payment models in the medical office - it works… · clean your baby’s gums before teeth come...

Payment Models in the Medical Office

It works…

• I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity.

• I do intend to discuss an “off label” use of a commercial product, fluoride varnish, that is currently approved and in use by the ADA and AAPD in this presentation.

Disclosure Information

C Eve J Kimball, MD Chapter Oral Health Advocate

PA Chapter, American Academy of Pediatrics

Healthy Teeth, Healthy Children A Pennsylvania Medical/Dental Partnership

PA Head Start Healthy Smiles Task Force

Pennsylvania Association of Community

Health Centers

Pennsylvania Coalition for Oral Health

Four Groups Collaborating for Children’s Dental Health in Pennsylvania

Etiology of Early Childhood Caries

Oral Health Examination, Screening, Risk assessment

The Role of Fluoride and Fluoride Varnish (and Sealants)

Anticipatory Guidance

Children with Special Health Care needs

Referral to a Dental Home

Making it Work for You

Fluoridation of Water

Oral Health Policy for Pennsylvania

Maintaining the Safety Net – increasing access to dental care

Access for Head Start Children

Connecting the Dots – Age One Dentistry

TOPICS THEY TACKLE!

Goals for Today

Participants will understand

Oral health prevention

Reimbursement

Progress made in PA

Challenges faced

when implementing preventive oral health

measures in the medical office for children

under 5 (and maybe to 18 or 21 some day)

ALL about oral health and physical

health – can’t have one without the

other

Billing - one payment for REFER

Coding – changes on the medical

horizon – consequences unknown –

D1206 99188, ICD9-CM ICD10-CM

ABC’s

Dental proficiency for medical

professionals, to help eradicate

preventable dental disease (goal

75% of 5 year olds will have no

cavities – currently only 54% are

cavity free)

ABC’s

Education – health literacy

Fluoride – where and when

Growing interest among

medical professionals

ABC’s

Healing of bodies and teeth

Imagine a world of 5 year

olds without cavities, and

65 year olds with teeth!

ABC’s

Justice issues – access to care isn’t

fair (or fare)

Keep on advocating and teaching

Law changes? What is needed?

ABC’s

Medical offices MUST BEGIN the

prevention efforts with first

tooth – it works!

No person left out

Open doors to ALL – Medicaid,

Commercial, and self pay

ABC’s

Payment models that work

- $25 for REFER in the

medical office is fair

Pain free population

ABC’s

Quality, evidence based methods

Referring between medical and dental

health homes

Sealants in schools - ? Glass ionomer for all

1st to 3rd graders on molars without

disease – how to finance it?

ABC’s

Teeth are important – both primary and

permanent!

Universal coverage for dental care – all

ages, all incomes

Varieties of care – utilize hygienists,

assistants, community workers at the

“top of their license”

ABC’s

Water fluoridated across the state (only

75% of municipal supplies are currently

fluoridated)

Xylitol becomes affordable and available

Yes to health homes – and medical/dental

collaboration

ABC’s

Zip up the package and

push it out to a health

literate public!

ABC’s

ECC Consequences Pain

Trouble sleeping

Trouble chewing / inadequate nutrition

Learning problems

Behavior problems (ex: crying, acting out)

School absenteeism

Speech problems

Low self-esteem

Hire-ability as an adult decreased

Systemic infections

Costly emergency visits & restorations

Caries in adulthood

Infectious illness

Negative impact on health - diabetes, obesity, etc - resulting in increased costs of healthcare

Death / decrease in life expectancy

Contributing Factors and

Progression of ECC Risk Factors: Frequent feeds of sugar (via bottle, breast,

or sippy cup; “grazing” “junk food”, sodas, juice drinks, and water flavored with juice)

Decreased saliva production from medications

Genetics Family caries experience Access to dental care Lack of fluoride exposure Poor oral hygiene Vertical bacteria transmission

Only Plain Fluoridated Water

In Sippy Cups and

Between Meals Please!

CONNECTIONS

+

Sugar Calories

Teeth/oral flora

Obesity

Cavities

Sugar

+

Early Childhood Caries (ECC) is the most prevalent chronic disease in U.S. children,

increasing in parallel with obesity

1. Clean your baby’s gums before teeth come in.

2. Brush your child’s teeth with a small smear of fluoride toothpaste twice a day, everyday.

3. Visit the dentist by your child’s first birthday. Healthy teeth are important for overall health.

4. Limit juice, foods, and drinks with sugar, to once a day with a meal.

5. Drink only water in-between meals.

5 Key Oral Health Messages

MO

DE

RA

TE

–

HIG

H R

ISK

• White spots, obvious decay, or previous

restorations • Caregiver had active decay in past 12 months • No dental home for child or caregiver • Frequent snacks, bottle or sippy cup

• Special healthcare needs • Developmental enamel defects • No systemic fluoride exposure

LOW

RISK

Has a dental home Has fluoridated water or takes fluoride supplements No family history of dental disease

** Risk should not be generalized. This is a useful tool for caries risk assessment that should be used in conjunction with clinical judgment and other patient factors**

A SIMPLE ECC Risk Assessment Summary

Use Risk Assessment to Guide the Medical Provider:

•Fluoride varnish application

•Anticipatory Guidance

•Urgency of dental referral

•Dental treatment plan (dentist)

Children with Special Health Care Needs

Oral hygiene-challenges •Adapt toothbrush

•Chewing/swallowing problems limit water intake and “natural” tooth cleansing

•Brushing takes extra time

CSHCN – Patient Factors

Medication effects

• Reduced saliva flow/dry mouth (antihistamines, anti-depressants, inhaled steroids)

• Gingival mucosa overgrowth (phenytoin, calcium channel blockers)

• Oral Candidiasis (steroids)

CSHCN – Patient Factors

•Must have dental home by age 1

• Immediate dental home if pathology is present at any age

•Emphasize prevention strategies

•Apply varnish at all checkups

Photo courtesy of Claudia Iatan

CSHCN – Provider Actions

Fluoride Varnish Application

Referral to a Dental Home

• First dental visit at 12 months (or first tooth)

• Dental appointment within 2-4 weeks if:

• White spots or tooth decay is observed

• Child is at moderate to high risk for ECC

• The first dental visit has not already occurred at age 1

• Immediate call to dentist if:

• Brown spots or advanced progression of ECC is observed

• A dental trauma/emergency is evident

Goals for Referral to a Dental Home

•Dental office contact information

• Insurance participation

•Dentists who

• see kids at 12 months

• see an emergency if you call

•Get to know them personally

•Make the dental appointment before the patient leaves the office

Dental Referral Lists

Repeat all steps every 3 months!

• Risk Assessment

• Examination of the teeth

• Fluoride varnish application

• Education of parents and child

• Referral to dental home

PCPS can REFER:

Making it Work for YOU

Patient calls for

appt.

Patient Arrives,

Insurance verified

MA rooms patient

Patient leaves

Medical Office Oral Health Implementation

MA gives patient

info about OHRA

MA puts varnish and educational materials in room

Provider with patient

Provider does

screening

Fluoride varnish

applied if mod/high

risk (by OHRA)

Educational materials and list of Dentists

Given

Office Champion

Compensable oral health services from Medicaid

• Billed under physician, or NPs (only if in independent practice)

• Training required – www.smilesforlifeoralhealth.org - module 6

• Submit Smiles for Life Training Certification from module 6 (and modules 1-8 have CME credit) – to DPW

• Use CPT (CDT) Code D1206 or CPT Code 99188 (after January 1 2015)

• With ICD-9-CM V07.31 – Need for prophylactic fluoride administration

• ICD 10-CM – Z418 – Encounter for other procedures for purposes other than remedying health state (!)

• Age limit - ≤ 5 years old

• Up to 4 applications per calendar year (every 3 months) for moderate to high risk

Coding and Reimbursement

• Medicaid

• Reimbursement Rates: $18-$25 per fluoride varnish application +OHRA

• Requires training before allowing payment

• Commercial insurance

• Rates not established – deadline May 2015

• So far, will not require training of medical providers for payment

Coding and Reimbursement For Medical Offices

• D1206 and CpT 99188 Medical Provider Procedures in Pennsylvania include:

– risk assessment

– varnish application if indicated

– education

– dental referral

• Can be done at any visit (not just checkups)

• Utilize EHR software for reminder “pop ups” for regular oral health assessments and fluoride application

Pearls for Medical Providers

Check List for Medical Offices Provider credentialing:

Take Smiles for Life Module 6 and obtain CME certificate.

Transmit certificate to PA Medicaid per the bulletin and also to all of the MCOs with whom you participate. Lobby with private insurances to pay.

Flow questions

Who does the risk assessment?

Who does the family education?

Who orders supplies? Who orders the varnish (must have DEA number to order)?

Who gathers the supplies for point of service? In sandwich bags? In baskets? Another way?

Supplies:

Who orders the varnish (needs DEA #)?

Who orders gloves, gauze, toothbrushes to give away? Plastic sandwich bags?

Who fills the bags and puts them in the basket or rooms?

Parent handouts – which ones? How to distribute

Policy: Who will write it (sample

provided) and where must it go?

Procedure: Where will risk assessment,

education, record of procedure, and record of referral be recorded?

• Smiles for Life Curriculum – module 6 required for payment for OHRA/Education/Varnish application/Dental Referral. Has 8 modules available for free CME - www.smilesforlifeoralhealth.org

• Resources – www.healthyteethhealthychildren.org

• Campaign for Dental Health – www.ilikemyteeth.org

• Dentists accepting Medicaid - http://www.InsureKidsNow.gov

• American Academy of Pediatric Dentists – www.aapd.org There is a link to a website for parents.

• “My Waters Fluoride” for fluoride concentration in tap water anywhere in the US - apps.nccd.cdc.gov/MWF/Index.asp

Professional Resources

A special thank you to

Paul Westerberg, DMD

David Kelley, MD

• American Academy of Pediatrics - Oral Health Section (has many practical resources and PACT detailed course with 11 hours free CME!) - www.aap.org/oralhealth/

• National Maternal & Child Oral Health (MCOH) Resource Center – www.mchoralhealth.org/PediatricOH/index.htm

• AAP website for parents - www.HealthyChildren.org

• Bright Futures in Practice: Oral Health – www.brightfutures.org/oralhealth/pdf/index.html

• National Head Start Oral Health Resources: http://eclkc.ohs.acf.hhs.gov/hslc/tta-system/health/Health/Oral%20Health

• Information re laws about fluoride in water: http://www.fluidlaw.org

Professional Resources

Eve Kimball, MD, Chapter Oral Health Advocate – 610-463-8775, ekimball@aacpp.com Thomas J. Maroon, MD, Chapter Oral Health Advocate – 724- 832-0850, thomasmaroon1@gmail.com Bonnie Magliochetti, Project Coordinator 484-446-3059, hthc@paaap.org

Additional Help or Information

Questions?