ICD-10 Coding and Documentation for Periodontitis

Hello everyone, and welcome to our podcast series. My name is Natalie Tornese and I’m a Senior Solutions Manager with Outsource Strategies International. I wanted to take this opportunity to talk to you about Periodontitis. Periodontitis is a serious gum infection that damages the soft tissue and destroys the bone that supports your teeth. It is also called gum disease or periodontal disease. This condition occurs due to poor brushing and flossing habits that allow plaque to build up around the tooth causing inflammation of the gums. This inflammation of the gums can result in redness, swelling and a tendency to bleed during tooth brushing. If left unchecked, the inflammation can spread down below the gums and along the roots of the teeth, causing possible destruction of the periodontal ligament and the supporting alveolar bones. Untreated periodontitis will eventually result in loosening and potential loss of the teeth. In addition, it can also increase the risk of stroke, heart attack and other health problems. Early identification of symptoms and related risk factors that could be directly contributing to this gum disease can help prevent the condition in the long run. As dental medical billing and coding is complex, physicians should correctly document the procedures performed in the medical records.
Reports from the Centers for Disease Control and Prevention suggest that about half of Americans aged 30 years or older have periodontitis, the more advanced form of periodontal disease. The potential risk factors that can increase the risk of gum disease include – gingivitis, poor oral habits, smoking or chewing tobacco, hormonal changes, vitamin deficiencies and use of medications. Maintaining good oral hygiene is part of both treatment and prevention. However, sometimes surgical intervention may be suggested in some severe cases when these non-surgical measures are not effective.
Gingivitis occurs before periodontitis. While, gingivitis occurs due to gum inflammation, periodontitis refers to gum disease and the destruction of tissue, bone, or both. In the early stages of gingivitis, the bacteria in plaque buildup, causing the gums to become inflamed and easily bleed during tooth brushing. However, no irreversible bone or other tissue damage may occur at this stage. Untreated gingivitis can lead to periodontitis, often without any obvious signs.
Generally, gum disease may progress slowly without producing any specific symptoms, even in the late stages. The common signs and symptoms include –
• Inflamed or swollen gums and recurrent swelling in the gums
• Receding gums, which make the teeth look longer
• Pus between the teeth and gums
• New spaces developing between your teeth
• Halitosis, or bad breath
• Gums that feel tender when touched
• Bright red, dusky red or purplish gums
• Bleeding gums
• A metallic taste in the mouth
• Loose teeth
• Painful chewing and
• A change in the way your teeth fit together when you bite
In most cases, a dentist/periodontist can normally diagnose periodontitis by analyzing the primary signs and symptoms and carrying out a mouth examination. The dentist will examine your mouth to look for plaque and tartar buildup and check for easy bleeding. They will measure the pocket depth of the groove between the gums and teeth by simply inserting a periodontal probe next to the tooth, under the gum line; usually this is at several sites throughout the mouth. If the tooth is healthy, the probe will not slide far below the gum line. On the other hand, if it is a case of periodontitis, the probe will reach deeper under the gum line. The dentist will then measure how far the probe reaches. In addition, dental X-rays are taken to check for bone loss in areas where your dentist observes deeper pocket depths.
Treatment for gum disease aims to clean the pockets around teeth and prevent damage to surrounding bones. Maintaining good oral hygiene is one of the primary methods to keep the teeth and gums healthy and prevent infection. Non-surgical methods for this condition include – Scaling and cleaning (remove plaque and calculus to restore periodontal health), root planning and prescription medications like antimicrobial mouth rinse, antibiotic gels and microspheres, enzyme suppressants and other oral antibiotics. If good oral hygiene and non-surgical treatments are not effective, dental surgery may be necessary. These surgeries include – Flap surgery which is a pocket reduction surgery, Soft tissue grafts and Guided tissue regeneration and bone grafting.
I’ll include a transcript that provides detailed diagnosis codes for this condition along with this podcast.
The American Academy of Periodontology reports that about 30% of Americans may be genetically susceptible to gum disease. Periodontitis is a chronic, or long-term, inflammatory disease, which will recur if good oral hygiene is not maintained properly. Incorporating good oral hygiene and dental care practices can help to prevent the occurrence of periodontitis. Proper dental care involves brushing your teeth at least twice a day and flossing at least once a day. Brushing removes plaque from the surfaces of the teeth and flossing removes food particles and plaque from in between the teeth and under the gum line. Antibacterial rinses can reduce bacteria that cause plaque and gum disease. Apart from these oral hygiene practices, various other health and lifestyle changes like – quitting the habit of smoking, consuming a well-balanced diet and avoiding clenching and grinding your teeth can help reduce the severity and pace of gum disease development in the long run.
I hope this helps.
But always remember that documentation and a thorough knowledge of payer regulations and guidelines is critical to ensure accurate reimbursement for the procedures performed.
Thank you so much for listening!