BRINGING TELEDENTISTRYINTO PRACTICE SERIES -WEBINAR 1: EMERGENCY MANAGEMENT & PATIENT RECORDKEEPING DentaQuest Partnership Continuing Education WebinarMay 11, 2020

DOI: 10.35565/DQP.2020.3006

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Learning Objectives

By the end of this webinar, participants will be able to:1. Understand the emerging opportunities for teledentistry2. Learn important protocols for conducting a teledental encounter3. Identify methods to capture and update patient records and chart entries in

documenting a teledental encounter

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Housekeeping

• All lines will remain muted to avoid background noise.• A copy of the slides and a link to the recording will be shared after the webinar

concludes. • In order to receive CE credit you must fill out the webinar evaluation, which

will be shared at the end of the presentation. The evaluation must be completed by EOD Friday, May 15 to receive CE credit. CE certificates will be distributed a few days after the webinar takes place.

The DentaQuest Partnership is an ADA CERP Recognized Provider. This presentation has been planned and implemented in accordance with the standards of the ADA CERP.

*Full disclosures available upon request

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Q&A Logistics

After the presentations we hope to have some time for Q&AWe will be monitoring the chat box throughout the entire presentation and we will do our best to answer all questions.• Type your question in the chat box

and make sure you send it to allpanelist.

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Presenter:

TELEDENTISTRY:DENTAL EMERGENCY MANAGEMENT & PATIENTRECORDKEEPING

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Determining if an issue is an emergency may be difficult when you cannot see the patient. Teledentistry is a way for dentists to offer consultation to patients without a face-to-face examination.

Emergency Teledental Training Program:What is emergency teledentistry?

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Teledental is a rapidly evolving process

• 2020 COVID-19 impact restricting dental access in clinical environments• Restricting non-urgent dental care• Need for urgent care delivery in non-aerosol producing environments• Need to maximize non-contact dental access and prioritize care• Provide patient options outside hospital EDs• Rapidly developing state and third party payers’ telehealth and

teledental policies

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Rationale for synchronous dental telehealth services

A 2-way video AND audio synchronous transmission is the gold standard:• Reduces risk of COVID-19 spread or exposure for the patient and

dental team• Enhances the provider-patient experience over telephone only• Enhances 1st line triage of urgent or emergent issues• Expedites assessment of patient’s status• Allows recognition of body language, comprehension and demonstration• May heighten diagnostic quality and education delivery

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Proactive quality assurance and improvement protocols

Consider building teledental protocols in a different way than when you see the patient in the clinic…. Major Goals:

1. Diagnosis

2. Identify care pathway

3. Develop a care plan WITH the patient

Diagnostic Codes

Dental Case Management Codes

Preventative Codes

For coding, code what you do and do what you codeFor billing, refer to criteria for Medicaid or commercial plan

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TELEHEALTH NEEDS ARE DIFFERENT!

MEDICAL DENTAL

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Timeline of pre-COVID-19 dental model(Surgical care model)

19101840 1945 1970

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Even Before COVID-19, patients welcomed teledentistry

https://dentavox.dentacoin.com/blog/teledentistry-surteledentistry-survey-shows-patients-are-ready-to-welcome-it/

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Updated CDC interim guidance for teledental encounters

• Contact patients prior to emergency dental treatment• Triage all patients in need of emergency dental care • Assess the patient’s dental condition and determine whether the patient

needs to be seen in the dental clinic• Use teleconferencing or teledentistry options as alternatives to in office care • If dental treatment can be delayed, provide patients with detailed home care

instructions and any appropriate pharmaceuticals

Source: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html

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The teledental emergency visit

Differential Diagnosis

Intermediate Care Plan

Minimally Invasive orLow-Aerosol?

Teledentalor in-office?

Initiate and consent for

teledental visitReview, updateclinical records

Collect today’s records: via interview, photos/video

Screen, assessor triage

Varies based on diagnosis and patient

preferences

Caries Risk Assessment

OTC or Rx Medication

Self Management Goals

Patient Education

Self Care Tips

COVID-19 Care Plan

Determine if in-person visit

is needed

Determine visit type and location

Dental office visit

Consider minimally invasive or low aerosol-producing procedures

Refer to medical professional or ED

if neededSchedule for next

visit or refer

If yes

No

Care plan until in-office visit

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Following applications are public facing and should NOT be used:• Facebook Live• Twitch• TikTok

HIPAA guidance on applications

https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html

Following applications can be used to provide telehealth during the COVID-19 nationwide public health emergency:• Apple FaceTime• Facebook Messenger video chat• Google Hangouts video• Zoom• Skype

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HIPAA guidance on telehealth for dentistry

The list below includes some vendors that represent that they provide HIPAA-compliant video communication products and that they will enter into a HIPAA BAA.

https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html

• Skype for Business / Microsoft Teams

• Updox• VSee• Zoom for Healthcare• Doxy.me

• Google G Suite Hangouts Meet• Cisco Webex Meetings /

Webex Teams• Amazon Chime• GoToMeeting• Spruce Health Care Messenger

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Other Options for Teledentistry

HIPPAA compliance may be built into a health center or hospital group’s EHR, or offered from software built specifically for teledentistry, or third party payers may host teledental platforms for their credentialed providers

Dental Specific:MouthWatchThe TeleDentistsVirtual DonticsDentalLuLuDenterActive

EHRs with add-on functionality:Epic (MyChart)eClinicalWorks (eRO)

And multiple EDRs

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HIPAA guidance on teledentistry

HIPAA does not prohibit using email or text communications, but a dental office that wishes to communicate with patients this way must conduct a written risk analysis and implement reasonable and appropriate safeguards.

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Patient Safety Check• Introduce yourself

• Discuss purpose and teledental basics

• Patient Id Protocols

• Note if accompanied parent

• Privacy check

• Consent

Quality Check• Check and note video

and audio quality

• Assist the patient in making adjustments to optimize video transmission

• Translation

The video teledental encounter preparation

Documentation• Document, document,

document!

• Code what you do and do what you code

• Highlight medical necessity

• Individualized Care Plan

• Preventative Plan

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TELEDENTAL & PATIENT CLINICAL NOTES

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Informed consent in teledentistry should cover everything that exists in a standard, traditional consent form. The patient should be informed of the inherent risk.

Informed consent

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• Purpose• Explanation of a teledental

consultation• Risks, benefits, alternatives• Confidentiality• Rights• Patient signature

Components of teledental informed consent

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Three primary components in teledental

Time & Date Teledental regulations requires that a visit occurs and is complete in a certain period of time

Data Collection Method

Should list what was used to collect data during the assessment e.g. photographs, x-rays (type and how many), intra or extra oral

Original Location Regulations require location and time a patient receives telecommunication services.

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Documentation components

Intake• Note if asynchronous or synchronous visit and time that a patient receives service via

a telecommunications system; this must be documented to include the originating site. The distance site where the exam actually occurs must be documented.

• Collect patient visit approval and assure documentation with faxed or e-signature if required.

• Assure what is coded is done and code what is performed

• Duration of encounter time should be listed.

• Method of data intake: important to list what was used to collect data during an assessment. These items will vary from radiography (how many, what type), photographs (intra-oral, extra-oral), dental instruments and services rendered.

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Teledental CodesD9995 – synchronous; real-time encounter

D9996 – asynchronous; information stored and forwarded to Dentists for subsequent review

Procedure CodesEmergency: D0140, D0160, D0170, D0171Evaluation: D9430, D0170, D0171Palliative: D9910, D9630Preventative: D1310, D1320, D1330Assessment: D0190, D0191

Code what you do and do what you code –Building a robust, quality teledental encounter

Refer to ADA https://success.ada.org/~/media/CPS/Files/COVID/ADA_COVID_Coding_and_Billing_Guidance.pdf

Caries Risk Assessment CodesD0601 – low riskD0602 – moderate risk

D0603 – high risk

Case Management CodesD9992 – care coordination D9994 – patient education

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Assisting in a patient’s decisions regarding the coordination of oral health care services across multiple providers, provider types, specialty areas of treatment, health care settings, health care organizations and payment systems.

This is the additional time and resources expended to provide experience or expertise beyond that possessed by the patient.

CaseManagement

Code

D9992

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Caries risk assessment in teledentistry

CRA Result From this result, offer the following: Code bundle

D0601 –Low Risk

• Patient Education / Anticipatory Guidance • Self-management goal setting • At-home care plan during COVID-19:

− Floss once per day− Brush morning & night with fluoride/xylitol toothpaste. Spit only, do not rinse.

In-office Return to Care: Yearly exam & cleaning

1. D9995 (synchronous)2. D0190 or D0191?3. D0601 (low risk)

+1. D9994 (case mgmt., pt education)

D0602 –Moderate Risk

• Patient Education / Anticipatory Guidance• Self-management goal setting • At-home care plan during COVID-19:

− Floss once per day − Brush morning & night with OTC or Rx fluoride/xylitol toothpaste. Spit only, do not rinse.− Xylitol mints or gum− Mouth rinse before bed

In-office Return to Care: Cavity prevention at 6 and 12 months. Yearly exam & cleaning.

D9995 (synchronous)D0190 or D0191?D0602 (moderate risk)

+D9992 (if referral is made), OR D9994 (case

mgmt.., pt education)

D0603 –High Risk

• Patient Education / Anticipatory Guidance • Self-management goal setting • At-home care plan during COVID-19:

− Floss once per day− Brush morning & night with OTC or Rx fluoride/xylitol toothpaste. Spit only, do not rinse.− Xylitol mints or gum− Mouth rinse before bed

In-office Return to Care: Cavity prevention at 3, 6, 9, and 12 months. Yearly exam & cleaning.

D9995 (synchronous)D0190 or D0191?D0603 (high risk)

+D9992 (if referral is made), OR D9994 for case mgmt. / pt educ.

DentaQuest Clinician’s Companion

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BEFORE COVID-19, patients welcomed teledentistry

https://dentavox.dentacoin.com/blog/teledentistry-surteledentistry-survey-shows-patients-are-ready-to-welcome-it/

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• What constitutes an emergency?• Who decides?• Objective criteria• PLACE and TIMING

The role of triage

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Triage steps

• Health history evaluation, update, & review

• Patient interview should be consistent with normal office documentation protocols for urgent care cases

• Use of S.O.A.P or subjective, objective, assessment and plan notes should be used for emergency intake

• Notes should be adapted to the limitations of telehealth connection which may exclude vital signs, BP, and temperature unless your system allows such connections

• Patient reported temperature and BP may be recorded if devices available to patient at time of teledental visit realizing the lack of calibration of such devices

• Patient reported history and information is critical for telehealth encounters lacking more direct methods

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Patient interview should be consistent with normal office documentation protocols for urgent care casesThe SOAP Note:

• Subjective

• Objective

• Assessment and

• Plan(At home care plan during COVID-19)

Triage & documentation

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Review and Update: • Medical dental history• Medications and allergies• Treatment plan

(existing TX plan for patients of record)

Record:• Chief complaint• Vital signs• Dental diagnosis• TX clinical notes

Triage & Documentation

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Follow up steps

Using all documentation and telehealthreported evidence, determine and recordthe planned course of treatment

Focus should be to avoid hospital ER and provide the minimal invasive method to address the problem possible

Determine if follow up is necessary and when

Set time and method for follow up interview, teledental method, and documentation

• Over-the-counter or Rx medication(s)• Patient self-help or education• If the situation is in need of direct care, determine the safest method

and appropriate means to provide e. g. medical consultation, referral, in office tx

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A few things to ponder….

Limited teledental or virtual visit services for new patients only• “My dentist’s phone is just ringing and no one is picking up, can you help me?”

– 19% closed and not seeing any patients (ADA HPI: N≈11,000 ADA Members)– State level reports of dentists closing offices permanently due to loss of lease

Requiring patients to activate the tele-visit • Limitations of cold calling for a billable procedure

Telehealth is not applicable to dentistry because it is a surgical sub-specialty only• In Medicaid (2017), 25% of all dental claims and 43% of all costs were for surgical

procedures (restorative care, oral surgeries, periodontal care, and anesthesia)• In Commercial Insurance (2017), 24% of all dental claims and 49% of all costs were

for surgical procedures

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Resources

DentaQuest Partnership for Oral Health Advancement:https://www.dentaquestpartnership.org/learn/online-learning-center/resource-library/teledentistry-resources

ADA Guidelines on Dental Records:https://www.ada.org/~/media/ADA/Public%20Programs/Files/MPRG_Dental_Records.pdf?la=en

State Telehealth Laws & Reimbursement Policies:https://www.cchpca.org/sites/default/files/2018-10/CCHP_50_State_Report_Fall_2018.pdf

NC Medicaid: SPECIAL BULLETIN COVID-19 #21: Telehealth Provisions –Outpatient Specialized Therapies and Dental Services:https://medicaid.ncdhhs.gov/blog/2020/03/27/special-bulletin-covid-19-21-telehealth-provisions-outpatient-specialized-therapies 1/1

QUESTIONS?

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Webinar Evaluation https://www.dentaquestpartnership.org/node/198146*Must complete by EOD Friday, May 15 in order to receive CE credit

Online learning modules available on our website!• Infection Control & Prevention During A National Health Crisis (Part 1)• Teledentistry: Providing Alternative Care During a Public Health Crisis• Infection Control Part 2: Questions & Answers about COVID-19 (Coming

soon!}

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