CLINICAL PRACTICE Implementing Teledentistry: The Why and the How

By Lorri Detrick

s the COVID-19 pandemic evolved, social distanc- n Asynchronous: The transmission of radiographs, ing became a primary strategy to mitigate the photographs, video, and digital impressions to a practitio- Aspread of infection. Doctors and their patients were ner through a secure electronic communications system. further separated when dental offices across the nation This information is then used to diagnose or provide a were asked to suspend nonessential and elective dental service. ATA defines asynchronous telemedicine as store-“ procedures. Although some states are beginning to gradu- and-forward transmission of medical images and/or data ally re-open businesses — including dentistry — the need because the data transfer takes place over a period of for social distancing due to the continued presence of CO- time, and typically in separate time frames.” Example: VID-19 is expected to be an ongoing realty for many Texted photos and videos or radiographs that are reviewed months. What the consumer demand for in-person, non- by the dentist at a later time. urgent dental treatment will be is unknown. Some predict n Remote patient monitoring (RPM): Collecting per- pent-up demand will overwhelm dental practices. Others, sonal health and medical data for an individual via elec- however, believe that fear of the disease may keep many tronic medical device technologies. The data are trans- from seeking preventive dental care. mitted to a different location (sometimes via a data Public health officials have called upon physicians and processing service) where a practitioner can access the dentists to maximize the use of telehealth as an alterna- data for monitoring conditions and supporting care deliv- tive to in-person visits. Although teledentistry may not ery. Example: Diabetes management via real-time delivery have been high on a list of priorities prior to the pandem- of blood glucose, weight, and blood pressure data. ic, a combination of these and other factors makes a com- n Mobile Health (mHealth): Health care education, pelling reason why it should be now. As dentists begin to practice, and delivery done over mobile communication re-open for business, a new normal will exist, and tele- devices, such as cellphones, tablet computers, and per- dentistry will be an important part of it. sonal digital assistants (PDAs). Example: Video education around specific oral health topics and/or dental procedures. What is teledentistry? In teledentistry, a provider in one location uses tele- How is teledentistry evolving? communications to deliver care to a patient at a distant Teledentistry has primarily been a tool to drive access site. It is a component of telehealth, where electronic and to care in underserved areas. The pandemic has dramat- telecommunications technologies are used to provide ically changed that. Now, teledentistry has become a hu- care and services at-a-distance. Telehealth involves a manitarian tool essential to our overall health care eco- broad scope of remote health care, including patient edu- system. The Health Policy Institute of the American cation and engagement. Dental Association estimates that in normal circumstanc- Teledentistry consists of various modes of delivering es (i.e., pre-COVID-19), someone visited an emergency oral healthcare services or oral health education from a department (ED) every 14 seconds for a dental condition. distance, such as: In our current climate, to ease the burden on EDs, den- n Synchronous: Live, two-way interaction between a tists have been enlisted to triage the treatment of these person (patient, caregiver, or provider) and a provider patients through teledentistry. Patients can be screened using audiovisual telecommunications technology. The via video chat or text chat with photos. Antibiotics can American Telemedicine Association (ATA) defines syn- be prescribed for infections to delay the need for emer- chronous telemedicine as “interactive video connections gent treatment. Treatment is then scheduled for in-per- that transmit information in both directions during the son visits away from the ED, at a dentist’s office. Many same time period.” Example: Live bi-directional video chat. (Continued on Page 38)

36 JOURNAL OF THE MICHIGAN DENTAL ASSOCIATION • JUNE 2020 “As clinicians reengage with patients they should maximize the use of telehealth to determine if an in-person visit is necessary” —Dr. Joneigh Khaldun, Chief Medical Executive, MDHHS

This quote comes from a letter from the Michigan Department of Health and Human Services to Michigan Clinicians — May 3, 2020. dentists have played a critical role in the overall public What drivers are promoting the implementation of health response to the crisis by reducing the load placed teledentistry? on front-line health care workers. In response to COVID-19, the Office of Civil Rights has Most significantly, with offices closed or operating relaxed HIPAA restrictions for the implementation of tele- with fewer staff members and a limited schedule, den- dentistry. Technology applications such as Zoom and tists are using teledentistry to efficiently assess a pa- Facebook Messenger video chat have been specified as tient’s needs and to determine if an in-person visit is nec- acceptable options to use for remote patient communica- essary. Social distancing is maintained by limiting the tion. Penalities for HIPAA violation are being waived, and need for office visits. This has proven to be an effective Business Associate Agreements are no longer required. way to maintain patient contact, address many routine Most dentists are now able, from a technology perspec- needs, and create patient satisfaction. tive, to begin providing teledentistry immediately using a The impact of this surge in utilization of teledentistry smartphone, tablet, or laptop. may have a lasting impact on its long-term use. Prior to Teledentistry facilitates compliance with CDC guid- the pandemic, the use of smart phones and tablets for ance on social distancing and pre-screening of patients taking photos and holding face-to-face chats was widely during the COVID-19 crisis. Patients can complete forms adopted. Many in business were using remote conferenc- remotely for touchless import into the patient’s record. ing technology. During the pandemic, the use of these Postoperative evaluations, consultations, treatment plan tools has exploded throughout society as we all try to presentations, and case management can each be con- keep connected. Our patients are now at ease using ducted without an additional office visit. these methods of communication and they will likely ex- Teledentistry will never replace hands-on, in-person pect to use them in the future. Patient demand for the dentistry. However, our collective society will expect the ability to interact with dental service providers through convenience and safety of digital interaction going forward. text and/or video chat, may make it difficult for payers People will be encouraged to social distance for months, if and regulators to dial back benefit coverage and require- not longer. Those who are aging or have chronic conditions ments for use of teledentistry to pre-pandemic levels. that make them at higher risk will surely re-enter main-

Flowchart — Teledental Emergency Flowchart for COVID-19 Impacted Dental Coverage

By phone, telehealth, video, as approved Bill Code: Initiate Patient-DMD/DDS/RDH D9995 Teledental Encounter (D9996 only if Bill Code: asynchronous) Limited use: D0350 Access, review, update and/or Initiate triage protocol Collect records via interview, create pt. record, med hx (ADA, CDC, etc.) patient photos/video

Include COVID-19 Screening Follow current state Bill Code: orders and CDC/ADA Limited use: D0XXX Conduct salivary- Use most based antigen or current ADA recommendations antibody test when guidance or triaging appropriate and screening Bill for patients procedures provided Flow chart courtesy of In DMD/DDS office — follow current Refer to medical professional or DentaQuest Partnership for CDC/ADA guidance to minimize need ED only if warranted Oral Health Advancement. for aerosol-producing procedures www.DentaQuestpartnership.org

38 JOURNAL OF THE MICHIGAN DENTAL ASSOCIATION • JUNE 2020 stream life cautiously. Maintaining patient contact may be Technology. In the short term, relaxing of HIPAA re- further challenged with unemployment at unprecedented strictions has permitted use of existing technology to ad- levels. Taking time away from work will be more prohibi- dress an urgent need. There likely will come a time when tive than ever. Offering teledentistry is a compassionate patient privacy concerns and HIPAA requirements will way to address these concerns and expand on face-to-face return to pre-pandemic status and technologies selected care. for the short term may need to be replaced. Desirable fea- Digital connectivity increases dental office accessibili- tures to look for in teledentistry solutions include the ty and helps maintain relationships, which in turn fosters ease of integration with patient records, practice man- loyalty to the practice and promotes patient retention. agement/billing software, imaging systems, laboratory Teledentistry provides opportunities beyond emergency intractability, patient communication platforms, and fi- triage. Consumers and dental practices alike can benefit nancial reporting tools. Many software options are from its use for a wide range of services that can improve emerging that address these needs. case acceptance, decrease non-productive use of chair Risk. It is unknown if regulations relaxed during the time, increase compliance with home care recommenda- crisis will return to the pre-COVID-19 status. Currently, tions, increase oral health knowledge, and increase pa- the Drug Enforcement Administration (DEA) has allowed tient engagement with the practice. It can further be used for providers to prescribe narcotics via telehealth. The to attract new patients and grow the practice as patients Centers for Medicare Services (CMS) has waived a re- begin to select dentists who offer this service. quirement that telehealth may only be utilized for exist- ing patients, allowing for the remote evaluation of new How does a practice successfully implement patients. Some states have waived the requirement that teledentistry, short-, and long-term? only providers licensed by the state where the patient re- To successfully implement telehealth services, there sides may provide telehealth treatment. In some jurisdic- are five key operational areas that must be addressed: tions, consent forms for telehealth are not required as technology, risk, reimbursement and coding, process, and long as consent is documented in the doctor’s notes. Pri- communication. (Continued on Page 40)

Flowchart — Teledental Emergency Flowchart for COVID-19 Impacted Dental Coverage

Bill Code: Bill Code: D1330, D9992 D0140, D0170, OTC or Rx medication Bill Code: D9994, and/or D0171, or D0190 Limited use: D0350 Patient self-help D 9311 Collect records via interview, Document Virtual care patient photos/video and Patient education treat Urgent Consultation with medical professional + Emergency Follow current state orders and CDC/ADA Decide if follow-up contact needed recommendations

Notate definitive treatment priority once business Dental professional follow-up: and operations have returned to normal

Refer to medical professional or Constant monitor community and state ED only if warranted recommendations related to COVID-19

JOURNAL OF THE MICHIGAN DENTAL ASSOCIATION • JUNE 2020 39 vate payers have generally made policy changes that correspond to these from governmental agencies in Figure 2 — Sample CDT Coding Scenarios terms of what and how they will reimburse services pro- vided through teledentistry. • An office staff member or call center triages a call to It will be critical for providers to monitor these regula- the dentist, who then talks to the patient and uses live tions as teledentistry services are implemented on a long- audio/video technology to evaluate the problem. Codes: term basis. As with patient privacy concerns, several of D0190 and D09995. Synchronous Screening these regulations may revert to previous restrictions, while • Patient texts photos and video to dentist as follow up many could remain relaxed in the interest of increasing ac- to an in-office procedure; dentist reviews and contacts the cess to care and encourage ongoing social distancing. patient at a later time. Codes: D0171 and D09996. Reimbursement and coding. There are several CDT Asynchronous Post-operative Re-evaluation and CPT codes that may be utilized in billing for teleden- • New patient schedules teledentistry via dentist’s tistry services. Each code set provides specific guidance website, complaining of tooth pain; dentist evaluates for the use of these codes. Additionally, the ADA and the patient via live audio/video technology. Codes: D0140 AMA have issued coding assistance for use of telehealth and D09995. Synchronous Limited Oral Evaluation-Problem codes, including practice implementation tips, coverage Focused and policy summaries, and example coding scenarios. It The ADA’s Interim Guidance for COVID-19 Billing and is important to refer often to these websites and other Coding notes that during the pandemic, many payers coding resources for appropriate use and complete cod- reimburse D0140 and D0170 but may not reimburse D0190, ing guidance, as they are being updated frequently to ad- D0171, or D9992. Additionally, most payers do not dress current needs. Providers may also check with payers to understand reimburse D9995, or D9996 but they do request one of them benefit policies for telehealth, and any specific limita- be added for administrative purposes to best understand the tions on covered services. Nonetheless, the clinician setting where care was provided. ADA guidance on the use must always choose the code that best applies to the ser- of D9995 and D9996 can be found in its COVID-19 Coding vice they deliver and not select a code based on the like- and Billing Interim Guidance document.

Figure 1 — COVID-19 codes to utilize in the billing for teledentistry

Codes that May Be Utilized in Billing for Telehealth Teledentistry CDT Codes Oral Evaluations D0140 limited oral evaluation — problem-focused When reporting a teledentistry service, to describe D0170 re-evaluation — limited, problem-focused the setting where the care was delivered, one or the (established patient; not post-operative visit) other of the following codes should be reported in D0171 re-evaluation — post-operative office visit addition to those for the actual service provided. D0190 screening D9992 dental case management — care coordination D9995 teledentistry — synchronous: Real-time encounter. Reported in addition to other procedures Additional codes to consider to record and report with (e.g., diagnostic) delivered to the patient on the date teledentistry patient care: of service. D1330 oral hygiene instructions D9994 dental case management — patient education to or improve oral health literacy D9311 consultation with a medical health care professional D9996 teledentistry — asynchronous: Information The existence of a CDT code does not assume a payer will stored and forwarded to dentist for subsequent reimburse it. Dentists must carefully review the CDT code to review. Reported in addition to other procedures choose the code that most appropriately represents the (e.g., diagnostic) delivered to the patient on the date service provided. Remember to only code for what you do! of service.

40 JOURNAL OF THE MICHIGAN DENTAL ASSOCIATION • JUNE 2020 lihood for reimbursement. The ADA has posted guidance related to many Figure 3 — CPT Codes and Telehealth specific dental payers and their crite- ria for teledentistry billing. If a payer denies a telehealth claim or reimburs- New Time Required es below the full fee, dentists must Patients Definition for Billing (in mins) learn if a plan contract permits bal- ance billing the patient for the service. 99201 Problem Focused 10 For those dental practices utilizing 99202 Expanded Problem Focused 20 CPT codes for medical billing, addition- al guidance is available through AAOMS 99203 Detailed Problem Focused 30 and the AMA . Figure 3 provides codes 99204 Problem Focused — Mod. Complexity 45 that can be utilized to record and re- port telehealth based on the amount of 99205 Problem Focused — High Complexity 60 time required per service. All dental specialists should confirm with their Established Time Required professional associations and state Patients Definition for Billing (in mins) boards for specific requirements for 99211 Minimal — doctor not required 5 the use of teledentistry. Ensuring that your EMR and prac- 99212 Problem Focused 10 tice management systems are set up 99213 Expanded Problem Focused 15 to bill (and be paid for) teledentistry is 99214 Detail Problem Focused 25 important. Someone overseeing your billing should be able to add the ap- 99215 Comprehensive Problem Focused 40 propriate billing codes, check billing rules of third party payers, and ensure New or needed documentation is added to the Established Time Required patient’s medical record. For example, Patients Definition for Billing (in mins) photos and videos utilized during tele- dentistry need to be saved and up- 99241 Problem Focused 15 loaded into the EMR in case they are 99242 Expanded Problem Focused 30 later requested by a payer as a part of 99243 Detailed Problem Focused 40 claims review. The use of SOAP notes in EMR charting will facilitate this pro- 99244 Problem Focused — Mod. Complexity 60 cess for medical billers. Once a fee has 99245 Problem Focused — High Complexity 80 been determined for a teledentistry encounter, the dentist should have a If your practice does utilize CPT codes for the billing of teledentistry, it is impor- method for remote billing the benefit tant to use the proper modifier, indicating that the visit was provided via telehealth. plan and receiving payment electroni- Two different modifiers can be used when medical billing a telehealth appointment: cally at the time of service. n If you are billing a commercial insurance payer, the modifier should be 95. Process. To best provide a positive n If you are billing Medicare, the modifier should be GT. patient experience and lessen prac- tice risk, it is critical to take the time to develop clear processes. It is im- call for an electronic consent form as a Office policies and procedures for portant that you train your team and component of a teledentistry applica- patient privacy and HIPAA, patient in- review these policies and procedures tion. Add on applications like Docu- take, health histories, patient billing, regularly for needed updates. Sign, Scannable (for printing, complet- need to be updated and/or created to Although formal patient consent ing and scanning back PDF’s), or those accommodate teledentistry. Minors or forms for the use of teledentistry are for creating a fillable online PDF are all others as applicable should not receive not currently required in this HIPAA re- options. Some teledentistry software telehealth services without a parent or laxed environment, the doctor must solutions integrate with common den- guardian visibly present during the document consent in the progress tal EMR systems and have incorporat- teledentistry visit. Request that pa- notes. Logically, best practice would ed these features. (Continued on Page 42)

JOURNAL OF THE MICHIGAN DENTAL ASSOCIATION • JUNE 2020 41 tients not record teledentistry sessions. Communication. Getting word out news about teledentistry and explain Part of your protocol should be to veri- to your existing and potential pa- how and the practice chose to incor- fy the patient’s identity prior to begin- tients can be done inexpensively and porate it into patient care. ning the teledentistry session and ob- effectively using a variety of meth- taining an address and contact number ods. The first important step is to set If you need help . . . should an emergency occur during the up a direct phone number that can be The ADA website has a great deal session for which paramedics or other provided to all patients that is specif- of information on teledentistry to con- agencies may need to be contacted. ic to your teledentistry services. If a sider prior to beginning or expanding It can be helpful to send patients third-party vendor or call center han- teledentistry services. The MDA has scheduled for a teledentistry visit an dles emergency calls, the option of developed a Frequently Asked Ques- email or text in advance of the ap- teledentistry can be added to the tions document addressing key topics MDA SERVICE pointment in order to ensure they are scripting. This option will help to of performing teledentistry during the prepared. Ask them to be in a well-lit screen emergencies requiring imme- COVID-19 virus. Involving the entire space, to have a flashlight, and some- diate care from those that can be office team can drive creativity to en- one with them to retract their cheek. seen via teledentistry on the next hance the processes to improve com- Request that they turn off noises in business day. An email address may munication and patient engagement. PROMISE the space (i.e., televisions, music) and also be linked to the practice website Additional resources can be found on silence notifications on their phones/ so a patient can easily submit a tele- Facebook and LinkedIn, with a pletho- tablets/laptops to avoid distractions dentistry appointment request. ra of webinars and podcasts on tele- during the visit. Once an incoming communication dentistry that can be found through a Consistent implementation of your strategy is developed, reach out to simple Internet search. teledentistry services by any associ- existing patients to let them know of A well-informed, coordinated ap- ates or other employees in your prac- this new service and how it can be ac- proach to teledentistry is the key for The MDA Service Promise: Helping You Succeed tice can reduce risk and improve the cessed. Direct communication via an initiative that will be successful in patient experiences. Developing a email, text, or printed letter using the near term and provide a founda- training plan for the team and being platforms like Lighthouse, Reve- tion for the future.  The MDA works hard to provide the very highest level of service to members. The MDA stands ready to available to assist and answer ques- nueWell, ProSites, or DemandForce help you access member benefits such as insurance products, endorsed services, continuing education, tions as the office implements teleden- are perfect tools for announcing this About the Author dental supplies, and more. Plus, the MDA is your resource to answer questions about human resources, tistry to assure success. information. It’s critical to share the licensure, dental benefits, HIPAA/OSHA, legal questions – everything about dentistry in Michigan. Lorri Detrick is a senior manager at Here’s the MDA Service Promise to you: Additional Resources You May Find Helpful West Monroe Partners, a ADA COVID-19 Coding and Billing Guidance national HELPFULNESS https://success.ada.org/~/media/CPS/Files/COVID/ADA_COVID_Coding_and_ consultancy, in The MDA will work hard to make sure your individual needs are met in a timely manner. Billing_Guidance.pdf the Health Care and Life KNOWLEDGE Telehealth Basics Sciences The MDA will be your information resource, providing you with what you need to know, no matter what your https://www.americantelemed.org/resource/why-telemedicine/ Detrick practice of the practice setting or stage of practice. Emergency Department Visits for Dental Conditions: A Snapshot Chicago office. https://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/ She has more than 20 years of HONESTY HPIgraphic_0420_1.pdf?la=en executive and C-suite experience, and The MDA will be your trusted source for accurate information, and will offer options to address your Notification of Enforcement Discretion for Telehealth Remote Communications nearly 10 years of this has been in particular challenges. leading Dental Support Organization During the COVID-19 Nationwide Public Health Emergency (DSO) operations. She has been https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency- involved in telehealth initiatives in VALUE preparedness/notification-enforcement-discretion-telehealth/index.html both dentistry and outpatient health The MDA will seek your input to create products, services, benefits and resources to enhance value and Medicaid.gov – Telemedicine care provider settings. Prior to joining help you succeed. https://www.medicaid.gov/medicaid/benefits/telemedicine/index.html West Monroe, she served in the chief Telehealth FAQs – AAOMS operating officer role for a mid-size DSO, and most recently provided https://www.aaoms.org/practice-resources/telehealth-faqs operational consulting services.

42 JOURNAL OF THE MICHIGAN DENTAL ASSOCIATION • JUNE 2020 For more information: michigandental.org/Service-Promise