Do what is right…
Can hygienists make a DHDX in clinical note? In my opinion not only can you, you are obligated to make a DHDX. Here is the link to the ADHA Standards of Clinical DH Practice https://www.adha.org/resources-docs/2016-Revised-Standards-for-Clinical-Dental-Hygiene-Practice.pdf The first D in ADPIED-the abbreviation for the dental hygiene process of care is diagnose. It doesn’t say if your DDS allows it, if you have or if you feel like it, it is our standard. And it’s a minimum standard not a maximum.
Is there a code for health on a reduced periodontium? if you have proof/documentation of surgical or non-surgical perio treatment, then its D4910. If there is <30% inflammation then the code is D1110, if its greater than 30% of the teeth and no proof of perio treatment then its D4346.
Does Case Type 0 Health exist? No this is part of the Type 1-V system and remember, I said those were treatment categories and have no place in the AAP updated system.
Can we code 4910 if no in office SRPs or written evidence? As noted above, if all we have is self-reported from the patient then it is not enough. We need documentation. Best practices when submitting for D4910 is to include the date of the previous treatment as well as the current medical necessity diagnosis and risk assessment.
Hope this helps. If there is anything else I can do, please don’t hesitate to ask. Join our Beyond Oral Health group as an Insider! https://programs.dentalcodeology.com/dcinsiders33499525