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Clowns to the Left of Me, Jokers to the Right. Here We Are…

Dental Insurance Today — June 2020

Clowns and jokers

Each and every facet of the American healthcare system has been stretched beyond any previous conceptual limitation. Never in modern history has such upheaval touched (now go wash your hands) every individual, community, and industry. Having spent the better part of the last 40 years in service to the dentistry profession, I can confidently share that there is not much I have not seen, endured, and, ultimately, survived. COVID-19 and its ever-changing implications are no different.

Charging for PPE

Over the last few turnings of the calendar, many so-called self-taught, ill-informed experts have been dishing out “free social media advice” with now proven disastrous results and consequences. Most disheartening was the concept of selectively charging separately for the indirect increased costs associated with patient care. The appropriate use of personal protective equipment, or PPE, is no more a separately billable entity as would be a line item charge from a restaurant that served you with clean utensils, plates, and glasses. And to separately identify it under the auspices of an unspecified preventive procedure (D1999) with a fee is almost as ludicrous as making reference to dentistry not being under the controlled guidance of the Centers for Disease Control and Prevention (CDC).

It is refreshing to see the benefit industry step up to the plate and automatically add additional “safety net” payments to provisionally help offset these increased costs. I’m seeing everything from $1000 repeatable block grants to dollar percentage of claim as well as flat rate per claim amounts being added to reimbursements. Unfortunately, these additional reimbursements are often, but not always, limited to “in network” participating providers. Interestingly, most all the payers addressing the additional reimbursements are not wanting offices to separately identify either a separate procedure code or fee.

Why not code and identify separately? Because the appropriate use of PPE is merely part of doing business. The patient in your operatory chair as well as your clinical support team has a “reasonable expectation of safety” that comes without price or reference to quality. From the witness stand or deposition you definitely don’t want to get trapped into explaining how your employee or patient would have been better protected if you simply would have done and charged more money. Face it, OSHA and PPE are merely part of the journey — simply a means to an end — just like teledentistry.

Teledentistry is a Technique, Not a Procedure

The overall parameters surrounding the conceptual applications of teledentistry are, to this hour, still being defined. Yet, when all is eventually said and done, we are merely communicating patient specific information both to and from another individual(s) in another location(s).

The documented transmittal of this information is currently identifiable with one of two teledentistry specific codes. They are intended to be reported in addition to other procedures (e.g., diagnostic) delivered to the patient on the date of service.

D9995 — synchronous; real-time encounter

D9996 — asynchronous; information stored and forwarded to dentist for subsequent review

These “teledentistry” codes are merely used as identifiers to specify that the patient encounter, as indicated by date and evaluation code, was not in the physical/actual presence of the licensed diagnostician dentist. Prior to specifying any completed procedures that were rendered on behalf of the patient, remember to identify the patient specific location of the non-face-to-face encounter.

D9410 — house/extended care facility call
Includes visits to nursing homes, long-term care facilities, hospice sites, institutions, etc.

D9420 — hospital or ambulatory surgical center call
Care provided outside the dentist’s office to a patient who is in a hospital or ambulatory surgical center.

Patient vs Doctor Location

These two “professional visit” codes are broad-based identifiers noting that the treatments rendered were not delivered in a traditional dental office environment. In addition to these location specific procedure codes, we must now concern ourselves with question #38 on the J430 © 2019 ADA Dental Claim Form. The “Place of Treatment” is yet another individual two-digit code to specify the entity where the service(s) were rendered. Let’s not forget question #56 as to the actual physical location where the treatment was rendered. It must be a physical street address and not a Post Office Box.

Image Capture Only

With the upcoming CDT-2021, there will be several new codes in the subcategory of “image capture only.” These procedures have the greatest applicability in teledentistry encounters where a locally licensed practitioner captures image(s) that are forwarded to a dentist for interpretation. The image interpretation is intended to be reported separately with code D0391, yet the million dollar question remains to be the identification of the original prescribing dentist when the image is anything other than a photograph.

What’s Next?

As we now embrace these soon to be post-COVID-19 lifestyle and business changes, we must not forget the all significant decision-making ability of the patient in the operatory chair. They, both with and without a plan of benefits, will be determining what dentistry does and does not separately charge for as well as ultimately collect. Our open free market economy will also eventually determine if dental fees are going to globally increase or decrease based upon the delicate balance of “supply and demand” vs “cost of goods sold.”

And what about the long-term role of Dental Insurance and Reimbursement®? Will the role and opinion of the patient’s plan in the overall treatment decision-making process hold greater or lesser significance? The real question remains to be the next step(s) with Medicaid and the other various forms of State and Federally funded plans. Maybe it’s time to take another look at being all in or all out.

Either way, here I am, stuck in the middle with you…

Tom Limoli

Tom Limoli

“The Nation’s Leading Reimbursement Expert”

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