LANAP®/Laser Procedures and Osseous Surgery (D4260) Coding
An ongoing controversy is how to properly code and bill for LANAP. Many insurance companies have no problem with the LANAP® procedure, efficacy, or the science behind it. The issue concerns how the procedure is coded and submitted for insurance benefits. Or more specifically, whether bone is being recontoured as per the intent of the D4260 code.
Here are some points made by LANAP providers, and some points made by insurance companies.
Insurance company positions
- Most insurance companies have the opinion that the LANAP® protocol is obviously not congruent with CDT D4260 Osseous Surgery procedure.
- Ostectomy/Osteoplasty is not part of the LANAP® protocol. But the CDT 2015 D4260 descriptor states that it "must include the removal of supporting bone (ostectomy) and/or non-supporting bone (osteoplaty)."
- LANAP protocol does not involve flap reflection. But the CDT 2015 D4260 descriptor states "...including elevation of a full thickness flap".
- LANAP is touted as a non-surgical treatment option. But the CDT 2015 D4260 descriptor includes "...during the surgical procedure".
- Insurance companies establish their own criteria for when specific procedures are a contract benefit and payable.
- Many companies specifically exclude LANAP® or laser procedures from D4260 benefits in the insurance contract, so it is not a covered benefit regardless of the technical or scientific arguments.
- Other companies will pay D4260 benefits only for traditional osseous surgical protocol where patient records document that osseous recontouring has purposely been performed as part of the procedure.
- The PerioLase® is a soft tissue laser. It is not promoted for use on hard tissue (bone). It has FDA 510(k) clearance only for soft tissue use, but not for hard tissue use. [Update: The FDA gave approval on March 15, 2016 for "Periodontal regeneration - true regeneration of the attachment apparatus on previously diseased root surface when used specifically in the LANAP protocol".]
- Billing an additional separate procedure for use of a laser is unbundling, is not allowed, and can be fraudulent billing.
- The ADA sent a letter to a Delta Dental Director in response to two specific questions he asked. The part of the letter that providers use to support D4260 coding/billing says "Whether or not LANAP procedures do, in some cases, modify the bony support of the teeth is not a coding issue, but a scientific and procedural issue." Insurance payors believe that if any bone is removed during LANAP®, it is incidental, extremely minimal, on the microscopic/histologic level, and is clearly not bone removal that the D4260 code or osseous surgery procedure intends to convey, which is to "modify the bony support of the teeth by reshaping the alveolar process to achieve a more physiologic form."
- Many LANAP® providers are hesitant to code/bill D4260 for the procedure. The fact that D4260 billing is not universally accepted and utilized by them illustrates the probable inappropriateness of using D4260 as the most accurate CDT code for describing a LANAP® procedure. Those dentists who do not agree with the D4260 billing see others taking advantage of a gray area, trying to utilize a loophole to increase their reimbursement, which ultimately hurts everyone doing LANAP®.
- There is currently no CDT code for LANAP® procedures, so the most appropriate code for this service would be a "D4999 Unspecified Periodontal Procedure, By Report."
- Some insurance contracts require that initial therapy be completed prior to osseous surgery for benefits to be payable. The LANAP protocol involves no initial perio therapy, as the scaling/root planing is part of the actual LANAP procedure.
- Changes in the 2015 code descriptor seem to strengthen the position that LANAP® procedure is not a D4260. Insurance companies will be more likely now to consider LANAP submitted as D4260 as a fraudulent insurance claim.
- CDT codes are not instrument-specific. They usually describe clinical treatments, but not how the treatment was accomplished.
- The ADA sent a letter to a Delta Dental Director in response to two specific questions he asked. The part of the letter that providers use to support D4260 coding/billing says "Whether or not LANAP procedures do, in some cases, modify the bony support of the teeth is not a coding issue, but a scientific and procedural issue." LANAP® proponents believe that bone is removed during the procedure, thus D4260 coding is appropriate.
- Insurance claims should not include any reference to laser or LANAP®, or further claim investigation might be triggered and the claim denied.
- Bone is removed during the procedure. The CDT descriptor does not specify how much bone must be removed.
LANAP® information from Millennium:
- Millennium Dental Technologies LANAP® pages
- It is a surgical treatment in which a laser is used instead of scalpel and sutures. It is a "significantly less traumatic alternative to traditional periodontal surgery that can be performed in a general practice setting."
- Summary of LANAP® protocol:
- Use the laser to remove sulcular epithelium and open pocket;
- Scale and root plane with ultrasonic and hand instrumentation;
- Use the laser to debride pocket and establish coagulation;
- Compress tissue against root surface to form fibrin clot;
- Occlusal adjustment with rotary instruments.
- Average LANAP®-treated patient results in $3,500 production. One patient per month boosts practice income by over $79,989.
- No cutting of flaps; no sutures.
- A 3-day hands-on training course is required.
- PerioLase brochure
- Research and literature
- This discussion mentions D4260 (four or more contiguous teeth or tooth bounded spaces per quadrant). It also equally applies to D4261 (one to three contiguous teeth or tooth bounded spaces per quadrant).
- Contracted dentists are usually obligated to provide copies of patient records to the insurance company if they are requested; this is part of the PPO contract that was signed. This is the checks-and-balances to assure that insurance claims submitted are legitimate. A dentist who is on Focused Review (for various reasons) or being investigated for other reasons will be asked for records more often than dentists who are not being reviewed.
- This concept is not unique to dental insurance; all insurance companies have a legal right to request documentation to prove legitimacy of any claim that is submitted for payment.
- Dentists should always have the latest CDT book, be familiar with the codes and descriptors, and submit claims using the code/descriptor that most accurately describes the actual procedure performed.
- AAP laser page
- ADA laser statement page