The difference in one line
A prophylaxis (D1110) is preventive care for a patient without active periodontal disease. Periodontal maintenance (D4910) is ongoing care for a patient who has already had active periodontal therapy, such as scaling and root planing.
Side by side: D1110 prophylaxis is preventive care for a patient without active periodontal disease. D4910 periodontal maintenance is ongoing care for a patient who has had active periodontal therapy, such as scaling and root planing, even if the gums look healthy today.
How to decide at the recall visit
- Has the patient had active periodontal therapy, such as scaling and root planing? If not, D4910 doesn't fit.
- If they have, today's visit is usually periodontal maintenance, even if their tissues look healthy now. That health is the result of the maintenance.
- Chart today's findings: probing depths, bleeding, recession and anything new. If disease has come back in an area, talk to the dentist about whether active therapy is needed again.
A decision flow. Question: has the patient had active periodontal therapy, such as scaling and root planing? If no, D4910 doesn't fit; consider D1110. If yes, today's visit is usually D4910 periodontal maintenance, even if the tissues look healthy. Either way, chart today's findings; if disease has come back in an area, talk to the dentist about active therapy.
What your notes need to show
- The history of active periodontal therapy, with dates.
- Today's periodontal findings, not just “stable”.
- What you did, and the interval you recommend for the next visit.
Your notes have to support every code you choose.
Mistakes new hygienists make
- Switching a maintenance patient back to prophylaxis because the tissue looks good.
- Coding periodontal maintenance for a patient who never had active therapy.
- Charting too little to support the code.
- Not explaining to the patient why their visit, and its cost, changed.