Interactive Presentation - Is 60 Minutes Enough Time? What is the Standard of Care? - Washington State Dental Association

Page created by Jason Mccarthy
 
CONTINUE READING
Interactive Presentation - Is 60 Minutes Enough Time? What is the Standard of Care? - Washington State Dental Association
Is 60 Minutes Enough Time?
What is the Standard of Care?
Presenter: Kathy S. Forbes, RDH, BS
            June 23, 2018
             8:30-11:30

Interactive Presentation

                                      1
Interactive Presentation - Is 60 Minutes Enough Time? What is the Standard of Care? - Washington State Dental Association
If you could have as much time as you
  want to complete all the dental hygiene
  procedures you believe are necessary for
  your patients, how much time would you
  schedule?

It all started in June of 2015 . .

October 2015
Issue

                                             2
Interactive Presentation - Is 60 Minutes Enough Time? What is the Standard of Care? - Washington State Dental Association
Dental Hygiene in 1972

                1972
What was the prevailing theory for the
cause of periodontal infections?
How did we treat patients who needed
more than one appointment to complete
their “cleaning”?
How were these appointments billed to
patients as well as “insurance”
companies?

                                         3
Interactive Presentation - Is 60 Minutes Enough Time? What is the Standard of Care? - Washington State Dental Association
Today we will examine:
• The 60-minute Hygiene Appt –
 *1972 vs 2018
 *What is expected of hygienists
 as licensed dental professionals?
 *What is in the best interest of
 the patient?
 *How can we manage a 60
 minute appointment?

   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/Chronic Periodontitis
Case Type IV – Advanced Periodontitis
Case Type V – Refractory Periodontitis

                                                     4
Interactive Presentation - Is 60 Minutes Enough Time? What is the Standard of Care? - Washington State Dental Association
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 = Clinical Attachment Loss

  Does your dentist perform a complete
  periodontal charting on new patients at the
  first appointment?
  Does s/he determine AAP classification?
  Does s/he create the dental hygiene
  treatment plan for that patient? (which
  procedures to be performed)
  Does s/he discuss his/her findings with
  you and collaborate on this classification?

                                                5
Interactive Presentation - Is 60 Minutes Enough Time? What is the Standard of Care? - Washington State Dental Association
Do you perform complete periodontal
 charting on a new patient at first
 appointment?
 Do you determine AAP classification?
 Do you determine the dental hygiene
 treatment plan for that patient?
 Do you discuss your findings with dentist
 and collaborate on this classification?

Development of a Classification System
for Periodontal Diseases and Conditions

                         Annals of
                       Periodontology
                      December, 1999
                       www.perio.org

                                             6
Interactive Presentation - Is 60 Minutes Enough Time? What is the Standard of Care? - Washington State Dental Association
AAP Classification of Periodontal
    Diseases and Conditions
           (Based on 1999 International Workshop)

     Gingival Diseases
     Chronic Periodontitis
     Aggressive Periodontitis
     Periodontitis as a Manifestation of
        Systemic Diseases
     Necrotizing Periodontal Diseases
     Abscesses of the Periodontium
     Periodontitis Associated with
        Endodontic Lesions
     Developmental or Acquired
        Deformities and Conditions

Gingival          A. Plaque                1. Associated
Diseases          induced                  with dental
                                           plaque 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.

                                                            7
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

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

                                                    8
Who determines how much time
you will need to complete the
necessary dental hygiene
treatment?

Should dental hygienists know the benefits
which may be paid (or not paid) for their
patients who have dental insurance?
Why is it important for dental hygienists to
understand what dental “insurance” is and
what it is not?

                                               9
Insurance:
Protection against the
occurrence of an
infrequent, catastrophic
event.

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

                           10
Dental “Insurance”
Not really insurance but a
      Dental Benefit
              or
 Healthcare Financing

But I don’t have time to document
everything!

                                    11
S.O.A.P.
– Subjective Findings (what patient says)
– Objective Findings (what you see)
– Assessment (dental diagnosis)
– Plan (what treatment needed)

A.D.P.I.E.
– Assessment (subjective data and objective
  data)
– Diagnosis (what is the problem)
– Plan (recommended treatment)
– Interventions (procedures completed that day)
– Evaluation (did plan work)

                                                  12
WAC 246-817-305
     Patient Record Content (4-17-16)
This is only a partial listing of requirements:
For each clinical record entry note, the signature,
initials, or electronic verification of the individual
making the entry note.

For each clinical record entry note, identify who
provided treatment if treatment was provided.

The physical examination findings documented by
subjective complaints, objective findings, an
assessment or diagnosis of the patient’s
condition, and plan.

          WAC 246-817-305
    Patient Record Content (4-17-16)
Up-to-date dental and medical history that may affect
dental treatment.
Notation of communication to or from the patient or
patient’s parent or guardian including:
 – Notation of informed consent discussion. This is a
   discussion of potential risk(s) and benefit(s) of
   proposed treatment, recommended tests, and
   alternative to treatment, including no treatment or
   tests.
 – Notation of posttreatment instruction or reference to an
   instruction pamphlet give to the patient.
 – Notation regarding patient complaints or concerns
   obtained in person, by phone call, email, mail or text

                                                              13
How much do you pay each year
   for Malpractice Insurance?
   What are the Limits of Liability?

    RDH Magazine
    November 2013

Top Reasons Hygienists Are Sued
Strategies for Avoiding Malpractice Claims

         Author:
   Dianne Glasscoe Watterson, RDH, BS, MBA

                                             14
Informed Consent

  Revised Code of Washington
   RCW 7.70.060 (updated 2012)
  Consent form – Contents –
  Prima facie evidence – Shared
  decision making - Patient
  decision aid - Failure to use.

                                   15
(a) A description, in language the patient could
    reasonably be expected to understand, of:
        (i)   The nature and character of the
              proposed treatment;
        (ii)  The anticipated results of the
              proposed treatment;
        (iii) The recognized possible alternative
              forms of treatment; and
        (iv) 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;
  (b) Or as an alternative, a statement that the
    patient elects not to be informed of the
    elements set forth in (a) of this subsection.

Examples of Fraud
 Billing for services not performed.
 Upcoding (AKA “remapping”) – billing for one
 procedure when you actually performed
 another
 Misrepresenting patient identities
 Waiver of co-payments and/or deductibles
 Not informing dental carrier you’ve billed
 medical carrier also.

                                                       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.

From
Insurance Solutions
Newsletter:

March-April 2014 Issue
Part 1
May-June 2014 Issue
Part 2

                                             17
Current Dental Terminology

  Jan. 1, 2018 – Dec. 31, 2018

     Where do we start?

                                 18
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.

  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.             > > >>>>>

                                              19
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

                                              20
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

                                                                                21
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.

                       From:
               Coding with Confidence
      (published by Dr. Charles Blair and Associates)
Recommend the following be included:
  Review/documentation of the patient’s medical
  and dental history
  Limited clinical examination including but not
  limited to:
  – Recording dental restorations and conditions such as
       Hard and soft tissue abnormalities
       Plaque and debris levels
       Dental caries
       Oral injuries
       Tooth eruption
       Tooth loss
       Etc.
  – Collection of other oral health data

                                                           22
From:
             Coding with Confidence
    (published by Dr. Charles Blair and Associates)

A dental assessment involves a limited
clinical examination, typically by an
independent hygienist or other mid-level
provider acting within the scope of his/her
state license.

                                       March 2014
                                       Issue

                                                      23
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”

                                                   24
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.

 *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 oral hygiene
Inadequate fluoride exposure
Prolonged nursing (bottle or breast)
Poor family dental health >>>>>>>

                                             25
*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
                                 *ADA Guidelines
    Drug/alcohol abuse
                                    July 2004
    Irregular dental care

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

                                                   26
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

                                                    27
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.

     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.

                                           28
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

                   Prophylaxis – Child
                        CDT 2018, p. 15: D1120

     Removal of plaque, calculus 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.

                                                                           29
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 bleeding on probing. Should
not be reported in conjunction with prophylaxis,
scaling and root planning, or debridement
procedures.

                                         www.ada.org

                                         CDT 2018
                                         pp. 288-298

                                                       30
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.

          Scaling and Root Planing
            CDT 2018, p. 39: 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 cementum 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.

                                                    31
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

Periodontal Maintenance Procedures
                 CDT 2018, p. 40: 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.

                                                         32
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)

 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

                                                33
Standard of Care
Ethical or legal duty of a professional to
exercise the level of care, diligence, and skill
prescribed in the code of practice of his or her
profession, or as other professionals in the same
discipline would in the same or similar
circumstances.

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.

                                                    34
What is ICD-10-CM?

  International Classification of Diseases,
  Tenth Revision, Clinical Modification
  Contains 68,000 codes.

           October 1, 2015 was the
           compliance date to transition
           to ICD-10 code sets.

                          From:
  Diagnostic Coding for Dental Claim Submission
        (published by Dr. Charles Blair and Associates)

  Examples of three diagnosis codes in ICD-
  10-CM:
• Z01.20 Encounter for dental examination
  and cleaning without abnormal findings
• Z01.21 Encounter for dental examination
  and cleaning with abnormal findings (use
  additional code to identify abnormal
  findings)
• Z13.84 Encounter for screening for dental
  disorders.

                                                          35
From:
Diagnostic Coding for Dental Claim Submission
     (published by Dr. Charles Blair and Associates)

    Diseases of the Teeth and Gums
•   KO2.9    Dental caries, unspecified
•   K02.62 Dental caries, extending into dentin
•   K02.63 Dental caries, extending into pulp
•   K02.3    Arrested dental caries
•   K02.51 Dental caries pit and fissure
             (subcategories)
•   K02.61 Dental caries of smooth surface
             (subcategories)
•   K02.7    Dental caries of root surface

 Dental Hygiene in 2018

                                                       36
What has changed since 1972?
 1992 – Washington State
 “Standards of Dental Hygiene
 Conduct or Practice”
 2001 - AAP released position paper
 “Guidelines for Periodontal Therapy”
 2008 - ADHA adopted “Standards
 for Clinical Hygiene Practice” updated
 2016

What has changed since 1972?
 2011 – “Comprehensive Periodontal
 Therapy: A Statement by the
 American Academy of
 Periodontology”
 2016 – “Dental Hygiene Diagnosis:
 An ADHA White Paper”

                                          37
The 60 Minute
Dental Hygiene Appointment

        How?

                             38
Contact info:
 Kathy S. Forbes, RDH, BS
 Phone: 253-670-3704
 FAX: 866-669-9308

 Email:
 prodentseminars@gmail.com
Professional Dental Seminars, Inc.
1702 Valley Oak Ct.
Castle Rock, CO 80104

                                     39
You can also read