What Algorithms Reveal
How does a dental payor know when looking at a claim for Periodontal Scaling and Root Planing (D4341 or D4342) that the service was performed as billed, or was the right treatment plan?
When a dentist presents a treatment plan to a patient, it is assumed that the diagnosis was determined based on review of the patient’s history, an oral examination, current radiographs, and a sound interpretation of the evidence.
Relevant to periodontal disease, the scope of care considers the prevention, diagnosis, and treatment of diseases of the supporting and surrounding tissues of teeth and dental implants and to provide care to maintain the patient’s optimal oral health. According to the American Academy of Periodontology*, the clinical guidelines for periodontal care include a comprehensive periodontal examination, medical and dental history review, clinical examination, and radiographic analysis. This is what a dental review should look for when determining the appropriateness of a bill or treatment plan involving the CDT codes D4341 or D4342.
How Dental Payment Integrity Works
MultiPlan’s Dental Payment Integrity algorithms look for precisely this type and level of evidence. They combine clinical knowledge, informatics and forensics to analyze dental claims well beyond the four corners of the claims themselves. In effect, they codify the results of a clinical review performed by a specialty-appropriate dentist trained to study a claim from a number of angles, including in the context of related claims.
When the claim under review contains the D4341 and/or D4342 treatment codes, our Periodontal Scaling and Root Planing Upcode algorithm is triggered. Among the items this algorithm considers are the patient claims history to indicate that this patient has periodontal disease, any recent claims submitted that may call into question the appropriateness of re-performing the service, past recent performance of other periodontal services that would contraindicate the perio scaling and root planing service, or supplemental remarks that support performance of the treatment despite what the records suggest.
A Comprehensive Review Approach
Periodontal Scaling and Root Planing Upcode is one of a number of algorithms in our Dental Payment Integrity program. In addition, to Periodontal treatments, our algorithms cover Diagnostic, Preventive, Restorative, Endodontic, and Oral Surgery procedures. We also look for billing that reflects impossible situations that violate assumptions about available time, and that measure statistical overuse. The findings can be used to deny or downcode charges prior to payment, to educate the provider on appropriate billing and treatment plans, and/or to provide the dental payor with insight into its provider network, utilization trends and plan benefits.
*American Academy of Periodontology. Guidelines for + Periodontal Therapy. J Periodontal 2001;72:1624-1628.