How to maximize coding and billing in your hygiene department

Narrator 2: You are now listening to another episode of the Insurance Untangled podcast, where we explore the various challenges faced by dental practices due to their reliance on insurance. Join us in this podcast as we dive deep into the issues surrounding dental insurance dependence, and offer practical solutions and strategies to help you take control of your practice’s financial future.

Erica: Jen, welcome back to the podcast.

Jen: Thank you for having me. Yeah,

Erica: This is gonna be fun. We spend a lot of time talking about this topic, and yes, please. I just, you know, I just wanna have this like, behind the scenes conversation with you about what we see with regards to billing department performance, and I guess I wanna let the listeners know what we see and why they need so much help. So, in today’s episode, um, I’m pretty sure I, I’m probably gonna do some type of introduction talking about it, but I really wanted to hone in on with you, uh, is perio performance. Yeah. Like, what does that mean? Why do offices need to understand when we’re talking about a billing department? Right. Why do offices, in your opinion, need to understand what perio performance percentage is? And then I guess a second question to that is, you know, what, what does it represent?

Jen: Yeah. So I think we’ll go backwards here. We’ll start with what is Perio performance? Um, perio performance is taking your total number of patients, and then we divide your perio patients and kind of separate your perio patients. So perio maintenance, SRP, um, 4346 patients, all those patients get separated. Um, and we divide that by your total number of patients, and that gives us your perio percentage. So that tells us how many of your total patients are in a periodontal protocol program in your office. One thing that’s super important with this is that we do include the 4346, because that is the start of a perio patient. Um, sometimes they can move towards SRP or then we kind of put them into perio maintenance, whatever that looks like. But it’s super important that we include the 4346 in this periodontic performance.

Now, why we look at that is, if you look at the CDC, it says that 70% of Americans have periodontal disease.

Erica: Mm-hmm.

Jen: If we are treating on average, I mean, what we see in our office, Erica, is like our offices are like five. I mean, I’ve even seen as low as 1%. Um, we just saw that 1% of the total patients.

Erica: Yes. I know, 1%.

Jen: Of your total patients have perio. I highly doubt that. Like, so the CDC says 70% of Americans have perio. That’s a conservative number, I think, because that’s only recorded patients. Right. A lot don’t go to the dentist. A lot of people in the US don’t go to the dentist. So I think that’s a conservative number at 70%.

Yeah. Then we see these perio performances that are at one, five, 15% is probably pretty average, I would say, for what we see.

Erica: Mm-hmm.

Jen: And that tells us, you know, as a hygiene perspective, that you’re only treating 15% of perio in your practice. Now, some of those things are dependent on population, your demographics, wherever you work in your area that you work in. You know, if you work in Beverly Hills, you’re probably not gonna have as much SRP as if you work in like Nebraska, but, it’s gonna be a different thing. You’d be—

Erica: Be surprised though. You’d be surprised. I’ve worked, true, in Beverly Hills and there’s a lot of perio there too. So…

Jen: It’s true. I have treated multiple dentists actually for full, full mouth perio. So.

Erica: Right. And, and just so the audience understands, Jen is a registered dental hygienist. Um, yes. And she’s also a biller, which is why, uh, we have her, she’s one of our coaches, um, with our OP Billing Optimization Program. Yep. And, um, you know, so if you’re a new listener, you’re, and you’re thinking, well, who’s Jen and why does she know this—

Jen: Who is this lady?

Erica: Uh, she, she kind of knows what she’s talking about. She, uh, was a practicing hygienist until last year. Right, Jen?

Jen: Yeah. December is when I kind of went out of clinical practice. I still sub here and there ’cause it’s fun, but nice. Yeah. Yeah. Mostly stick to, you know, coaching and helping practices increase production and collections.

Erica: Yes. Uh, yes. So that when she says she’s treated, uh, dentists for full mouth perio, it’s because she is a hygienist. Yes.

Jen: Yes.

Erica: Let’s just be clear there. Okay. So sorry. Sorry for that. I just thought for the new listeners, maybe they should know that you’re a hygienist.

Jen: Yeah, that’s kind of helpful when I talk about all this. But yeah, so I think when we’re looking at those perio percentage numbers, um, as a hygienist, I’m looking at how, how many patients in your practice, what percentage of patients are you treating properly? And I think when, you know, when we look at ideal numbers, we’re looking at 60%, which again, 70 is conservative. So I think 60 is also very achievable.

Um, and I think we have only had one practice, Erica, that was close to that, and now they’re at that percentage.

Erica: Yes. They were at like 56%. Yeah. Which is on the higher end when we initially start working with clients. Um, I’d say on average, most of our offices are less than 10% perio performance. In fact, I just met with Dental Intel ’cause we’re potentially gonna be, um, collaborating on the reports that we give to the clients. And Dental Intel shared with me that their average client perio performance is 0.6%.

Jen: Wow. I would love to know their formula too.

Erica: Yes. For that. Absolutely. Yeah. But I mean, we’re in talks of doing something together. But yeah, the point here is that it’s not just us reporting perio performance percentage, um, as a part of the, you know, the billing department. Right. And I think that a lot of times we point that out and sometimes people get offended.

Jen: Yes, yes. So this definitely does not represent the education or the ability of the hygienist.

Erica: Yeah.

Jen: I think that’s something that we make very, very clear when we’re talking to clients, right? Like, this is not reflective of you and your hygiene department. It’s reflective of processes and systems that you don’t have in the practice.

Erica: That’s exactly it.

Jen: Yep. That’s exactly what it’s—

Erica: The whole, the whole analysis, right? Like the whole analysis that we do represents systems, lack of systems in place. Because the idea is, when you are talking about putting systems in place, it’s not about training the current team, although the team could be worth the investment. I’m not saying they’re not, but I’m just saying, as a business owner and having been a partner in two offices, I want systems in place that no matter who the hygienist is, they’re gonna follow the same system that we have in place.

Uh, and I want you to talk to us about that system and what that looks like when we’re implementing change into a hygiene department. Um, what are the most common challenges, you know, in terms of incorporating, say 4346?

Jen: Yeah, I think there’s, there’s a couple. Um, one has to do with timing. You know, if hygienists are already burnt out, they’re exhausted, they don’t have, they need to implement systems and processes, but they keep getting shut down every step that they try, you’re gonna have a lot of pushback there. And then if a dentist comes in and says, "Hey, we hired this consultant," now when this hygienist has been trying to change things and trying to implement things and they keep getting hit with a brick wall, they’re gonna be really defeated and you’re not gonna keep that staff member.

Yeah. So we really, really focus on like staff retention. Um, you know, you wanna keep the staff that you have because in this environment, this economy right now, it’s very, very hard to find staff members, including hygienists. And hygienists are producers. So—

Erica: The hygienists, more importantly, hygienists. I mean, uh, offices are really struggling to retain. And we’ll talk about that in a second, but yeah. Um, I think, yeah, you, you hit the nail right on the head when you’re, when you’re saying, look, you know, we gotta, we gotta evaluate more than just codes, right?

Yeah. When we’re trying to improve systems or the billing department as a whole, we’re not talking about just looking at codes that we can incorporate for things that we’re already doing. We’re talking about, you know, really a big overhaul. Like, how are we scheduling?

Jen: Yep.

Erica: You know, overbooking our hygienist, are we doing back-to-back SRPs? Like, we don’t wanna, we don’t wanna burn our hygienists out. They’re already burnt out for the most part.

Jen: Yeah.

Erica: Um, so talk to us a little bit more about like, when we talk to a hygienist about now incorporating a different type of cleaning.

Jen: Mm-hmm.

Erica: I think a lot of times they may get a little overwhelmed with the possibility of now we’re adding a new cleaning to the decision-making. What is it? Tracks? Yeah. Um, so talk to us a little bit about 4346.

Jen: Yeah. So there’s a lot of pressure when it comes to, um, patients. And when we’re talking about diagnosing and we’re talking about SRP and we’re saying, you have gingivitis or you have perio, now you need X, Y, Z—whatever that is that we determine that they need—it can be a huge barrier with time. Um, burnout, things that we, we already feel tired, that we’re like, this one more thing? Are you kidding?

And I think that’s what, that’s the pushback that we get a lot from hygienists is, I’m just, I’m already so tired, I’m so spent, how in the world am I gonna have another 20-minute conversation to convert this perio or this prophy patient to a perio patient?

And in that sense, we definitely wanna, um, pursue that with caution because we don’t wanna push the patient. We don’t wanna, um, bait and switch them by any means.

Jen: We don’t wanna burn out our hygienists, we don’t wanna overwhelm our hygienists. So there’s things that we can do that take off the load from the hygienist and put it back on the patient in a way that is not pushy, in a way that is, um, making the patient hold accountability for their own health and still making the hygienist feel like they’re treating them effectively.

So, you know, we, we talk about prepping the patient a lot. So we’re not gonna go in and tell you, you need to, you know, treatment plan SRPs and gingivitis patients. That’s not gonna happen. What we do is more focus on the conversation, the relationship, the trust that you have with that patient, and really capitalize on that to make it easier for you to have that conversation with the patient.

So, and it’s not a lot more for the hygienist. You know, we’ve talked to a few offices that they’re like, it really wasn’t a lot and it was already things that they were doing, but now it seems so much easier, it flows so much better, and they don’t feel like they’re pushing things, and yet they’re still producing twice as much during the day.

So it’s a huge, huge conversation to have. And not a lot of hygienists are having it for 4346. Um, and a lot of—honestly, a lot of hygienists don’t even know about this code. Like, they’ve never used it for—

Erica: For the individuals that don’t know what 4346 is, it’s a gingival inflammation is what it’s defined as in the CDT book. But we call it the gingivitis cleaning, or as Jen likes to refer to it, you like to refer to it as a therapeutic prophy.

Jen: Yeah.

Erica: Yeah. Yeah. So I agree with you. Not a lot of hygienists even know about this code. Um, but I love the way you describe integrating this code. Do you always—and I, I can say I’m like a parrot, right? When you say something, I repeat it. When Tessa says something, I repeat it. Like, I feel like I learn around you guys all the time, but—

Jen: Oh yeah. Constantly learning.

Erica: Always tell clients, you know, and I’m sure you guys can do the same with some of the things that I say. Like we all have our—

Jen: Oh yeah, I’ve said your things too.

Erica: —deliveries. Um, so like, I love how you explain to the hygiene teams that you work with, that the 4346 is a bridge. It gaps the—you say it better. Why don’t you go—

Jen: It bridges the gap.

Erica: There we go.

Jen: Patient-involved patient. So it’s that patient that comes in that always has gingivitis, always has inflammation—just like, what? Like why can we not get on top of it? And there’s a lot of reasons.

And that also contributes to your burnout, right? Like, if you’re constantly treating gingivitis and you’re just like, why are they not getting better? That’s why—you don’t have the right systems in place. You don’t have more frequent recalls. You don’t have the correct, you know, um, processes in place to treat this patient. So you’re not totally burnt out every single time you see them and wondering why they’re not getting better.

Erica: Exactly.

Jen: So this code bridges that gap between a very healthy individual that’s a prophy patient and the patient that comes in and needs SRP. We’re making it more doable for hygienists and, honestly, a more appropriate code to treat patients that have gingivitis. They’re not SRP, they’re not healthy—like where do they fall? And that’s why the ADA came up with this code.

Erica: So I’m thinking that there’s some offices, there’s some people out there thinking, "Our patients will never go for this," because there might be a copayment involved with this code. And let’s be honest, sometimes there is. But when a patient has perio, we don’t think twice about charging the patient their copay. We just do it.

Um, you know, when there’s a copay for a filling, we just charge the patient. So what do you say to individuals who are thinking to themselves right now, "Our patients will never go for this"?

Jen: Yeah. So that’s where that prepping the patient conversation comes into play. Um, if you get to the end of your appointment and your patient isn’t convinced that they have gingivitis, that’s kind of on you. So we go through systems again, you know, step one, step two throughout the entire appointment that say, you know, kind of put things back on the patient. We ask them questions, we involve them in the diagnosis.

So then by the end of it, they’re like, "I have gingivitis. How do I treat this?" Right? And that’s the goal. That’s the goal, is they need to be accountable. And I always say this: you’re not responsible for going in and brushing their teeth every day. You’re not responsible for flossing their teeth every day. You’re not responsible for their finances. So—and we can’t automatically assume that they can’t cover anything or can’t pay for their copay.

Jen: Right. So we wanna be really careful with assumptions in a practice and just tell them what they need clinically.

When we’re talking about finances—I am a cheerleader for front office. I love great front office. They are the bread and butter, I swear, of a dental practice. They are my best friends typically. Um, because when hygienists and front office are able to work together symbiotically, it’s like harmony in the practice.

Erica: Magic.

Jen: Yeah. It’s beautiful, and it’s a wonderful way to work. And so that takes the pressure off of the hygienist of, "Oh, now I have to talk about money."

Jen: Dentists, if you’re listening, please don’t make your hygienist talk about money. Let them do clinical work and let them focus on the patient. You’re able to have that conversation and the trust with the patient. So typically if there is pushback with the 4346, I always say, you know, I’m not really sure. All I can tell you, if they ask for a cost or whatever, I’m just gonna say, "I’m not sure. All I can tell you is that this is what I see today."

And then I go back to the clinical information. And then I say, "If you’re concerned about that, we can have our front office come talk to you about any costs involved." But honestly, most of the time when I say that, by that point, they’re like, "Oh no, it’s okay. I’m gonna do it anyway."

Erica: And then—

Jen: We don’t even have to have that conversation.

Erica: —they have taken responsibility. You’ve done your job as a clinician, as a hygienist, you’ve explained what is going on in the mouth. They have accepted responsibility for it, and, um, you know, that the coverage is no longer a concern.

Now, there are gonna be some patients that are still gonna be insurance-driven and only wanna do what insurance covers. And that’s okay. And at that point, I think it’s up to the office to decide whether or not, you know, they want to keep a non-compliant patient.

You know, ’cause you do have those very difficult non-compliant patients that just wanna do what insurance covers. And, um, that’s a whole other conversation.

Jen: Yeah.

Erica: I don’t wanna get into that right now. But I do also wanna point out that there can be times when there are copayments associated with 4346. However, we are noticing—on the flip side—we are also noticing that more and more insurance companies are covering 4346 as a preventive procedure. So, at 100% they’re—

Jen: Yeah.

Erica: And talk to us a little bit about why you think that’s happening.

Jen: Yeah, so I think insurance companies are starting to realize that offices are using the 4346. They are recognizing that if they treat it at this point at a preventive level, they don’t get to that SRP stage, and then they don’t have to pay more frequently for perio maintenance and everything else.

So, I mean, as hygienists, right, we’re always looking at preventive measures that we can do. This just kind of falls in that category. Yes, they have the start of disease, but it’s still reversible. So—and insurance is starting to notice that. So they’re like, "Oh, it’s still reversible. Let’s pay for this one." Yeah, maybe two times. You can do it twice in a year. It doesn’t have to be like a one-and-done type of thing.

But I think they’re starting to recognize that and they don’t wanna pay down the road.

Jen: So they’re starting to see that 4346 is valuable.

I will say, you know, Erica, you and I have talked about this before, but some insurance companies and some doctors have reported that 4346 is getting reimbursed at a lower rate than prophy. But when we look at the numbers and we take a look at your total numbers for 18 months, right? We’re looking at your average reimbursement. So that can be cash-paying patients, that can be other insurances that you’re out of network with—all of those things factor into it too.

So in total, you’re still getting reimbursed more for 4346.

Erica: Oh yeah, absolutely. And—

Jen: And I wanna make that very clear because it is more—it’s more work for the hygienist and it is more of a conversation.

Erica: And the question then that I get when I’m having this discussion at, say, a live event that we’re hosting, and, you know, I always get one or two doctors that will stand up and say, "But," and it’s always Delta—"Delta Dental reimburses us less for a gingivitis cleaning than for a prophy. Therefore, why would we not bill for a prophy?"

Jen: Yeah. So thanks, Delta Dental, for encouraging us.

Erica: Thanks a lot, Delta. I mean, it’s almost like you’re asking these doctors to commit fraud. Not saying that they do—no—but I mean, it’s hard enough with low reimbursement, and now you’re saying for the office to bill for something that, you know, is gonna get us reimbursed for less than a prophy… you know… so the question becomes, well, what do we do when that happens?

And that, my friends, is when you go back to the last episode with Tessa Bullock, and she talks about getting the insurance commissioner involved. And, um, you know, I have taught how to appeal claims for so many years, and I learned of Tessa’s technique, um, not too long ago, and I just cannot stop advocating her method.

Now, I also was a big advocate for getting the insurance commissioner involved—I just took a little bit longer to get the insurance commissioner involved. I like how she cuts out the middleman, and we just get straight to the point.

So when these patterns start to emerge in a practice where you’re trying to improve perio performance percentage, you’re trying to educate your patients, you know, you’re doing all the things, and then insurance comes back and says, “Oh, we’re gonna pay you less than, you know, a prophy.” Yep. Then we need to start reporting those types of patterns of abuse, right?

Jen: Bullying. Bullying.

Erica: This is a more invasive procedure, and we’re getting paid less for than—uh, uh—what am I trying to say here—for a prophy.

Jen: Right?

Erica: We’re not doing prophy, so we wanna get paid for the more invasive procedure. We wanna get paid more for that. I mean, it makes sense, right?

Jen: Yeah. Yeah. Well, you’re still treating disease. It’s just not periodontal disease. It’s gingivitis. But you’re not treating full-on disease. But at the same time, it is the start of disease. So you are treating something. With prophys, you’re just preventing disease. So it’s not apples to apples.

And I think that’s where insurance companies are really falling short—is they’re not seeing the comparison between the two. And that’s where they need us to educate them and tell them why this procedure needs to get paid at a higher rate. You know, because X, Y, and Z. And we fight them on that.

And also, it all comes down to—and you preach about this too, Erica, all the time—but billing what you do. You know, if you are doing a gingivitis cleaning, honestly—I mean, I know it sucks—but the insurance is gonna pay less, but you’re doing it. So document it. Bill for it correctly.

And also, on the flip side of that too with insurance, they’re gonna see that, oh, the offices are billing 4346 a lot more, at a way higher rate. And how are they gonna know if we just keep pushing out prophys all the time? They’re gonna say, “Oh well, you know, 90% of our claims are prophys, so we’re gonna pay prophys at a higher rate.” Right?

It’s just—it’s all insanity to me, but—

Erica: It’s a whole ecosystem. And we all have to do our part.

Jen: Yeah.

Erica: You know, for the overall good, right? So, yeah.

Um, Jen, I wanna—I just—so for the offices that have just learned about 4346, right? So they’re like, “Whoa, I didn’t even know this code existed.” What should they do now? What type of conversation should they have with their team? You know, like, what do you suggest they do now?

Because now they’re like, “Okay, I’m aware of this code. I have no idea what to do with it. I know Jen said gingivitis, and I heard all that, but what is that one action item that you would suggest an office that just learned about this code do?”

Most of my listeners are listening on the way into the office.

Jen: Yeah.

Erica: Yeah, they’re about to walk into their office.

Jen: In their commute. Yeah.

Erica: Yeah.

Jen: Yeah. So I would say the very first thing is to read the ADA code book description for 4346. 

Closing Thoughts 

Erica: Oh my gosh. Yes, yes, yes.

Jen: Um, and if you—

Erica: Don’t have it, go buy it.

Jen: —go buy it. Or even just look it up online. Say for D4346 ADA code description, um, and read that and see exactly what it is that we’re talking about. Because that’s your first step. If you—you don’t know what you don’t know, right? So let’s figure out what that is. And then, um, like you said, we’ll talk about 4346 a lot more, but there’s a lot of, um, kind of criteria for that that we wanna go into—so where you can be compliant, um, as well as bill correctly and document correctly. So, but that would be my number one tip: go look it up, research it, and, um, know the criteria for billing.

Erica: And if you have any questions pertaining to perio performance or anything related to hygiene and you want to connect with Jen—Jen, why don’t you let the listeners know how they can connect with you?

Jen: Yeah. So right now, uh, I think the best would probably be email. So that’s jen@hiddendentalprofit.com.

Erica: So with that, we’ll close out and, uh, yeah, we look forward to having everybody join us in the next three episodes. This is gonna be a lot of information.

Share this episode with an office that you feel could benefit from this information. And we’ll see you in the next episode, friends.