FULL MOUTH DEBRIDEMENT TO ENABLE COMPREHENSIVE EVALUATION AND DIAGNOSIS
The gross removal of plaque and calculus that interfere with the ability of the dentist to perform a comprehensive oral evaluation. This preliminary procedure does not preclude the need for additional procedures.
© 2013 American Dental Association
- Full mouth debridement (D4355) is justified when the comprehensive oral evaluation (D0150) or comprehensive periodontal evaluation (D0180) cannot be performed due to excessive and bulky calculus, heavy plaque, and debris buildup.
- A comprehensive oral evaluation (D0150 or D0180) should follow the full mouth debridement on a subsequent date giving the debrided area sufficient time to heal/react to the D4355 treatment so that an oral evaluation may be performed. The D0150 or D0180 would follow on the subsequent treatment date. D4355 is ONLY a paid benefit in 25-33% of contracts when sequenced perfectly.
- D4355 is not a definitive treatment. It is preparatory in nature. The procedure is performed to prepare the mouth for a subsequent oral evaluation. The patient may or may not be a patient that will require periodontal treatment. Either a prophylaxis (D1110), scaling and root planing (D4341/D4342), or referral to a periodontist follows this preliminary D4355 procedure.
- Do not report D4355 as a “first visit prophy”. This preliminary procedure is provided so that a comprehensive oral evaluation (D0150/D0180) and diagnosis may be completed at the second visit. The patient could be either a perio or non-perio patient.
- It is inappropriate to report D4355 following periodontal maintenance D4910, unless the patient has been absent from the practice for such a long period that a new oral evaluation cannot be performed due to excessive plaque and calculus that interfere with the ability of the dentist to perform a comprehensive oral evaluation. D4910 always follows osseous surgery (D4260/D4261) and generally follows periodontal scaling/root planing (D4341/D4342) or gingival flap surgery (D4240 or D4241). See D4342 for a possible exception where prophylaxis ( follows SRP (D4342) in very limited circumstances.
- Full mouth debridement is a full mouth procedure.
- Full mouth debridement is performed when heavy buildup of plaque and calculus makes the completion of a comprehensive oral evaluation (D0150 or D0180) impossible. It is important to note that D4355 is a preliminary procedure.
- A definitive procedure (D1110 or D4341/D4342) will be necessary after the completion of a comprehensive oral evaluation (D0150 or D0180).
- The sole purpose of full mouth debridement (D4355) is to “pave the way” for the oral evaluation by removing the “roadblocks” and to allow for preliminary healing. The roadblocks being: excessive plaque and calculus that interferes with the dentist’s ability to perform a comprehensive oral evaluation. This preliminary debridement should be performed prior to the comprehensive oral evaluation (D0150) or comprehensive periodontal evaluation (D0180). If the evaluation cannot be completed due to the plaque and calculus buildup, an evaluation should not be submitted on the same service date as D4355. The evaluation would be completed on a subsequent date. Preliminary data may be gathered and recorded at the first visit. D4355 is not typically reimbursed by payors when submitted on the same service date as a comprehensive oral evaluation (D0150) or comprehensive periodontal evaluation (D0180). Note: A comprehensive oral evaluation D0150/D0180) may be submitted on the same service date as the D4355 but D4355 will most likely not be reimbursed.
- Proper sequencing of D4355 is very important for reimbursement. Improper sequencing results in either a denial or a “remapping” to a different code. For instance, many payors will remap the full mouth debridement (D4355) to a prophylaxis (D1110). In this scenario, when a subsequent prophylaxis (D1110) is submitted, the payor denies reimbursement, stating a prophylaxis within the typical “one per six-month” limitation period has already been reimbursed. If the comprehensive oral evaluation (D0150) or comprehensive periodontal evaluation (D0180) is performed prior to full mouth debridement, many payors will convert the D4355 to a prophylaxis (D1110) for reimbursement purposes and limitations apply.
- When D4355 is reimbursed, it may be classified as preventive, basic, or major, but most often D4355 is classified as preventive. In some cases, a plan deductible may apply. Plan limitations are highly variable.
- When a comprehensive oral evaluation (D0150 or D0180) cannot be performed due to plaque and calculus that interfere with the ability of the dentist to perform a comprehensive oral evaluation, a full mouth debridement and full series or panoramic diagnostic radiographic images (optional) are performed at visit #1. A healing period of 14 to 21 days should follow D4355 to allow resolution of the gingival tissue. The comprehensive oral evaluation is then completed at visit #2. Generally, diagnostic radiographic images (pan or full series) can be taken at the first visit in conjunction with the full mouth debridement (D4355) without effecting reimbursement.
- Plan limitations regarding frequency of full mouth debridement (D4355) are highly variable. Limitations vary from “once per lifetime” to once per every three to five years.
- Some payors will reimburse full mouth debridement (D4355) when reported as D4999. Some payors may reimburse D4355 by “remapping” the service as Palliative (D9110). See TIPS below and also refer to palliative (D9110) for further details.
- Under current nomenclature, there is no alternate classification code for a second prophy or a “difficult” prophy. To report a “difficult” prophylaxis requiring additional time, simply report D1110 at a higher fee. Note that PPO contracts limit reimbursement for D1110 to the contracted fee regardless of the time required to complete a difficult prophylaxis.
- A narrative should be used when reporting D4355. That narrative might read: “Patient has not seen dentist in three years. A full mouth debridement is necessary for a subsequent comprehensive oral evaluation”. The narrative should describe excessive plaque and calculus. The narrative should be specific as to how condition was preventing an evaluation. Include photographs and radiographs showing heavy plaque and calculus.
- Sequence properly for best reimbursement.
- Palliative (D9110) may possibly be reimbursed for partial mouth debridement under an acute and spontaneous discomfort scenario. If reimbursed, it generally reimburses at a lower fee than D4355. The use of the palliative D9110 code may result in paymkent for non-PPO contracted offices, since the patient pays any balance of the fee. See D9110 for comments.
- If unable to perform a comprehensive oral evaluation (D0150/D0180) due to excessive buildup of calculus and debris, proceed to a gross debridement to enable comprehensive oral evaluation (D4355).
- Necessary diagnostic films may be taken on either/both gross debridement (D4355) or comprehensive oral evaluation (D0150/D0180) service dates. For instance, a panoramic film (D0330) on the gross debridement (D4355) service date and four bitewings (D0274) on the subsequent comprehensive oral evaluation (D0150/D0180) date may avoid “remapping” or downcoding to a complete series (D0120), UCR fee.
- The comprehensive oral evaluation (D0150 or D0180) should follow gross debridement (D4355) on a subsequent service date, with a suggested interval of fourteen days or more for healing. Reimbursement for D4355 is only available from about 25% – 30% of insurance contracts, so inform the patient of potential responsibility for out-of-pocket costs. See also palliative D9110 as a possible alternative if the patient has discomfort.