All the current CDT codes that involve debridement (D1110, D4355, D4341, D4342 and D4910) have major flaws and need to be replaced.  I recommend replacing all of them with a single debridement code.  In this post, I will discuss the primary goal of debridement, some of the major flaws with the current codes, and how a single debridement code could work in practice.

No matter what the periodontal status of the patient happens to be, our primary goal is to always remove (debride) everything that doesn’t belong (plaque, calculus, stain, food, etc.) from the bottom of the sulcus/pocket to the occlusal surface of every tooth.  How you debride (polish, air polish, power scale, hand scale, etc) or how many visits it may take to debride is irrelevent.  The primary goal never changes.  Of course, ultimately, comprehensive treatment of periodontal disease (gingivitis or periodontitis) may or may not involve other procedures (e.g. systemic or locally applied antibiotics, oral irrigation, oral hygiene instruction, surgery, laser treatment, etc.), but in all cases the debridement procedure is always involved and the goal is always the same, and in my opinion, should be treated as the same procedure in all cases.

The current codes have many flaws, but for the sake of brevity, I’ll only mention a few.  One, they are confusing and ambiguous.  Ask five hygienists what qualifies for a “Prophy”, “Perio Maintenance”, Full Mouth Debridement” or “Scaling and Root Planing” and you’ll probably get five different answers.  Even well intentioned experts give us conflicting answers on this topic, which unfortunately, is completely understandable with the current system.  Two, the typical price gap for debriding a healthy patient, or a patient with gingivitis, and a patient with localized, slight periodontitis is huge, even though the time gap (and difficulty level) to complete the procedure is often quite narrow, or in some cases, the same.  Three, the ability to distinguish between gingivitis and periodontitis in theory is easy, but in practice it is impossible to do with any certainty.  Here’s why.  The accuracy of probing is plus or minus 1mm (measuring CAL when the CEJ is below the gingival margin is even less accurate), and early bone loss (or attachment loss) cannot be seen on radiographs.  So by entangling diagnoses (gingivitis vs. periodontitis) with the debriding codes only exacerbates the problem.

How can one debridement code work?  Step one, define the proposed code.  New debridement code = 1 unit of debridement.  One unit = relative effort for the average clinician to debride the average healthy adult patient.  I know that’s a pretty subjective measurement, but the only viable objective measurement available is straight time (which is not bad), but time based coding has one primary flaw.  It takes away the incentive to be more efficient (the faster I work, the less I get paid).  Step two, assess each patients’ debridement needs based on a subjective scale from 1 to 10 (level 1 = healthy adult patient, level 10 = generalized, advanced perio with tenacious calculus).  Step three, make a simple calculation.  Let’s go through a few examples to see how this works.  Example one, a patient presents with generalized, moderate “gingivitis”, moderate amount of calculus (supra and sub), plaque and light stain.  His last cleaning was 18 months ago and his homecare is mediocre.  Subjective debridement assessment = 2.  One debridement unit = $90.  So 2 units x $90 = $180.  How you tackle the debridement is based on what’s best for you and the patient.  You may complete all the debridement in one visit, or half the mouth on the first visit and the other half on the second visit, or maybe do an initial debridement in all four quads on the first visit and then a final debridement in all four quads on the second visit.  And that’s my favorite part of this system.  It allows you to essentially debride however you want without making you feel like you are committing insurance fraud, lying on the patient record, or over/under charging the patient for debridement.  Example two, patient is “healthy” overall, homecare is good, last cleaning was 3 months ago, light calculus on lower anteriors, slight recession generalized, slight bone loss generalized, light stain generalized, moderate stain localized.  Subjective debridement assessment = 1.5 x $90 = $135.

What are the chances of a system like this being implemented?  I’m guessing slim to none, but you never know!  But I think the one thing we can all agree on is that the current codes stink and need to be replaced.  Can I get an Amen on that?  

Mark Frias, RDH