The Dental Billing Podcast

Debunking Hygiene Billing Myths with Jennifer Lyman, RDH - Part 3

• Ericka Aguilar • Season 9 • Episode 3

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What if everything you thought you knew about dental hygiene billing was wrong? Join us for an eye-opening discussion with Jen, a veteran hygienist turned billing expert, as she uncovers the hidden intricacies of dental billing and the imperative role of accurate documentation. From debunking myths like the impossibility of combining SRPs and prophylaxis to the critical need for detailed perio charting, Jen provides actionable insights that can revolutionize how you approach patient care and billing.

We also delve into best practices for addressing periodontal disease, exploring why a significant portion of your patient base should be receiving more specialized care. Learn about the common pitfalls in hygiene billing—from overlooked services like desensitizers and local anesthesia to the importance of standardized protocols within hygiene teams. Thanks to Jessica's dedication, discover how implementing cohesive guidelines can lead to a more efficient practice, better patient outcomes, and increased job satisfaction for hygienists. Don't miss this chance to enhance your practice’s efficiency and patient care standards.

Want to learn Dental Coding and Billing? Join here:

https://tr.ee/efzYrY7mp-

Would you like to set-up a billing consultation with Ericka or Jen? We would love the opportunity to discuss your billing questions!

Email Ericka:
ericka@dentalbillingdoneright.com

Email Jen:
jen@dentalbillingdoneright.com

Perio performance formula:

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


Want to know what your fee should be for D4346? Send Ericka an email to ericka@dentalbillingdoneright.com


Speaker 1:

And I want to now move on into the hygiene portion of the webinar. So we've got some rock star hygienists that we're going to talk to. Jen, we're going to start with you, and why don't you tell us a little bit about what you do and a little bit about you?

Speaker 2:

I know everything.

Speaker 2:

I am a hygienist, so I've been a hygienist for about 15 years or so. During the COVID timeframe, when everything was crazy, my husband was deployed. I needed to figure out a way to stay home with my kids during that whole homeschool chaos. So I ended up helping start up a dental practice from day one credentialing, billing, all of that and doing hygiene and front office all at the same time. So it was kind of chaotic.

Speaker 2:

We also started during COVID, so I did that work part-time and kind of built up my knowledge and now I own a medical and dental billing company so we help practices with hygiene coaching and billing and implementing diagnosis codes and Medicare DME, all of it. So I even have some eye doctors I bill for and STs and OTs, so very well-rounded in the billing industry and it's really fun to see the connection between dental and medical as the years have progressed. Now currently I do a lot of hygiene consulting and billing and even software services. So like I'm pretty well-versed on open dental, so I'm happy to help with that if there's setup issues, anything like that. But really what I love doing is educating offices on what hygiene is supposed to be in a practice for a healthy practice financially and healthy patients. So that is my number one goal and that's pretty much what I'm going to focus on today.

Speaker 1:

Awesome, okay, so let's start with your myth, and I know I stole a little bit of your thunder and I'm sorry, I didn't mean to but your myth is you can't do D-43-42, limited SRPs the same day as a prophy.

Speaker 2:

Yes. So the very beginning, you can't do. I absolutely hate those words in clinical practice, because we are saying you can't do because of an insurance, contractual obligation, whatever that is as a clinician for the patient, you can do whatever you think is medically necessary for that patient. So, regardless of insurance okay, If we're talking about insurance, though, if we're talking about doing a localized SRP with a prophy, you do need to show necessity for that. So you need to have a complete perio chart. That means bleeding, that means clinical attachment loss, that means frications, mobility, separation, any of that that you see. And if you don't see it, chart that Chart that you do not see separation, you do not see mobility, you do not see bone loss, things like that Documentation. I know we've been hammering on that this entire time and we'll continue to do that with hygiene especially.

Speaker 2:

But perio charts are kind of trump everything in perio claims. So if you do not have an accurate perio chart and I see a lot of offices that we've dealt with, Erica, you know we look into their practice and we'll look at some perio charts from their SRP and it's like 434-434-323-323-222. And I'm like, okay, that's textbook. You just put that into the computer, and I know you did because I've done that in the past.

Speaker 2:

You know other hygienists do that. And I look back and I'm like why aren't you perio charting? And you'll see perio charts go from those to then where now they have recession and now they have bone laws and they have clinical attachment loss infarctions and you can look at them side by side and you know the difference between the two and so does the insurance company. So if we don't have an accurate insurance breakdown, knowing that we can do that ahead of time, and if we don't have an accurate period chart and we don't have x-rays included that don't show bone loss, that do show bone loss, they're never going to pay for it. So we need to make sure that we have all the documentation to prove necessity for SRP and that we did, and it is localized. So we can also, you know, argue with your insurance company that we did clean the rest of the teeth with a prophylaxis above the gum line.

Speaker 1:

Yeah. So the debunking is that we cannot do, because I Trish, I think you and I experienced that one naysayer and it was around SRPs and a prophy and it was like you can never do this. And I don't even think, jen, she was talking about billing, I think she was just talking about in general, as a hygienist, you can never do these two procedures together. So I agree with you If, if the patient qualifies and you do it, then document that you did it and let us in the front deal with everything else. Right, like I think it's a big. All too often we get too caught up in what is the insurance company going to pay for, what do they allow, and we allow the insurance companies to start dictating the standard of care within the practice, right? So I can appreciate how you debunked that myth.

Speaker 2:

And well, I always relate it to cancer. You know you can have. You can have cancer in your brain, but maybe it hasn't spread to the rest of your body, but you're not going to do radiation on your entire body If you only have cancer in your brain. It's very similar to that. Or you broke you know your arm. You're not going to cast all of your limbs, you're going to cast one arm. So it's just the thinking around. It is insurance based and we need to get away from that.

Speaker 1:

Yes, and you're speaking to all the clinicians that are attending right now Like, just stop worrying about what the insurance is going to cover and just emphasize what the patient needs. Okay, great, yes, all right. So the first question we have for you is around the infamous D4346, your gingivitis cleaning that. I mean you and I and Tess, we've delivered these coding and billing analysis to many offices and, would you say, would you agree with me when I say 4346 is virtually is underutilized across the nation?

Speaker 2:

Oh, absolutely. It's not even in their coding sometimes. Sometimes their coding isn't even updated to include that code.

Speaker 1:

Yeah, so why should we be utilizing a D4346 in our practice? Like, I see a lot of offices that are just doing prophy or perio, but not but the nothing in between. So talk to us a little bit about.

Speaker 2:

Yeah. So the first thing I want to do is address the description, the ADA description, of 4346. So it's scaling in the presence of generalized, moderate or severe gingival inflammation, full mouth after oral evaluation. There is a note in the ADA that says note generalized inflammation with some pseudopockets, no apparent attachment loss. So just in those two statements it's very clear that this is for those interim patients that are not healthy but they're not periodontally involved fully yet. They do not have bone loss but they have inflammation that is going to start leading that way if it's not treated sooner than later.

Speaker 2:

So this is a code that kind of bridges that gap is what we always like to call it Bridges, that gap between a healthy patient and an SRP patient. This is something that we used to call a difficult prophy or we used to call like an extra prophy appointment, because it was they had more calculus or whatever. Calculus doesn't matter when it comes to this code. Inflammation and no bone loss, that is the biggest things. Moderate to severe. So 30% or more bleeding on the perio chart needs to be charted, as well as documentation that that is exactly what you're seeing as a clinician in there, and I guess I'll just go into documentation too with this.

Speaker 1:

That was my next question.

Speaker 2:

Yeah, I'll just go straight into it.

Speaker 1:

What kind of documentation is needed for 4340?

Speaker 2:

Yeah, so a full and complete perio chart. So that includes pocket depths, including any pseudopockets. It doesn't matter if they have fives. If you know that there's no bone loss there and it's just due to gingival inflammation. We need to have bleeding on probing and it has to be more than 30% of the entire mouth for it to be covered. There needs to be no loss of attachment or bone loss involved in that either, and diagnostic images is part of that. So any x-rays that you have that show no bone loss and just in gingival inflammation pictures are really helpful, like ortho hyperplasia, things like that, pregnancy gingivitis. We can usually get this code covered for them because they're just more prone to gingivitis with that. So in your notes you have to have those three things moderate to severe gingivitis, more than 30% what the tissue looks like, and no bone loss attack.

Speaker 1:

Good. Thank you for that. Thank you for sharing. I'm sure everybody's taking notes here. Okay, so let's get into perio performance, or hygiene performance. This is a biggie and I think it's really important that we understand where we where we are right now. So can you help us, help the audience not help me, but help the audience understand why it's so, what is periodontal performance percentage and why is it so important to monitor that number?

Speaker 2:

Yeah, so periodontal performance is the total number of periodontally involved patients that you've seen in a given timeframe. So we usually for our audits we do 18 months, 12 to 18 months, whatever that practice wants, but on a month to month basis. It's helpful to know that monthly so you can track it a little bit better. So patients with SRP, debridement and perio maintenance you want to take that total number, divide by your total number of hygiene patients seen within that given timeframe and that will give you the percentage of your patient base currently being treated for perio. Now, the reason that you want to know this number it's not just for another metric or a KPI, but it tells you the health of your practice and your hygiene department. So an honest, conservative benchmark that we like to go off of. Erica, 60% of your patients should be periodontally involved. Now that's just not some arbitrary number that we pulled out and said 60% just because of financial reasons. That's due to the CDC reporting that 80% of Americans have had periodontal disease sometime in their lifetime. That's 80% of Americans. So if you are treating 10% in your practice, you're not taking care of your patients and we need to be doing localized SRPs when necessary. We need to be doing these ging of your patients and we need to be doing localized SRPs when necessary. We need to be doing these gingivitis cleanings. We need to be placing desensitizer and Reston and laser and irrigation if that's what your protocol is, whatever that looks like for your practice.

Speaker 2:

If we're effectively treating perio and we're going to stop doing bloody prophy, our patients are better taken care of as well as they're getting the care that they need. But they need to be informed of their health. If we're doing prophy, prophy, prophy, they have gingivitis and then they go to another practice and they use this code correctly, they're going to say why did my other hygienist never tell me about this? Same thing goes for periodontal procedures. You know, like SRP, if they do not treat accordingly and you go to another practice for some reason, they're not feeling something is off and you go to another practice.

Speaker 2:

You could be found at fault too for not informing the patient. So healthy, healthy perio performance is healthy patients, less risk for audits. Because you're doing what the patient needs and you can prove it with your documentation. And also I know Trisha is going to talk about this but you have well-paid hygienists because they are producing more for your practice collecting more and you have less turnover rates. Because the hygienists are going to be more happy with their care, I'm going to be happier with their salaries and patients are going to be easier on maintenance protocols than you, constantly working harder and harder.

Speaker 1:

I love that. I love that we could spend so much time talking about aerial performance. I love that. I love that we could spend so much time talking about aerial performance. So for those of you that want to know what your current aerial performance is and you want us to figure that out for you and deliver, the opportunities that you have.

Speaker 3:

You know feel free to. I believe Hernan have you placed the link for that free coding and billing analysis that includes the payroll performance in the chat. Anybody that has replied ready, we have added them to the process so that process has already started. So if you're ready for the coding and billing analysis, just put ready in the chat and we are taking care of you.

Speaker 1:

Awesome, okay. So I'm really excited to share your results with you guys, and we'll definitely go over that, okay. What do'm really excited to share your results with you guys, and we'll definitely go over that, okay. What do you think is the biggest mistake hygienists and offices make when it comes to billing hygiene procedures?

Speaker 2:

All right, this is my loaded question for hygiene. Everyone has one, this is mine. I see a lot of mistakes in this arena, so the two main ones though that come to mind and you've already discussed this too, erica, and everybody has actually is not billing for what you do. So if you are seeing a prophy patient, the first thing I always ask is do you have any sensitive areas that you want me to take a look at? Pretty much everybody has recession and they have this one spot that always bothers them during the cleaning. Pretty much everybody has recession and they have this one spot that always bothers them during the cleaning Place.

Speaker 2:

Some desensitizer bill it and you are using the patient's benefits that they're paying for and you're taking care of the patient and documenting for what you do. So you put it in the notes, you put it in the ledger and you bill it out If the patient's responsible for that. You need to know that ahead of time in the insurance verification. If you do a 43-46, bill it. If you do a 43-46, bill it If you do a Reston bill it Local anesthesia for a prophy patient. I had one patient that every time she came in every six months, upper right and upper left anesthesia. Every time I said okay, but I'm going to bill you for it because it's taking more of my time and there is a code for that. You should know all of the codes that are available to you. Carries, risk assessments If you're doing that, which every patient is we're talking about nutritional counseling and tobacco counseling and talking about their daily life and how we can decrease carries you are doing an assessment that is also billable.

Speaker 1:

That's something I want to. I want to say when Jen says billable, we're talking about paid like payable it. You know carries risk assessments are a very big blind spot. I'm so glad that you brought that up, because there's so many blind spots that we experience during a traditional prophy visit and prophy's are the number one interactions that we're having with our patients and we're just not billing for what we're doing. I love that you pointed out local anesthesia.

Speaker 1:

Like it's one of those things that if it's not a part of a normal procedure, you can bill for that. You know, it's just we miss so much opportunity. Yeah.

Speaker 2:

And if a doctor does their exam and they diagnose a crown, I will take a PA same day because I want that production in my column, not in theirs. So I will bill out a PA with the POE, with the fluoride, sdf, desensitizer, all of it, because that's all of the things that I'm doing and I'm spending my time giving these things to the patient and giving them value. I think that's the biggest thing is we're not going to tell the patient you need desensitizer, it's $49. Do you want that? I have literally heard hygienists say that. Do you want fluoride? It's $49. Your insurance doesn't cover it.

Speaker 1:

What You're saying that in the chair no value there's no value there.

Speaker 2:

There's no value. Instead, you say due to this Keri's risk assessment that we have performed, you are at high risk. Let's think of some ways that we can reduce that risk for you, one of those being you know, there's a couple spots the doctor is monitoring. Let's put some SDF on there and top that with fluoride. Let's send you home with this you know, hydroxyapatite or fluoride toothpaste Like your production just completely increased. But you didn't do it in a way that felt gross, that felt pushy, that felt salesy.

Speaker 1:

Well, it was very much for the patient. Yeah, you, I think you hit the nail right on the head. When I'm, I always talk about this and anybody that has ever listened to my podcast, you guys know I talk about this. I am a huge fan of relational business, not transactional, and I think that what you just said. You know you need fluoride. It's $49. It's not a covered benefit. What do you want to do, like?

Speaker 1:

that is such a transactional conversation to have with your patient, like we want to have relational conversations like what you just explained. I mean, just from what you said right now it sounds like you care more about me than, rather than, caring about the dollar. You know, at the end of the day we all the patients know this is a business. They know they're going to have to pay something and I think just being more relational right and your interactions. I was talking to a hygienist. She is probably one of our top performing hygienists with our clients and I think you know who I'm talking about.

Speaker 2:

I know who you're talking about.

Speaker 1:

Jessica and she is me something recently that I'd never thought about. And she said you know, some hygienists just can't talk and clean at the same time. And so what do you say to that hygienist who has a hard time? Is that because they're newer? Is that because it's their personality Like why? Because I find that that is the right time to talk about what you're seeing in the mouth.

Speaker 2:

Yeah, I use that time to my advantage. You know, while I'm cleaning and it starts bleeding, I'm like whoa, that's, that's really bleeding. Right there, is that tender, and then you can start that conversation with SRP. You know, I think to those hygienists you need to gain the confidence that you have the education, the ability and everything at you know, at your fingertips, to take care of this patient, and you need to think of it that way. I do think some of that comes from, maybe, some doctors that are a little bit harder to work, for that maybe they don't feel confident in their ability to help diagnose that patient and help explain what they may need.

Speaker 2:

I know some doctors are restrictive on that. They like to help control that situation a little bit. So that would need to be a conversation that you have with your doctor. You know, where do you want me to talk about this? What are you comfortable with me talking about? And then come to an agreement with them on what you see and what you're able to do within your chair. I think, though, once you start, it's awkward at first, it's super awkward at first, but once you start, you'll see the benefits of it time and time again, with patients coming back too.

Speaker 1:

I agree with that. Okay, last question, and then we're going to get into the, then we're going to dive in with Trish. We have dealt with this, jen. I mean, we we've had so many conversations. How do we get stubborn hygienists to consider changing the way they have done things for years? So now you've got this new code 4346. I mean, I can think of a couple of examples right off the top of my head. I know, you know who I'm thinking about, and they just don't want to incorporate it.

Speaker 2:

Yeah. So there's a couple of different ways to go about that. I think the first mistake is too much, too soon. You know, if you hire one of us to do coaching and we do a hygiene coaching and we're like giving you all of the information and they're just completely overwhelmed and they don't want to do that at all. So you're forcing too much at one time. So my first suggestion would be to gradually implement hygiene protocols and make them a part of the process. So use their expertise and their years of experience to your advantage as a practice owner or as a hygiene team, and kind of put them in that role to say, okay, we want to revamp this. This is why you know if you're a doctor, this is why you know, according to the CDC, 80% of Americans have periodontal disease. We're treating 5%. Where can we help, you know, bridge that gap between those two percentages? So you're going to use that to your advantage.

Speaker 2:

I would, you know, sit down with them and have them dream a little bit and tell them, to tell you what their perfect day looks like. So you know, if they come to work and they're constantly grumpy and they're just doing profis all day long and they just don't want to do anything else, then there's something going on there that maybe is deeper than what you think. So I would ask them what does your ideal work day look like? What do your patients look like during this day? You know, how much do you want to make? Ask them that question. People are much happier when they make what they want to. How would the flow go? Tell me what you think this practice could be in your eyes and just sit back and let them talk. Write it out, if they would. If they want some time, if they're kind of a little bit more standoffish with that, let them write it out, but give them the opportunity to have to feel heard and put their input and voice their concerns and frustrations.

Speaker 2:

I think that's the biggest part with those stubborn hygienists that are just like no, not changing. It's because they don't know what they don't know and we need to educate them, but we also need to give them the space to say what they want to do with their career. Yeah, I think these are also crucial questions to ask to gauge their commitment to their patients and to their practice. So you want to make sure that you want to get their excitement back for hygiene. You want to get them like excited to implement these things, to see the numbers go up. All of those things, I will say some hygienists aren't going to get on board and in that case they may not be receptive to change. If they're bringing down the whole team, if they're constantly complaining to the front office and the doctor and even the patients. I've heard some hygienists just talk to the patients like, oh man, yeah, there's practice, you know, blah, blah, blah, that is toxic to your practice.

Speaker 2:

Me too, just honestly, if they're defiant about it and it's toxic to the rest of the team, the health of your practice, your patient's health and the health of your team depends on them leaving, unfortunately.

Speaker 1:

Yeah, yeah, I agree. Yeah, A few fold there, but I will start with the first part, I think so. I've had conversations with Jessica, who's chiming in here. I see her, I see her comments here, and Jessica says accountability and standard of care and you know, education on the CDT descriptions. I, I 100% agree with that and I think accountability is a big deal, right, you know, making sure that the team understands what the doctor's standard of care is when we see a patient who has the signs and symptoms of gingivitis, but not necessarily perio, right? So, understanding how to have and that's what you do, right, you're coaching and you're coaching to not just implement this code.

Speaker 1:

I mean, cause I'll have this conversation all the time and I get this what, what's the code for that? What do I need to do to bill it? And that's it Poof, they're gone. And then there's a part two to that conversation. Then then they come back and go um, our patients aren't. They're not accepting it, or is there a copayment involved? And there are so many missing components to implementing that code and the other ones that you talked about. I think having the right conversation with the patient, based on the standard of care that is established within the practice, making sure that everybody understands the three different types of classifications, if you will, I mean correct me if I'm wrong, jen, but you know, this is what a protein patient looks like, this is what a gingivitis patient looks like, this is what a perio patient looks like. Like having those taking the guesswork out of everything is really where you see that success with this.

Speaker 2:

And there's a lot of really big hygiene teams that there's just no consistency.

Speaker 2:

None, they're all doing their own kind of thing. They're all doing their own thing and their own verbiage. And then they'll go to one and be like, oh, you don't need full quads, guys get on the same page. Like you need to make sure. Yeah, I've seen that happen where they got diagnosed SRP. They go to another hygienist and they're like, oh no, actually you don't need that. So between those standard protocols, you know they need, they need to be there. If you have more than one hygienist, you need to have standard protocols and I know we've worked with you know, jessica, trying to get those in place for these upcoming hygienists that they were planning on hiring so that they come in with the expectation. This is how we run the practice full communication, accountability, education. You know you're not just going to be sitting here doing bloody profis all day. So that's for sure.

Speaker 2:

We love.

Speaker 1:

Jessica. I should have had Jessica here in the panel too. Yeah, I know she's here, okay, so, jen, oh, my gosh, thank you. So she said absolutely not yeah.

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