regardless of the fee schedule dictating how you're going to bill. Now what if the insurance does allow 4346 but chooses to downgrade the payment to what they would allow for a prophy? That's a different story. Like with any downgrade fillings crowns, you charge the patient the difference between your fee and what the insurance allows if they are downgrading. Or in other words, you charge the patient the difference between what you did and what the insurance is actually paying for. So if your 4346 fee is 210 and Delta only allows 140, based on reimbursing for a downgraded pro fee, you collect the remaining $70 from the patient.

Speaker 1:

Keep it simple, clean and ethical, and that's why it's critical to ask better questions during insurance verification. You need to know if this plan will cover 4346A, will they downgrade it B, and what are the frequency limitations. Some plans are going to alternate 4346 with 1110, meaning the patient can only get one or the other within a certain time frame. Others are going to allow both. The point I want to make here is that there's no standard answer because these plans are designed by employers, so always verify what the parameters are around 43-46. Lastly, be prepared, have a system for when you have a prophy patient in the chair but during your exam you uncover signs of disease that warrant 43-46.

Speaker 1:

This is not a problem. It's what we call a perio-conversion. If you recognize it, document and educate the patient in real time, you will then be able to correct the code confidently. There you have it, my friends a full breakdown of how to ethically, confidently and clinically convert your gingivitis patients out of a prophy category and into the proper care that they need. When we know better, we do better right. This isn't just about higher reimbursement. It's about delivering the right care at the right time and saying goodbye to the days of prophy everything.

Speaker 1:

I want you to pull a few charts this week. Look at your prophy patients and determine how many of them meet the criteria for 4346. You'd be surprised. This is what I did all day, every day, when I was analyzing hundreds of billing departments. I would always go straight to hygiene notes and then take a look at how the prophy was documented. Go take a look at the perio chart. Typically, what I would see is prophy's documented with moderate bleeding, and then I would go over to the perio chart, which would support either perio or gingivitis. If this episode helped clarify things, share it with your friends who need to hear it, and don't forget to subscribe. We've got more of this coming and until next time, keep up the good work.

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Ericka Aguilar

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