How to get Paid for a Gingivectomy
Estela Vargas, CRDH
The business of billing claims is alive and well as dentists, and their teams struggle to get paid for their hard work. I get questions frequently regarding the travails of denials for gingivectomies. Insurance companies seldom pay them due to processing policies.
Here is an example of a request for help from a doctor-client:
Dear Estela: I need some suggestions and inputs about getting paid for gingivectomy D4212 and restorative procedures. Many policies bundle it up, and it's a non-paid free service. I am getting frustrated with performing free dentistry.
D4212 Gingivectomy or Gingivoplasty to Allow Access For Restorative Procedure, Per Tooth—To allow access for a restorative procedure on a per tooth basis by removing gingival tissue to access, restore, or take an impression. The tissue is healthy.
Dear Doctor:
Defined: D4212 - gingivectomy or gingivoplasty is to allow access for the restorative procedure per tooth. It is also for providing margins for crown preparation.
Most payers include any soft tissue procedure at the same time as the tooth restoration to be global or inclusive of the restorative process. They will not pay it as a separate fee.
This code does not report purely periodontal conditions or clinical crown lengthening, which is covered by other codes.
The rationale the insurance company uses is based on gingival healing time. They use the same for crown lengthening if done the same day as a crown prep.
How will you get a good impression or scan if you didn't allow the gingiva to heal after the procedure?
How sure can you be that the margin of your restoration will be perfect?
Insurance companies use research that supports that rationale to create processing policies. If you agree to be in-network, you agree to follow those rules unless you request a peer-reviewed appeal and they agree with your rationale to overturn that processing policy.
You coded it correctly as a standalone procedure that is not inclusive of the "soft tissue management" part of the procedure. In the appeal, be able to document the rationale for the procedure at the time of the prep. It will get overturned and paid, or the insurance payer will make the patient responsible for the fee.
At the treatment plan stage of patient communication, make sure the patient understands the limitations of their policies and that they are financially responsible. Some processing policies are not available to the dentist during treatment planning. The plan payer will deny treatment because the treatment wasn’t part of the contract with the employer or the subscriber.
