Treating, Reporting and Managing Periodontal Diseases: A ’s Perspective Presenter: Kathy S. Forbes, RDH, BS

June 23, 2018 12:30-3:30

• Diagnosis Case Types I-V and AAP Classifications I-VIII • Chart Documentation Risk Management Issues • Dental “Insurance” Not really insurance . . . Really!

1 • Treatment Planning for *Non-surgical Dental Hygiene Procedures/Procedure Code Selection *Evaluations *Adult/Child Prophylaxis * *”” Procedure *Periodontal Maintenance

Concerns?

There are dental hygienists who provide periodontal procedures (SRP, PM) but document preventive procedures (AP).

There are business staff who bill for adult prophylaxis when the hygienist has provided periodontal procedures.

2 Concerns?

Both scenarios cause the practice to lose money.

Both scenarios would be considered risk management issues.

Classification/Case Types of Periodontal Diseases (Based on 1989 World Workshop in Periodontics) Formerly AAP Classification System Case Type I – Early/Chronic Gingivitis Case Type II – Established Gingivitis/Early Periodontitis Case Type III – Moderate/ Case Type IV – Advanced Periodontitis Case Type V – Refractory Periodontitis

3 General Guidelines Extent Severity

Localized = 30% or less Slight = of sites are involved LOA/CAL 1-2 mm Generalized = more than Moderate = 30% of sites are involved LOA/CAL 3-4 mm

Severe = LOA/CAL 5+ mm LOA = Loss of Attachment CAL =

Case Types I-V (recognized by most “Insurance” Companies)

Case Type Status Defined Loss of Attachment/ Clinical Attachment Loss Type 0 Clinically healthy No LOA/CAL Type I Early/Chronic Gingivitis No LOA/CAL Pseudopocketing possible Type II Established Gingivitis/Early Slight LOA/CAL = Periodontitis 1-2 mm Type III Moderate Periodontitis/ Moderate LOA/CAL = Chronic Periodontitis 3-4 mm Type IV Advanced Periodontitis Severe LOA/CAL = 5+ mm Type V Refractory Periodontitis

4 Development of a Classification System for Periodontal Diseases and Conditions

Annals of December, 1999 www.perio.org

AAP Classification of Periodontal Diseases and Conditions (Based on 1999 International Workshop) Gingival Diseases Chronic Periodontitis Periodontitis as a Manifestation of Systemic Diseases Necrotizing Periodontal Diseases Abscesses of the Periodontitis Associated with Endodontic Lesions Developmental or Acquired Deformities and Conditions

5 Gingival A. Plaque 1. Associated Diseases induced with only 2. Modified by systemic factors 3. Modified by medications 4. Modified by malnutrition B. Non-plaque 1. Bacterial, induced viral, fungal, allergic, genetic, etc.

Chronic A. 1. Modified by Periodontitis Localized systemic factors ≤ 30% 2. Modified by medications 3. Modified by malnutrition B. 1. Modified by Generalized systemic factors ≥ 30% 2. Modified by medications 3. Modified by malnutrition

6 Update will commence in 2017 to review: • Attachment level • Chronic versus aggressive periodontitis • Localized versus generalized periodontitis

AAP Disease Classification/Diagnosis – Use descriptive words: Generalized chronic periodontitis Localized plaque-induced gingivitis with generalized slight chronic periodontitis Localized chronic periodontitis - stable Billing Class/Case Type/Code – Use Roman numerals (I-IV) – May use description title also: IV: Moderate chronic periodontitis

7 Fee for Service PPO (20% discount) $100 procedure $80 procedure - $60 overhead - $60 overhead $40 profit $20 profit

Insurance: Protection against the occurrence of an infrequent, catastrophic event.

8 : Involves the frequent occurrence of non-catastrophic events.

Dental “Insurance” Not really insurance but a Dental Benefit or Healthcare Financing

9 Dental “Insurance” 1972 Most plans paid by incentive: – First year: paid 70% of ’s fees – Second year: paid 80% of dentist’s fees – Third year: paid 90% of dentist’s fees – Fourth year and beyond: paid 100%

Maximum benefit?

Dental “Insurance” 2018 Paid according to negotiated contract between employer and insurance company Varying rates of reimbursement – Some based on % of UCR computed by insurance company – Some rely on “evidence-based” research – Some based on “who knows what”

Maximum benefit?

10 Documentation Top Two Areas of Claim Frequency: #1: Failure to diagnose periodontal disease. #2: Failure to diagnose oral cancer #3: Legal considerations, poor record keeping, and a lack of informed consent. Also note #9: Failure to refer or referring too late.

 Avoid personal shorthand that others cannot understand and non-relevant comments that could prove embarrassing if read in court.  Allow adequate time to complete the treatment record to avoid poor documentation and frustration.  Document all data immediately; delays lead to inaccuracies.

11 RDH Magazine November 2013

Top Reasons Hygienists Are Sued Strategies for Avoiding Malpractice Claims

Author: Dianne Glasscoe Watterson, RDH, BS, MBA

Informed Consent defined: The patient’s agreement that he or she has had a thorough discussion with the doctor (dentist), understanding the recommended treatment or procedure, its alternatives, risks and consequences, and desires the dental procedure to be preformed.

12 Informed Consent defined: Informed consent is more than simply getting a patient to sign a written consent form. It is a process of communication between a patient and physician (dentist) that results in the patient’s authorization or agreement to undergo a specific medical (dental) intervention.

Revised Code of Washington RCW 7.70.060 Consent form – contents – prima facie evidence – failure to use.

13 (1) A description, in language the patient could reasonably be expected to understand, of: (a) The nature and character of the proposed treatment; (b) The anticipated results of the proposed treatment; (c) The recognized possible alternative forms of treatment; and (d) The recognized serious possible risks, complications, and anticipated benefits involved in the treatment and in the recognized possible alternative forms of treatment, including non- treatment;

INFORMED REFUSAL

Periodontal Scaling and Root Planing Periodontal Maintenance X-ray Consent Withheld

14 Examples of Fraud

Billing for services not performed. Altering dates of service. The American Dental Association’s Code of Ethics (5.B.4) states: A dentist who submits a claim form to a third party reporting incorrect treatment dates for the purpose of assisting a patient in obtaining benefits under a dental plan, which benefits would otherwise be disallowed, is engaged in making an unethical, false or misleading representation to such third party.

Examples of Fraud

Misrepresenting patient identities

Not disclosing existence of primary coverage

Not informing dental carrier you’ve billed medical carrier also

15 Examples of Fraud

Up coding (now referred to as remapping), for example: Billing Scaling and Root Planing when you provided Periodontal Maintenance. Billing a night guard or fluoride trays when you’ve only provided whitening trays.

Example of Fraud

Waiver of co-payments and/or deductibles The insurance plan is a contract between the patient’s employer and the insurance company. The dentist is not a party to that contract. As such, cannot accept payments from insurance companies as payment in full when a co-payment is contractually required.

16 Example of Fraud

Unbundling Codes – separating dental procedures so the benefits of the component parts total more than the procedures as defined would normally be reimbursed.

Procedure Codes designated for dental hygiene/periodontal diagnosis and therapy

17 How many codes are available to hygienists in Washington State?

Where do we start?

18 Clinical Oral Evaluations

(Not Exams)

Periodic Oral Evaluation – established patient CDT 2018, p. 5: D0120 An evaluation performed on a patient of record to determine any changes in the patient’s dental and medical health status since a previous comprehensive or periodic evaluation. This includes an oral cancer evaluation and periodontal screening where indicated and may require interpretation of information acquired through additional diagnostic procedures.

19 What is the definition of a “Periodontal Screening” ?

Many hygienists and dentists consider a periodontal screening to include nothing more than spot probing BUT… The American Academy of Periodontology states that a charting containing only six points per tooth pocket depths is a Periodontal Screening.

Comprehensive Oral Evaluation – New or Established Patient CDT 2018, p. 6: D0150 Typically used by a general dentist and/or specialist when evaluating a patient comprehensively. This applies to • new patients; • established patients who have had a significant change in health conditions or other unusual circumstances, by report, or • established patients who have been absent from active treatment for three or more years. > > >>>>>

20 Comprehensive Oral Evaluation – New or Established Patient

Evaluate and record:  An evaluation for oral cancer where indicated  Extra-oral and intra-oral hard and soft tissues  Dental history  Medical history  A general health assessment

>>>>>>>

Comprehensive Oral Evaluation – New or Established Patient

 Dental caries, missing or unerupted teeth  Restorations  Existing prostheses  Occlusal relationships  Periodontal conditions, including periodontal screening and/or periodontal charting  Hard and soft tissue anomalies

21 What is the definition of a “Periodontal Charting” ?

The American Academy of Periodontology states that a complete periodontal charting, including a description of periodontal conditions, includes – six points per tooth pocket depths, – recession, – furcations, – mobilities, – bleeding points, – minimal attached gingiva notations, – AAP diagnosis, etc.

Re-evaluation – post-operative office visit CDT 2018, p. 7: D0171

No specific definition included in CDT 2016 or 2017 but October 2014 issue of Insurance Solutions Newsletter states: “May be used to document the re- evaluation of a patient four to six weeks after periodontal scaling and root planing. However, most payers include follow-up evaluations in the global procedure fee.”

22 Comprehensive Periodontal Evaluation – New or Established Patient CDT 2018, p. 7: D0180

This procedure is indicated for patients showing signs or symptoms of periodontal disease and for patients with risk factors such as smoking or diabetes. It includes evaluation of periodontal conditions, probing and charting, evaluation and recording of the patient’s dental and medical history and general health assessment. It may include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, occlusal relationships and oral cancer evaluation.

What is the difference in the definitions?

Comprehensive Oral Evaluation Comprehensive Perio Evaluation Evaluation of oral cancer Oral cancer evaluation Extra-oral/intra-oral hard/soft tissues NOT INCLUDED Dental history Dental history Medical history Medical history General health assessment General health assessment Dental caries, missing or unerupted Dental caries, missing or unerupted teeth teeth Restorations Restorations Existing prosthesis NOT INCLUDED Occlusal relationships Occlusal relationships Periodontal conditions including Periodontal conditions including periodontal screening and/or periodontal charting charting Hard and soft tissue anomalies NOT INCLUDED

23 Oral evaluation for a patient under three years of age and counseling with primary caregiver CDT 2018, p. 5: D0145 Diagnostic services performed for a child under the age of three, preferably within the first six months of the eruption of the first primary tooth, including recording the . . .

Oral evaluation for a patient under three years of age and counseling with primary caregiver

• Oral and physical health history, • Evaluation of caries susceptibility, • Development of an appropriate preventive oral health regime, • Communication with and counseling of the child’s parent, legal guardian and/or primary caregiver.

24 Pre-diagnostic Services

…. and other individuals may report any of the listed CDT Codes as long as they are acting within the scope of their state law.

Screening of a Patient CDT 2018, p. 7: D0190

A screening, including state or federally mandated screenings, to determine an individual’s need to be seen by a dentist for diagnosis

25 Assessment of a Patient CDT 2018, p. 7: D0191

A limited clinical inspection that is performed to identify possible signs of oral or systemic disease, malformation, or injury, and the potential need for referral for diagnosis and treatment.

Diagnostic Codes (related to caries risk)

26 Caries risk assessment and documentation, with a finding of low risk. Using recognized assessment tools CDT 2018, p. 11: D0601

Caries risk assessment and documentation, with a finding of moderate risk. Using recognized assessment tools CDT 2018, p. 11: D0602

Caries risk assessment and documentation, with a finding of high risk. Using recognized assessment tools CDT 2018, p. 11: D0603

“Evaluation of caries susceptibility”

Caries Risk Assessment Forms for –Age 0 to 6 years and –>6 years

www.ada.org Search, enter: “caries risk assessment forms”

27 Preventive Services

Other than Prophylaxis or Periodontal Procedures

Fluoride Treatment (Office Procedure)

Prescription strength fluoride product designed solely for use in the dental office, delivered to the dentition under the direct supervision of a dental professional. Fluoride must be applied separately from prophylaxis paste.

28 *Factors increasing risk for caries may include but are not limited to:

High level of caries experience or demineralization History of recurrent caries High titers of cariogenic bacteria Existing restoration(s) of poor quality Poor Inadequate fluoride exposure Prolonged nursing (bottle or breast) Poor family dental health >>>>>>>

*Factors increasing risk for caries may include but are not limited to: Developmental or acquired enamel defects Developmental or acquired disability Xerostomia Genetic abnormality of teeth Many multisurface restorations Chemo/radiation therapy Eating disorders Drug/alcohol abuse *ADA Guidelines Irregular dental care July 2004

29 Topical application of fluoride varnish CDT 2018, p. 15: D1206

Topical application of fluoride – excluding varnish CDT 2018, p. 15: D1208

Interim caries arresting medicament application – per tooth CDT 2018, p. 16: D1354

30 Documentation for Radiographs

Guidelines for Prescribing Dental Radiographs

From: American Dental Association and U.S. Food & Drug Administration 2004, then Updated 2012

www.ada/org/prof/resources/topics/radiography.asp www.fda.gov/cdrh/radhlth/adaxray.html

Guidelines for Prescribing Dental Radiography, 2012 Page 3 of Report Radiographic screening for the purpose of detecting disease before clinical examination should not be performed. A thorough clinical examination, consideration of the patient history, review of any prior radiographs, caries risk assessment and consideration of both the dental and the general health needs of the patient should precede radiographic examination.

31 ADA Clinical Indicators for Dental Radiographs A. Positive Historical Findings 1. Previous periodontal or endodontic therapy. 2. History of pain or trauma. 3. Family history of dental anomalies. 4. Postoperative evaluation of healing. 5. Remineralization monitoring 6. Presence of implants or evaluation of implant placement.

ADA Clinical Indicators for Dental Radiographs B. Positive Clinical Signs and Symptoms 1. Clinical evidence of periodontal 13. Evidence of foreign objects disease 14. Pain and/or dysfunction of the 2. Large or deep restorations TMJ 3. Deep carious lesions 15. Facial asymmetry 4. Malposed or clinically impacted teeth 16. Abutment teeth for fixed or 5. Swelling removable partial prosthesis 6. Evidence of dental/facial trauma 17. Unexplained bleeding 7. Mobility of teeth 18. Unexplained sensitivity of 8. Sinus tract (“fistula”) teeth. 9. Clinically suspected sinus 19. Unusual eruption, spacing or pathology migration of teeth 10. Growth abnormalities 20. Unusual tooth morphology, 11. Oral involvement in known or calcification or color suspected systemic disease 21. Missing teeth with unknown 12. Positive neurologic findings in reason the head and neck 22. Clinical erosion

32 “Cleaning” Codes

Prophylaxis – Child CDT 2018, p. 15: D1120 Removal of plaque, and stains from the tooth structures in the primary and transitional dentition. It is intended to control local and irritational factors. Prophylaxis – Adult CDT 2018, p. 15: D1110 Removal of plaque, calculus and stains from the tooth structures in the permanent and transitional dentition. It is intended to control local and irritational factors.

33 Scaling in the presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation. CDT 2018, p. 39: D4346

The removal of plaque, calculus and stains from supra- and sub-gingival tooth surfaces when there is generalized moderate or severe gingival inflammation in the absence of periodontitis. It is indicated for patients who have swollen, inflamed gingiva, generalized suprabony pockets and moderate to severe . Should not be reported in conjunction with prophylaxis, scaling and root planning, or procedures.

www.ada.org

CDT 2018 pp. 288-298

34 Full mouth debridement to enable comprehensive evaluation and diagnosis on a subsequent visit CDT 2018, p. 39: D4355

Full mouth debridement involves the preliminary removal of plaque and calculus that interferes with the ability of the dentist to perform a comprehensive oral evaluation. Not to be completed on the same day as D0150, D0160,or D0180.

Full mouth debridement to enable comprehensive evaluation and diagnosis Narrative needed describing: ● why debridement necessary ● description of tissues, bleeding, amounts of plaque and calculus, etc. ● length of time since last “cleaning” ● x-rays and/or photos showing calculus deposits and degree of gum infection

35 When is Initial Periodontal Therapy (Scaling and Root Planing) Indicated? When there is evidence of active disease bleeding on probing Increased pocket depth Continued attachment loss (i.e. recession) Increased Purulent (pus) discharge/suppuration Sequential radiographic change of crestal bone

Comprehensive Periodontal Therapy: A Statement by the American Academy of Periodontology

• Health Professionals • Clinical/Scientific Resources • Scroll to Academy Statements • Comp Perio Therapy (from jop, July 2011)

36 Report sets forth the scope, objective and procedures that constitute periodontal therapy: Scope of Periodontal Therapy Periodontal Evaluation Establishing a Diagnosis, Prognosis and Treatment Plan Informed Consent and Patient Records Treatment Procedures Evaluation of Therapy Factors Modifying Results Periodontal Maintenance Therapy

Our responsibility to our patients:

We inform. We document. We all share the same culture in the office. We all have the same “Standard of Care”. We have a team on board serving the patients’ perio and restorative treatment needs.

37 Scaling and Root Planing CDT 2016, p. 36-37: D4341/D4342

This procedure involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. It is indicated for patients with periodontal disease and is therapeutic, not prophylactic, in nature. Root planing is the definitive procedure designed for the removal of and dentin that is rough, and/or permeated by calculus or contaminated with toxins or microorganisms. Some soft tissue removal occurs. This procedure may be used as a definitive treatment in some stages of periodontal disease and/or as a part of pre-surgical procedures in others.

Periodontal Periodontal Scaling and Root Scaling and Root Planing – Planing – four or more one to three teeth, per teeth, per quadrant quadrant

CDT 2018, p. 39: D4341 CDT 2018, p. 39: D4342

38 Periodontal Maintenance Procedures CDT 2016, p. 37: D4910

This procedure is instituted following periodontal therapy and continues at varying intervals determined by the clinical evaluation of the dentist, for the life of the dentition or any implant replacements. It includes removal of bacterial plaque and calculus from supragingival and subgingival regions, site specific scaling and root planing where indicated, and polishing the teeth. If new or recurring periodontal disease appears, additional diagnostic and treatment procedures must be considered.

Example: “If benefits unavailable or exhausted for Periodontal Maintenance, please consider an alternate benefit for Adult Prophylaxis.”

39 RDH Magazine February, 2014

Site Specific Scaling & Root Planing

What code to use?

40 RDH Magazine November, 2014

After active periodontal therapy and a period of maintenance, is it ever appropriate to report code D1110 (prophylaxis) for recall visits?

What does the American Dental Association say?

41 Response . . . “This is a matter of clinical judgment by the treating dentist. Follow-up patients who have received active periodontal therapy (surgical or non-surgical) are appropriately reported using the periodontal maintenance code D4910. However, if the treating dentist determines that a patient’s oral conditions can be treated with a routine prophylaxis, delivery of this service and reporting with code D1110 may be appropriate.” From CDT 2016, p. 103

Other Procedures Which may be necessary for patients requiring periodontal therapy

42 Implant maintenance procedure when prostheses are removed and reinserted, including cleansing of prostheses and abutments. CDT 2018, p. 63: D6080 This procedure includes active debriding of the implant(s) and examination of all aspect of the implant system(s), including occlusion and stability of the superstructure. The patient is also instructed in thorough daily cleansing of the implant(s). This is not a per implant code and is indicated for implant supported fixed prostheses.

Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure CDT 2018, p. 63: D6081 This procedure is not performed in conjunction with D1110, D4910 or D4346.

43 Debridement of a peri-implant defect or defects surrounding a single implant, and surface cleaning of the exposed implant surfaces, including flap entry and closure. CDT 2018, p. 58: D6101

No descriptor; however, at the Code Maintenance Committee meeting in March 2018, a submission suggesting a new code for “disruption of subgingival using air and water pressure combined with a low-abrasive powder on Tooth surfaces and implants” was rejected because “The CMC determined that this action request is for a technique that is appropriately reported with CDT code D6101 ….”

Local Anesthesia Codes

“Local anesthesia is usually considered to be part of Restorative, Endodontic, Periodontal, Removable Prosthodontic, Implant Services, Fixed Prosthodontic and Oral and Maxillofacial Surgical Procedures”

Local anesthesia CDT 2018, p. 87: D9215 Local anesthesia not in conjunction with operative or surgical procedures CDT 2018, p. 87: D9210

44 Oraqix™ (Lidocaine and Prilocaine)

Kovanaze™ (Tetracaine HCl and Oxymetazoline HCl)

FDA approved as of June 29, 2016

• Regional anesthesia (#4 - #13) • Pre-filled, single-use sprayer • 2 sprays (0.2 ml per spray) 4-5 minutes apart. www.st-renatus.com

45 OraVerse® (Phentolamine Mesylate)

• Local Anesthetic reversal agent • Accelerates the reversal of lingering numbness • Takes ½ the time

www.septodontusa.com

Cleaning and Inspection of a removable appliance CDT 2018, p. 91

This procedure does not include any required adjustments. Cleaning and inspection of removable complete denture, maxillary D9932 Cleaning and inspection of removable complete denture, mandibular D9933 Cleaning and inspection of removable partial denture, maxillary D9934 Cleaning and inspection of removable partial denture, maxillary D9935

46 Localized delivery of antimicrobial agents via controlled release vehicle into diseased crevicular tissue, per tooth CDT 2018, p. 40: D4381 FDA approved subgingival delivery devices containing antimicrobial medication(s) are inserted into periodontal pockets to suppress The pathogenic microbiota. These devises Slowly release the pharmacological agents so they can remain at the intended site of action in a therapeutic concentration for a sufficient length of time.

Gingival irrigation – per quadrant CDT 2018, p. 40: D4921

Irrigation of gingival pockets with medicinal agent. Not to be used to report use of mouth rinses or non- invasive chemical debridement.

47 Fluoride gel carrier CDT 2018, p. 56: D5986 Synonymous terminology: fluoride applicator A prosthesis, which covers the teeth in either dental arch and is used to apply topical fluoride in close proximity to tooth enamel and dentin for several minutes daily.

Periodontal medicament carrier with peripheral seal – laboratory processed CDT 2018, p. 56: D5994 A custom fabricated, laboratory processed carrier that covers the teeth and alveolar mucosa. Used as a vehicle to deliver prescribed medicaments for sustained contact with the gingiva, alveolar mucosa, and into the periodontal sulcus or pocket.

48 Adjunctive General Services Application of desensitizing medicament CDT 2018, p. 90: D9910 Includes in-office treatment for root sensitivity. Typically reported on a “per visit” basis for application of topical fluoride. This code is not to be used for bases, liners or adhesives used under restorations. Application of desensitizing resin for cervical and/or root surface, per tooth CDT 2018, p. 90: D9911 Typically reported on a “per tooth” basis for application of adhesive resins. This code is not to be used for bases, liners or adhesives under restorations.

Contact Information:

Kathy S. Forbes, RDH, BS Phone: 253-670-3704 FAX: 866-669-9308 Email: [email protected] Professional Dental Seminars, Inc. 1702 Valley Oak Ct Castle Rock, CO 80104

49