carta circular #m2004118 a todos los dentistas...

Triple-S Salud, Inc. and Triple-S Advantage, Inc. are independent licensees of the BlueCross BlueShield Association.

PROV_2020_65_S

CARTA CIRCULAR #M2004118

20 de abril de 2020

A TODOS LOS DENTISTAS PARTICIPANTES DE TRIPLE-S SALUD, INC.

(COMERCIAL) Y TRIPLE-S ADVANTAGE, INC. (TRIPLE-S)

Re: Aclaración de reglas de facturación y tarifas aplicables para servicios dentales

mediante uso de tecnología (Teledentistry) durante la emergencia por el COVID-19

En Triple-S continuamos trabajando para garantizar el acceso a servicios de salud a nuestros

asegurados y afiliados y ayudar a mitigar la propagación del virus COVID-19. En respuesta a las

reacciones de nuestra red de proveedores dentales generadas por la Carta Circular #M2004102

emitida el 16 de abril de 2020, queremos repasar las reglas de facturación aplicables a estos

servicios.

Según establecido por las reglas de la ADA el 31 de marzo de 2020, y aclarado en la Guía de la

ADA Versión 2 del 27 de marzo de 2020 (Anejo 2), los códigos de Teledentistry deben ser

facturados en conjunto con el código de procedimiento ofrecido al paciente. Por tal razón, le

notificamos que Triple-S está reconociendo los códigos de Teledentistry en conjunto con los

códigos de servicios brindados, entiéndase la evaluación aplicable, según el nivel de cuidado

requerido. Dichos códigos deben venir identificados con el POS 02 en el campo #38 de su

facturación electrónica. La tarifa aplicable es la tarifa actual contratada. Para su referencia,

se adjunta la tabla de códigos aplicables (Anejo 1).

A tales efectos, le incluimos los códigos que deberá utilizar para facturar los servicios prestados

mediante tecnología y aclaramos la tarifa correspondiente. Lo aquí descrito será efectivo de

manera retroactiva al 20 de marzo de 2020.

CDT DESCRIPCIÓN TARIFA

D9995

Teledentistry – synchronous; real-time encounter. Reported in addition

to other procedures (e.g., diagnostic) delivered to the patient on the

date of service

$15.00

D9996

Teledentistry – asynchronous; information stored and forwarded to

Dentist for subsequent review. Reported in addition to other procedures

(e.g., diagnostic) delivered to the patient on the date of service.

$15.00

Cada servicio prestado debe ser documentado en su expediente médico, según descrito en esta

comunicación. Del mismo modo, debe tomar en consideración los siguientes puntos:

• No se le aplicarán deducibles o coaseguros;

• La facturación podrá ser electrónica;

• Deberá documentar en su nota de progreso la tecnología utilizada;

• Las órdenes médicas para medicamentos o estudios especializados deben ser enviadas de

manera electrónica al proveedor de preferencia del paciente.


PROV_2020_65_S

A manera de ejemplo, en una situación en la cual el médico preste un servicio mediante una

evaluación telefónica por video teleconferencia por un problema de dolor molar, el médico debe

documentar el historial del paciente, la evaluación dental, la metodología de tecnología utilizada

y el consentimiento del paciente. En este caso, la facturación debe contener lo siguiente:

• D0140 con POS 02 en campo número 38

• D9995

El pago emitido corresponderá a la tarifa contratada para el código D0140 sumado a la tarifa del

código D9995 cuyo resultado sería mayor al pago de una tarifa presencial previo al estado de

emergencia por el COVID-19.

Cabe destacar que estos servicios son aplicables a todos sus pacientes independientemente

de la condición que tenga y no se limita a aquellos pacientes que presenten síntomas del

virus COVID-19.

Se advierte que esta carta circular podrá ser revisada de tiempo en tiempo durante esta

declaración de emergencia por el COVID-19, según sea necesario. Dicha política de pago será

efectiva hasta tanto culmine el periodo de emergencia por el COVID-19 o el regulador aplicable

establezca lo contrario, lo que ocurra primero. Agradecemos que tome conocimiento de lo aquí

informado.

Si desea obtener más información, puede comunicarse con nuestro Centro de Servicio al

Proveedor según la línea de negocio aplicable:

Triple-S Advantage

1-855-886-7474

lunes a viernes 8:00 a.m.-4:30 p.m./ sábado 8:00 a.m.-2:00 p.m.

Triple-S Salud (Comercial)

787-749-4700 o al 1-877-357-9777 (libre de cargos)

lunes a viernes 8:00 a.m.-4:30 p.m. / sábado 8:00 a.m.-12:00 p.m.

Cordialmente,

Benjamín Santiago, MD

Vicepresidente

División de Manejo Médico

Triple-S Salud, Inc.


PROV_2020_65_S

Anejo 1: Tabla de Códigos de Evaluación Dental

CDT DESCRIPCIÓN

D0120 Periodic oral evaluation – established patient

D0140 Limit oral evaluation – problem focused

D0150 Comprehensive oral evaluation – new or established patient

D0160 Detailed and extensive oral evaluation – problem focused, by report

D0180 Comprehensive periodontal evaluation – new or established patient

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This is evolving guidance and will be modified as more information becomes available. Please checkback frequently.

VERSION: March 31, 2020

Contents

Coding ........................................................................................................................................................... 1

Sample Coding Scenarios (NEW) ................................................................................................................. 3

Frequently Asked Questions ......................................................................................................................... 3

HIPAA & Telecommunication Technology .................................................................................................... 6

Virtual Services During the COVID-19 Pandemic: Practice Considerations Checklist ................................. 6

Informed Consent Forms: Sample Language For Virtual Services .............................................................. 8

Practical Tips for Performing Virtual Evaluations .......................................................................................... 9

Billing: Policies by Payer ............................................................................................................................... 9

The American Dental Association (ADA) recognizes the unprecedented and extraordinary circumstances

dentists and their patients face. Our guiding principles are to mitigate transmission while also supporting

emergency care for patients so as to help prevent overwhelming hospital emergency departments over

the next few weeks. Under these circumstances, while some services will continue to be performed in

dental offices, the ADA recognizes that patients would be best served when telecommunication

technology can be leveraged to support dental care.

The ADA had previously disseminated guidance on use of the teledentistry codes. (D9995 and D9996 –

ADA Guide to Understanding and Documenting Teledentistry Events). The following guide is intended to

help dental offices navigate issues related to coding and billing for virtual appointments during the current

COVID-19 pandemic.

Coding For services rendered in a dental office:

If you see a patient during the current COVID-19 quarantine environment the services you render in the

office should be coded and billed per your current office routines.

For services rendered using telecommunication technology:

If you are providing care using telecommunication technology to triage patients or offer an evaluation to

determine if the situation is urgent or emergent, then the following CDT codes can be used to document

and report the services in the patient’s record and to a third party payer.

Oral Evaluations:

D0140 limited oral evaluation – problem focused

Anejo 2

https://www.ada.org/%7E/media/ADA/Publications/Files/CDT_D9995D9996-GuideTo_v1_2017Jul17.pdf?la=en


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An evaluation limited to a specific oral health problem or complaint. This may require

interpretation of information acquired through additional diagnostic procedures. Report additional

diagnostic procedures separately. Definitive procedures may be required on the same date as the

evaluation.

Typically, patients receiving this type of evaluation present with a specific problem and/or dental

emergencies, trauma, acute infections, etc.

D0170 re-evaluation – limited, problem focused (established patient; not post-operative visit)

Assessing the status of a previously existing condition. For example:

- a traumatic injury where no treatment was rendered but patient needs follow-up monitoring;

- evaluation for undiagnosed continuing pain;

- soft tissue lesion requiring follow-up evaluation.

D0171 re-evaluation – post-operative office visit

Case Management:

D9992 dental case management – care coordination

Assisting in a patient’s decisions regarding the coordination of oral health care services across

multiple providers, provider types, specialty areas of treatment, health care settings, health care

organizations and payment systems. This is the additional time and resources expended to

provide experience or expertise beyond that possessed by the patient.

Teledentistry:

When you are providing services in a teledentistry environment one or the other of the following codes

would be reported in addition to those cited above –

D9995 teledentistry – synchronous; real-time encounter

Reported in addition to other procedures (e.g., diagnostic) delivered to the patient on the date of

service.

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

Reported in addition to other procedures (e.g., diagnostic) delivered to the patient on the date of

service.

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Sample Coding Scenarios (NEW) [Note: In all cases below the relevant teledentistry code should be included. Real-time synchronous

versus Store and forward asynchronous]

Patient contact with dentist who provides the consultation using audio means only

• DENTIST: D0190 (screening) or D0999

Patient contact with dentist who provides the problem focused evaluation using audio and visual means

• DENTIST: D0140 or D0170 or D0171

Patient contact with triage call center who then forwards to dentist who provides the problem focused

evaluation using audio and visual means

• CALL CENTER: D0190 (screening) or D0999

• DENTIST: D0140 or D0170 or D0171

Patient contact with GP dentist (or specialist) who then forwards to specialist (or different specialist) who

provides the problem focused evaluation using audio and visual means

• GP Dentist: D0190 (screening) or D0999

• GENERAL PRACTITIONER OR SPECIALIST DENTIST: D0140 or D0170 or D0171

Frequently Asked Questions What is teledentistry?

Telehealth refers to a broad variety of technologies and tactics to deliver virtual medical, health, and

education services. Telehealth is not a specific service, but a collection of means to enhance care and

education delivery. Teledentistry refers to the use of telehealth systems and methodologies in dentistry.

Teledentistry can include patient care delivery using, but not limited to, the following modalities:

• Live video (synchronous): Live, two-way interaction between a person (patient, caregiver, or

provider) and a provider using audiovisual telecommunications technology.

• Store-and-forward (asynchronous): Transmission of recorded health information (for example,

radiographs, photographs, video, digital impressions and photomicrographs of patients) through a

secure electronic communications system to a practitioner, who uses the information to evaluate

a patient’s condition or render a service outside of a real-time or live interaction.

• Remote patient monitoring (RPM): Personal health and medical data collection from an individual

in one location via electronic communication technologies, which is transmitted to a provider

(sometimes via a data processing service) in a different location for use in care and related

support of care.

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• Mobile health (mHealth): Health care and public health practice and education supported by

mobile communication devices such as cell phones, tablet computers, and personal digital

assistants (PDA).

For more information: D9995 and D9996 – ADA Guide to Understanding and Documenting Teledentistry

Events

Do I need specialized equipment or apps to perform a problem-focused evaluation or re-evaluations virtually?

During this pandemic our goal as dental care providers is to use telecommunication technology to triage

patients and conduct problem-focused evaluations to limit office visits to only those patients who need

urgent or emergency care. Thus, at this time, most dentists will potentially be leveraging

telecommunication technology to provide a limited scope (i.e., problem-focused evaluations and re-

evaluations) interactions with patients. This can facilitate providing advice and performing triage. It can

also facilitate planning for in-person interactions should they become necessary.

There are commercially available applications (apps) that can used through cell phones, tablet computers

and personal digital assistants (PDA). Further, as noted below the federal government has indicated that

they will waive penalties for HIPAA violations against health care providers that serve patients in good

faith through certain non-public facing everyday applications, such as Zoom, FaceTime or Skype. Having

both an audio as well as a visual (video or photographs) component appears necessary to appropriately

conduct a problem-focused dental evaluation. Note that some third party payers in both private and public

(Medicaid) programs may have additional guidelines to determine payment.

Once an evaluation is completed as described by the nomenclature and descriptor of the appropriate

CDT Code, then D0140 or D0170 or D0171 (the procedure performed) can be documented. In addition,

given the current exigent conditions, D9995 or D9996 (indicating the method of transmission i.e.,

synchronous or asynchronous) may be included. Please remember the foundation for the ADA’s position

on coding – “Code for what you do, and do what you coded for.” The dentist is responsible for, and

retains the authority for, ensuring the safety and quality of services provided to patients using

telecommunication technologies and methods. Services delivered should be consistent with in-person

services in the professional judgment of the doctor, and the delivery of services utilizing these modalities

must abide by laws addressing privacy and security of a patient’s dental/medical information.

Can I use my smart-phone or a video conferencing service like Skype? What about text messages and emails?

Telephones that have audio and visual capabilities are appropriate for virtual evaluations. During the

COVID-19 public health emergency, Office for Civil Rights (OCR) will not impose penalties for HIPAA

noncompliance against health care providers that serve patients in good faith through certain everyday

communications technologies. Providers are encouraged to notify patients that these third-party

applications potentially introduce privacy risks, and providers should enable all available encryption and

privacy modes when using such applications.

• DO NOT USE public-facing technologies (examples): Facebook Live, Twitch, and TikTok, etc.



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• CAN USE (examples): Apple FaceTime, Skype, Facebook Messenger video chat, Google

Hangouts video, Zoom

Regarding emails and text messages, the OCR Notification does not address email and text

communication. HIPAA does not prohibit using email or text communications, but a dental office that

wishes to communicate with patients this way must conduct a written risk analysis and implement

reasonable and appropriate safeguards. For some examples of safeguards contact

[email protected].

I am hearing that my insurance company stopped processing claims. Is this true?

Many dental benefit administers have required their staff to work remotely to conform to national

guidelines requiring communities to mitigate transmission of COVID-19. ADA has been informed that

claims submitted electronically are more likely to be processed on time and offices with Electronic Fund

Transfer (EFT) capability will likely receive payment on time. Any transactions that involve paper

processing will take longer under these extenuating circumstances.

Can I perform a problem-focused evaluation on a new patient?

Yes. During these times, there could be patients looking for dental care and may find you through the

ADA’s Find-A-Dentist tool or the benefit plan’s provider directory. The ADA recommends that you offer

assistance to these patients. Please note that a benefit through their plan may be dependent on the

payer’s policies. If you need assistance with claims please contact [email protected].

I understand that some dental benefit plans do not reimburse for teledentistry as reported with CDT code “D9995 teledentistry – synchronous…” or “D9996 teledentistry synchronous…” Even so, what fee should I show for these procedures when I report them on a claim in addition other services (e.g., diagnostic) delivered during the virtual encounter?

The teledentistry procedure codes exist to document and report the additional costs associated with

delivery of services when a patient and their dentist are not in the same physical location. These codes

are analogous to other well-established CDT codes – “D9410 house/extended care facility call” and

“D9420 hospital or ambulatory surgical center call” – that enable to dentist to document and report

additional costs borne by a dentist to deliver services that would otherwise be delivered in-office.

A dentist should separately report the full fee for the actual services (e.g., D0140, D0170, D0171, D9992)

delivered to the patient. Dentists must also determine and report their full fee for the teledentistry

procedure (D9995 or D9996 as applicable to a specific encounter). Note that additional costs that you

incur will depend on the type of tools/technology you have in place and the type of services you will

provide. For example, under normal circumstances a virtual dental home, which offers the patient an

opportunity to receive comprehensive care may be established using advanced telehealth

tools/technologies. However, under the current exigent conditions, procedures that can be performed

virtually are potentially limited to those noted in this guidance document requiring less complex

tools/technology.

https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html

https://www.hhs.gov/hipaa/for-professionals/faq/2006/does-the-security-rule-allow-for-sending-electronic-phi-in-an-email/index.html

mailto:[email protected]


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Factors to consider when determining the full fee include the costs to enable remote communication

technology for the transmission of health information required to effectively connect and interact with the

patient. The teledentistry procedure fee does not include the fees for actual services delivered to the

patient as noted above. A separate payment for the D9995 and D9996 procedures will depend on payer

policies.

Preventive procedures such as prophylaxis and fluoride varnish applications are covered “once every 6 months” rather than “twice a year”. Can the frequency limitations be standardized to twice a year to allow some flexibility as we reschedule patients?

The ADA is looking into this issue as of this writing and will provide an update at a later date.

HIPAA & Telecommunication Technology The Centers for Medicare & Medicaid Services (CMS) and the Office for Civil Rights (OCR) issued

guidance regarding HIPAA and use of telehealth remote communications during the COVID-19 public

health emergency that includes the following information:

• OCR is exercising its enforcement discretion to not impose penalties for noncompliance with the

HIPAA Rules in connection with the good faith provision of telehealth using non-public facing

audio or video communication products during the COVID-19 nationwide public health

emergency.

• Under this Notice, covered health care providers may use popular applications that allow for

video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video

or Skype, to provide telehealth without risk that OCR might seek to impose a penalty for

noncompliance with the HIPAA Rules related to the good faith provision of telehealth during the

COVID-19 nationwide public health emergency.

• Providers are encouraged to notify patients that these third-party applications potentially

introduce privacy risks, and providers should enable all available encryption and privacy modes

when using such applications.

• Under this Notice, however, Facebook Live, Twitch, TikTok, and similar video communication

applications that are public facing should not be used in the provision of telehealth by covered

health care providers.

Virtual Services During the COVID-19 Pandemic: Practice Considerations Checklist The checklist below helps dentists who are new to using remote telecommunication technology, or those

dentists who have systems that won’t function well in the current environment, to perform problem-

focused evaluations virtually.

https://www.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf

https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html

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Identify your support system

• Are you doing this on your own or do you have staff to assist?

• Will you offer virtual services only to your established patients or to any new patients as well?

TIP: Plan on allowing time for paperwork to be done either by you or your staff.

Identify the right technology

• Do you have a dedicated business cell phone or laptop?

• Do you have reliable internet connection?

• Are you going to use free tools like Skype, FaceTime or Zoom? Or do you want to use

commercial applications?

• What technology are your patients most likely to have access to and be comfortable using?

• Are you open/able to using multiple platforms for greater patient choice, or would it be best for

you to pick the one that you are most comfortable with?

TIP: The advantage of commercial applications is that they might allow you to manage paperwork (e.g.

patient consent) and they offer HIPAA compliant encryption for data transmission. However, there will be

a cost to use these commercial applications. Some will only work with intra-oral cameras since they were

designed for pre-COVID teledentistry applications. Patients may need to download this additional

application on their phones or personal computers to make it work. The popular non-public facing

consumer telecommunication services like FaceTime, Zoom and Skype can use the smartphone’s

camera system. The Office for Civil Rights (OCR) will not impose penalties for HIPAA noncompliance

against health care providers that serve patients in good faith through certain non-public facing everyday

communications technologies during the COVID pandemic.

Inform your patients

• Do you want to identify preferred times during the day when patients can reach you virtually,

especially if you are continuing to see patients who need emergency services in your office?

• How will you schedule appointments and send reminders if needed?

• How will the patients be informed that they can reach you for virtual services?

TIP: Patients may call you in case of emergency at any time. However there may be patients who are

unsure and still need a consultation. Such patients likely can be requested to call during preferred times

during the day.

Prepare for the paperwork

• Do you have the following paperwork ready?

o Patient intake forms, especially if you do not have access to your practice management

software

o Informed Consent form (which includes information on billing/charges)

o Medical/Dental History forms for new patients

• How will you securely save any images that the patient may have shared with you to include this

in the patient’s record?

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• Can you update the patients’ records within your practice management system to record the

virtual services that you have provided?

• How will you submit claims if you have performed a problem-focused evaluation?

Prepare for follow-up and care coordination

• If the patient needs follow-up care, do you know what procedures you are able to safely provide?

• Do you know which specialists are accepting patients?

• How will you document your referral and care coordination?

• How will you keep a paper or digital record of all of the patients needing non-urgent follow up care

when you get back to the office?

If you need assistance with claims please contact [email protected]

Informed Consent Forms: Sample Language For Virtual Services Our dental office [OR: NAME OF DENTAL PRACTICE] will be using [NAME OF REMOTE COMMUNICATION APPLICATION(S)] remote communication technology to conduct problem-focused evaluations/re-evaluations virtually, to help manage your oral health problem and to determine whether you have a condition that requires immediate in-office treatment.

During the current pandemic the federal government announced that it will not enforce HIPAA regulations (privacy for health records) in connection with medical and dental offices’ good faith provision of medical or dental services using non-public facing audio or video remote communications services. Remote patient consultations may take place over applications that allow video chats such as Apple Face Time, Facebook Messenger video chat, Google Hangouts, or Skype and may involve or be based on photos or videos taken with smart phones by the patient and transmitted to the dental office. Please do not contact us using public-facing services such as Facebook Live, Twitch, or TikTok, which are not permitted by the federal government for this purpose.

As always, our office will take dental record confidentiality very seriously, and will do what we can under the circumstances to protect the information you send us. While we believe the risk to such confidentiality is not high, it may be greater than it would be if these remote electronic communications were encrypted, which is one of the main HIPAA requirement that is being relaxed during the nationwide COVID-19 public health emergency.

Certain major dental plans have announced that they will reimburse dental offices for conducting such remote evaluations, and we will submit claims in connection with them.

Our dental office is using one or more of the permitted modalities listed above for remote transmission of information to conduct limited problem focused evaluations. While entirely adequate in the vast majority of cases for such limited purposes, these evaluations may not reveal conditions that would be discovered during an office visit or through the use of specialized teledentistry technology.


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Please indicate your understanding of and informed consent to these terms, which will be in effect until the government rescinds its suspension of these HIPAA requirements, by typing your name in the space provided and return via email to this office.

Practical Tips for Performing Virtual Evaluations The following tips may be helpful in conducting virtual evaluations:

• Request patient to have a flashlight handy.

• Request patient to have a family member assist in holding the phone or retracting the cheek as

needed.

If you have conducted virtual evaluations and have tips to share please email [email protected]

Billing: Policies by Payer The ADA has been reaching out to third party payers to determine their policies with regards to payment

for services rendered using telecommunication technology. Below is the information we have collected

thus far. The ADA has also been following guidance being issued by CMS de-regulating telehealth and

offering benefits for virtual check-ins as a means to support primary care. We are exploring if this

guidance applies to dental care.

The ADA advises that all patient encounters using telecommunication technology continue to be

appropriately documented in the patient’s record including date/time/duration of encounter, reasons for

such encounter and associated clinical notes.

See next page. As of 8 AM CENTRAL March 30, 2020 [will be updated daily during this public health

emergency]


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Payer Information as received by the ADA (in no particular order):

Would plans you administer benefit limited problem-focused evaluations performed using telecommunication technology? (D0140, D0170, D0171)?

Would plans you administer benefit a consultation with the patients’ physician? (D9311)

Will frequency limits be waived to not count towards evaluations that may be needed later in the year when D0140, D0170 and D0171 are submitted?

United Healthcare We will administer benefits for TeleDentistry for codes D0140, D0145, D0170, D0171, D9992, D9995, and D9996.

NA Limits on frequency will be waived until April 30, 2020, at which time we will re-evaluate an extension.

Delta Dental National Dental Policy Committee Recommendations

Yes, unless there is a specific exclusion, member companies will benefit D0140 per group contract whether provided in a dental office or virtually. D0170 and D0171 are generally considered inclusive in the prior treatment or consultation. It is important that dental offices and members verify coverage of D0140, D0170 and D0171 on the web portals, electronically, or with the Interactive Voice Response (IVR) systems.

D9311 is generally not a covered benefit. Please check your patients’ benefits for those groups that may cover a physician consultation

In light of the extraordinary circumstances arising from the COVID-19 crisis, member companies will consider frequency limitations for exams on a case-by-case basis, with the goal of covering routine exams in addition to any emergency exams that may be conducted during the crisis.

Envolve In response to COVID-19 emergency measures, Envolve Dental, Inc. (a Centene Corporation subsidiary) will cover CDT codes D0140, D0170, D0171, and D0350 when reported with teledentistry codes D9995 or D9996, as applicable. Envolve Dental will pay D9995 and D9996 at established state fee schedule rates, if available. In the absence of respective state rates, D9995 will be reimbursed at $12.27 and D9996 will be reimbursed at $14.80. It is limited in

-- NA -- -- NA --

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time to the shorter of 90 days or thelifting of COVID-19 emergencymeasures limiting dental services toemergency services only.

AetnaWill reimburse for it when performed viateledentistry, same as if it is performedin a traditional practice setting.We cover D0140 and D0170 today. Wedo not currently cover D0171.We do not offer a separate benefit forthe two teledentistry codes. Whensubmitted, we use those codes to alertus that the service was not performed ina traditional office setting.

We do not currently cover D9311. In most of Aetna’s dentalplans, members are allowedtwo problem-focused exams(i.e., D0140 or D0170) in acalendar year in addition totwo comprehensive orperiodic oral exams (D0150or D0120.) Moreimportantly, when D0140and D0170 are performed bya specialist, those examsare not subject to frequencylimits.Aetna Dental is currentlyinvoking our disasterrecovery protocols that allowus to take unique situationsinto account to help dentalmembers andproviders. Our “servicewithout borders” approachallows our service team toconsider a provider’s specialcircumstances whenprocessing a claim.

Liberty Yes. Yes. Yes

MetLife Limited and problem focusedevaluations are typically covered byMetLife plans. To the extent it iscovered by a MetLife plan, suchevaluations via tele-dentistryconsultation would becovered. However some employerdental plans may not cover limited and

MetLife dental plans typically coverphysician consultations with respectto covered services. However someemployer dental plans may not coverphysician consultations so MetLiferecommends that dentists andcovered plan members check withMetLife to determine if this service is

MetLife has developedspecific criteria to addresssituations where an enrolleddental plan member’s dentalbenefits are adverselyaffected because theindividual is a victim of theCovid-19 virus. If the claim

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problem focused evaluations so MetLiferecommends that dentists and coveredplan members check with MetLife todetermine if these services are coveredunder the specific employer’s dentalplan that the patient is enrolled in.

MetLife also recommends that dentistsand covered plan members check withMetLife to determine if tele-dentistryservices which may be separate fromthe actual completion of the evaluationsare covered under the specificemployer’s dental plan that the patient isenrolled in. Benefit coverage can alsobe verified using MetLife’s webportal, MetDental, for dentists as well asMetLife’s interactive voice response[IVR]] capabilities.

covered under the specificemployer’s dental plan that thepatient is enrolled in. Benefitcoverage can also be verified usingMetLife’s web portal, MetDental fordentists as well as MetLife’sinteractive voice response [IVR]capabilities.

meets these criteria and weare notified that theindividual is a victim of thevirus, MetLife will allowbenefits. This criteria is inplace for insured dentalplans. MetLife has alsorecommended thatemployers with self-fundeddental plans also follow thesame criteria that has beendeveloped.

[Metlife continues to evaluate this guidance. Updates will be posted as available]

United Concordia Yes to D0140 when performed usingphoto image or video will be covered

No There would be case-by-case exceptions. UCDexpects dentists to bill 0140for teledentistry for the next90 days.

Humana Yes - Humana will allow benefits fortele-dentistry consultation for limited andproblem-focused evaluation and re-evaluation (D0140, D0170 & D0171).Please note that the aforementionedevaluation codes should beaccompanied by the tele-dentistry codesD9995 or D9996. These codes arerequired as descriptor codes and arenot paid as an additional benefit.

Yes – Humana will allow benefits fora physician consultation (D9311) viatele-dentistry.

Frequency limits will bewaived such that theseevaluations do not counttowards a member’s annualfrequency limitations.

Principal Principal will reimburse for serviceswhen performed via tele-dentistry, same

We do not cover code D9311 Principal has enacted ourpandemic response plan,

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as if it is performed in a traditionaldental office setting.We cover D0140 and D0170 today. Wedo not cover D0171. We do not offer aseparate benefit for the two tele-dentistry codes

which allows us to handleclaim situations on anindividual basis. We willtake into consideration thespecial circumstances forboth the member andprovider when determiningfrequency applicability.

Guardian We approve these codes today whenthey are submitted, with or withoutTeledentistry.

No, physician consultations are notcovered under our dental insurancepolicies

No, but we plan to reassessthis policy.

Ameritas We will adjudicate claims the same forservices performed via teledentistry orin person in a traditional practice setting.Our most common plans cover D0140and D0170. We do not cover D0171.We do not offer a separate benefit forthe two teledentistry codes (D9995 andD9996) and will have noreimbursement.

We do not currently cover codeD9311

We will handle on anindividual basis taking intoconsideration the specialcircumstances for both themember and the provider.

Lincoln FinancialGroup

Lincoln will continue administeringlimited and problem-focused evaluationsaccording to policy provisions, whetherperformed in office or through tele-dentistry consultations.

Lincoln’s Dental plans do not providebenefits for physician consultation(D9311)

Under Lincoln’s dental plans,limited and problem-focusedevaluations do not counttoward the frequency limitsfor Preventive oralexaminations.

Cigna Cigna allows benefits for limited andproblem-focused evaluations (D0140,D0170). We will cover these evaluationsif performed in traditional practicesettings or if completed throughteledentistry.Cigna considers post-operative servicescovered as part of the primary servicecompleted.Cigna considers teledentistry (D9995and D9996) as reporting a modality to

Cigna considers (D9311) a dentistconsultation with a medical healthcare professional to be part of thedental services provided directly tothe patient. No separatereimbursement is allowed unlessrequired by state law.

Applicable frequency limitsfor evaluations,including limited andproblem-focused evaluationswill remain in place.

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deliver services generally covered as part of the primary service completed. But D9995 and D9996 may be separately reimbursable where specific plan designs allow or depending on state regulations.

Sun Life Sun Life will reimburse D0140 and D0170 per plan provisions whether service is conducted in the provider’s office or virtually. We do not currently cover D0171.

Our dental plans do not cover physician consultations under ADA code D9311.

Sun Life will consider both the provider and member’s circumstances and handle each request individually.

Dominion National Benefits allowed include consultation for limited and problem-focused evaluation and re-evaluation (CDT codes: D0140, D0170 and D0171).

Dominion will also allow benefits for a physician consultation (D9311) via teledentistry.

Dominion is waiving frequency limits and these evaluations will not count toward a member’s annual frequency limitations until further notice. This will be reviewed periodically and updated as needed.

Anthem Anthem reimburses for all covered dental services the same regardless of provided in a dental office or using teledentistry. Our standard benefit for examinations includes a 2 per 12 month frequency for limited-problem focused exams (inclusive of D0140, D0170) with a separate 2 per 12 months for routine exams. D0171 is a post-operative examination and is standardly disallowed as inclusive of dental surgical or similarly situated care and not reimbursed separately. In relation to synchronous and asynchronous teledentistry (D9995, D9996) we disallow reimbursement, but encourage the submission of these codes with or without fees per ADA/CDT guidance

Anthem’s standard benefit allows reimbursement of D9311 at the same reimbursement as D9310, which is a consultation with a dentist or physician other than the dentist or physician the member originally sought care and may include diagnostic and/or therapeutic services.

We are monitoring member utilization of services provided through teledentistry and dental office visits and will make a determination on the ability to waive frequency limits in consultation with stakeholders. At this time, general guidance among third party teledentistry solutions, is to primarily utilize D0140 mitigating a need to remove standard benefit frequency limits at this time.

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when used as the modality of providingdental care.

Argus Dental Yes – Argus Dental & Vision, (asubsidiary of Aflac, Inc) will cover codesD0140 and D0170 performedtelephonically with the correspondingD9995 or D9996 Tele-Dentistry code.

We do not currently cover the D9311code.

For any plans which includeD0140 or D0170 as coveredbenefits, normal in-officeevaluations done after thepandemic has subsided willbe covered, subject to statedplan limitations.

Blue Cross BlueShieldMassachusetts

Until further notice, we will coverconsultations by telephone or video(“virtual consultations”) between dentalproviders and their patients, effectiveMarch 23, 2020, for all members whoalready have coverage for problem-focused exams (D0140), with no costshare (deductible, copayment, or co-insurance).

• Report virtual consultationservices using CDT codeD0140 (Limited Oral Evaluation– Problem Focused).

• Virtual consultations should bepatient-initiated and related to aspecific dental problem whichwould otherwise have requiredan in-person office visit.

• In the patient’s chart, pleasedocument the problem thatnecessitated the telephone orvideo consultation and what you

• recommended to the patient.

NA NA

Unum/ColonialLife

D0140 or D0170 will be covered perplan provisions when performed virtuallyand submitted with a D9995 or D9996,as descriptor codes, through 6/30/2020or when the COVID-19 emergency

No A D0140 accompanied witheither D9995 or D9996 willnot be counted againstfrequency limitations duringthis period.

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measures limiting dental services arelifted. The D9995 and D9996 will not bepaid as an additional benefit.

GEHA Awaiting response

Wellpoint Awaiting response

Brought to you by the ADA’s Council on Dental Benefit Programs & the Practice Institute, Center for Dental benefits, Coding and

Quality. For questions contact [email protected]


D9995 and D9996 ADA Guide – Version 2 – March 27, 2020 – Page 1 of 10©2020 American Dental Association (ADA). All rights reserved.

D9995 and D9996 – ADA Guide to Understanding andDocumenting Teledentistry Events

Developed by the ADA, this guide is published to educate dentists and others in the dental community onthese procedures and their codes first published in CDT 2018 and effective January 1, 2018.

Introduction

Teledentistry provides the means for a patient to receive services when the patient is in one physicallocation and the dentist or other oral health or general health care practitioner overseeing the delivery ofthose services is in another location. This mode of patient care makes use of telecommunicationtechnologies to convey health information and facilitate the delivery of dental services without the physicalconstraints of a brick and mortar dental office.

The two full CDT Code entries are:

D9995 teledentistry – synchronous; real-time encounter Reported in addition to other procedures (e.g., diagnostic) delivered to the patienton the date of service.

D9996 teledentistry – asynchronous; information stored and forwarded to dentist for subsequent review Reported in addition to other procedures (e.g., diagnostic) delivered to the patienton the date of service.

The following pages contain a number of Questions and Answers, and Scenarios, all intended to providereaders with insight and understanding of how care is delivered and reported when teledentistry is a facetof the process.

Questions and Answers

1. What is telehealth and teledentistry?

Telehealth is not a specific service; it refers to a broad variety of technologies and tactics todeliver virtual medical, health, and education services. As an umbrella term, it is further definedwhen applied to specific health care disciplines, such as dentistry.

Teledentistry, according to the ADA’s Comprehensive Policy Statement on Teledentistry, refers tothe use of telehealth systems and methodologies in dentistry. Teledentistry can include patientcare and education delivery using, but not limited to, the following modalities:

• Live video (synchronous): Live, two-way interaction between a person (patient, caregiver,or provider) and a provider using audiovisual telecommunications technology.

• Store-and-forward (asynchronous): Transmission of recorded health information (forexample, radiographs, photographs, video, digital impressions and photomicrographs ofpatients) through a secure electronic communications system to a practitioner, who usesthe information to evaluate a patient’s condition or render a service outside of a real-timeor live interaction.

• Remote patient monitoring (RPM): Personal health and medical data collection from anindividual in one location via electronic communication technologies, which is transmittedto a provider (sometimes via a data processing service) in a different location for use incare and related support of care.

D9995 and D9996 ADA Guide – Version 2 – March 27, 2020 – Page 2 of 10 ©2020 American Dental Association (ADA). All rights reserved.

• Mobile health (mHealth): Health care and public health practice and education supported by mobile communication devices such as cell phones, tablet computers, and personal digital assistants (PDA).

2. Why are there two teledentistry CDT Codes, but four delivery modalities?

Delivery of Remote Patient Monitoring (RPM) and Mobile Health (mHealth) may occur in either a synchronous or asynchronous information exchange environment.

3. What prompts the need for teledentistry?

Teledentistry is a means to an end – a patient’s oral health. The reason or reasons why a teledentistry event occurs depends on the circumstances, such as when all persons who must be involved are not able to be in the same physical location. Another determining facet is the judgment of the dentist or other oral health or general health practitioner, all acting in accordance with applicable state law, regulation or licensure.

4. How is a teledentistry event affected when the health care practitioners are in different states?

A teledentistry event is subject to applicable state law, regulation or licensure. All involved persons (the dentist or other oral health or general health care practitioner) must determine if a teledentistry event can occur when all participants are not in the same state.

5. What are the notable attributes of a synchronous encounter reported with D9995, and asynchronous teledentistry reported with D9996?

Synchronous teledentistry (D9995) is delivery of patient care and education where there is live, two-way interaction between a person or persons (e.g., patient; dental, medical or health caregiver) at one physical location, and an overseeing supervising or consulting dentist or dental provider at another location. The communication is real-time and continuous between all participants who are working together as a group. Use of audiovisual telecommunications technology means that all involved persons are able to see what is happening and talk about it in a natural manner.

Asynchronous teledentistry (D9996) is different as there is no real-time, live, continuous interaction with anyone who is not at the same physical location as the patient. Also known as store-and-forward, asynchronous teledentistry involves transmission of recorded health information (e.g., radiographs, photographs, video, digital impressions and photomicrographs of patients) through a secure electronic communications system to another practitioner for use at a later time.

6. Who would document and report a D9995 or D9996 CDT Code?

The dentist who oversees the teledentistry event, and who via diagnosis and treatment planning completes the oral evaluation, documents and reports the appropriate teledentistry CDT code. Applicable state regulations may also determine the oral health or general health practitioner who documents and reports these codes.

As noted in their descriptors, either one or the other teledentistry code is reported in addition to other procedures delivered to the patient on the date of service. In addition, both the individuals collecting records in the off-site setting and the dentist reviewing the records should document those activities in the progress notes in the patient’s chart.

7. Are there CDT Codes for: a) documenting collection and transmission of information in a teledentistry event; and b) for receipt of the information?


There are no such discrete codes. As noted in the answer to question #6, the collection, transmission and receipt actions should be noted in the patient’s record. An unspecified procedure by report code may also be used as part of this documentation, with the required narrative report containing the pertinent information.

8. Who would document and report other procedures delivered during a teledentistry event?

The dentist or other oral health or general health practitioner acting in accordance with applicable state law, regulation or licensure, reports the appropriate CDT Code for these procedures, such as prophylaxis, topical fluoride application, diagnostic images. Supervision requirements within a state practice act determine whether the dentist must document and report all the other procedures, or if they may be reported whole or in part by another type of licensed practitioner.

More than one claim submission may be necessary when:

• there is a continuum of care that begins with a teledentistry encounter at a remote location, and continues with other services being delivered at a dental practice location, or

• state practice acts permit different licensed health care practitioners to submit claims for the particular services they provided during the teledentistry encounter.

Notes:

a) Teledentistry is a mode of dental service delivery that, when applicable, is reported in addition to the other procedures provided to the patient.

b) Procedure delivery is by a natural person (e.g., dentist); the billing entity may be a natural person or a legal person (i.e., the facility where the service is delivered).

c) The ADA’s “Comprehensive Policy Statement on Teledentistry” states that dentists and allied dental personnel who deliver services through teledentistry modalities must be licensed or credentialed in accordance with the laws of the state in which the patient receives service. The delivery of services via teledentistry must comply with the state’s scope of practice laws, regulations or rules.

9. Who has responsibility for services delivered via teledentistry?

Responsibility, and liability, for services delivered is determined by applicable state law and regulations. Each dentist, hygienist and others involved in a teledentistry appointment should become familiar with applicable state or federal regulations to determine their liability exposure, and whether or not the person receiving care becomes their patient of record. Please note that “patient of record” may be defined differently under applicable state regulations. This could be a factor to consider in a teledentistry event where the patient and some members of the team of providers are in different states.

10. With responsibility comes potential liability – what should I do to protect myself and my practice when I engage in teledentistry?

As noted in the answer to question #9 (immediately above) liability is determined by applicable state law and regulations. This concern should be discussed with your personal legal counsel and insurance advisor to determine whether or not your existing liability insurance policies cover this risk. Additional personal, professional and practice insurance coverage may be needed to address any coverage gaps.


11. How would D9995 or D9996 be reported on a dental claim submission?

A claim submission includes the services provided to one patient. Each claim detail line identifies the particular procedure and the date it was delivered to the patient. D9995 or D9996 are reported in addition to the codes for other procedures (e.g., prophylaxis; diagnostic imaging) reported separately when the patient presents for care.

Appendix 1 contains teledentistry claim completion instructions illustrated with the ADA Dental Claim Form (©2019) for simplicity. The applicable teledentistry code is reported on a separate service line of a claim submission that also reports all the other procedures delivered during a virtual evaluation. These instructions are also the model for reporting teledentistry CDT Codes on the HIPAA standard electronic dental claim transaction (837Dv5010).

12. Are D9995 and D9996 used when a claim for teledentistry is submitted to a medical benefit plan?

D9995 and D9996 are CDT Codes that are applicable to claims filed against a dental benefit plan. Dental claim content, format and completion instructions differ from claims filed against a medical benefit plan. Claims filed against a medical benefit plan use a unique format, are prepared with different code sets, and follow their own completion instructions. Medical benefit claims are outside the scope of this guide.

13. What documentation should I maintain in my patient records, and what will be needed on a claim submission when reporting D9995 and D9996?

The patient record must include the CDT Code that reflects the type of teledentistry encounter, and there may be additional state documentation requirements to satisfy. A claim submission must include all required information as described in the completion instructions for the ADA paper claim form and the HIPAA standard electronic dental claim. Some government programs (e.g., Medicaid) may have additional claim reporting requirements.

14. What dental benefit plan coverage – commercial or governmental – is anticipated?

Current dental benefit plan coverage and reimbursement provisions should apply to services delivered in-office and via teledentistry. However, there is no expectation that commercial and government dental benefit plans must create new coverage provisions pertaining to teledentistry. Further, coverage and reimbursement for D9995 and D9996 is likely to vary between commercial benefit plan offerings and by state for government programs (e.g. Medicaid).

The ADA’s “Comprehensive Policy Statement on Teledentistry” sets an expectation of consistent and equitable coverage for all procedures associated with teledentistry services – as noted in the following extract.

Reimbursement: Dental benefit plans and all other third-party payers, in both public (e.g. Medicaid) and private programs, shall provide coverage for services using teledentistry technologies and methods (synchronous or asynchronous) delivered to a covered person to the same extent that the services would be covered if they were provided through in-person encounters. Coverage for services delivered via teledentistry modalities will be at the same levels as those provided for services provided through in-person encounters and not be limited or restricted based on the technology used or the location of either the patient or the provider as long as the health care provider is licensed in the state where the patient receives service.

This policy statement concerns equitable application of existing coverage and reimbursement provisions, and recognizes that dental benefit plan coverage and reimbursement provisions are likely to vary.


15. How would dental benefit plan reimbursements, meaning claim payments, be processed when more than one oral health or medical health practitioner is involved in a teledentistry encounter?

Dental benefit plan reimbursements are, as today, payable to the billing entity on the claim submission, who may be a natural person (e.g., dentist) or a legal person (e.g., dental practice). Allocation of reimbursements is subject to the business relationships between the reimbursement’s recipient and other oral health or medical health practitioners involved in the teledentistry event – such relationships are outside the scope of this guide.


Coding Scenarios

Note: These two scenarios assume that the persons and services involved are in accordance with local state practice act, laws, rules, and regulations

1. A “Real-Time” Teledentistry Encounter

A locally licensed practitioner (e.g., hygienist) is scheduled to meet with residents of a local senior living facility in order to assess their potential need for dental treatment. The facility does not have dedicated space or equipment for dental assessments, so the hygienist brings a laptop computer and an intraoral camera. This equipment is used to enable information capture and a real-time connection with the dentists via a HIPAA-compliant (Security and Privacy) connection that uses encryption and a secure “cloud” server.

During her or his visit the local practitioner records patient information that includes perio probing and charting, a visual oral cancer examination, and capture of high-quality intraoral diagnostic images. The dentist through this real-time connection sees 10 patients exhibiting evidence of the need for immediate or further care (e.g., restorations; soft tissue biopsies). Several of the senior living facility residents schedule their care at the affiliated brick and mortar dental practice.

What CDT Codes would be used to document the services provided on the day of this real-time encounter?

In this scenario patients present for diagnostic and evaluative procedures. The dentist is at a different physical location with complete and immediate access to patient information being captured, and the ability to interact vocally and visually with the patient

The following procedure codes are reported by the oral health or general health practitioner, as applicable, for each patient who received the services described.

D0191 assessment of a patient

D0350 2D oral/facial photographic image obtained intra-orally or extra-orally

D0351 3D photographic image

Note: The types of diagnostic image (2-D or 3-D), as well as the number of separate images captured would be determined by the dentist to adequately document the clinical condition.

D01xx (oral evaluation CDT Code – determined and reported by the dentist – or by another oral health or general health practitioner in accordance with applicable state law)

D9995 teledentistry – synchronous; real-time encounter

Note: D9995 is reported once for each patient, in the same manner as CDT Code “D9410 house/extended care facility call” (once per date of service per patient) to document the type of teledentistry interaction in this setting on the date of service.


2. A “Store and Forward” Teledentistry Encounter

A locally licensed practitioner (e.g., hygienist) in an off-site setting collects a full set of electronic dental records as allowed in the state where the facility is located. These records include radiographs, photographs, charting of dental conditions, health history, consent, and applicable progress notes. This stored information is forwarded to the dentist via a HIPAA-compliant (Security and Privacy) connection that uses encryption and a secure “cloud” server. At a later time the dentist completes a comprehensive oral examination, diagnosis, and treatment plan.

What CDT Codes would be used to document the services provided in this scenario?

In this scenario the individual interacts only with the local practitioner. Information collected is conveyed to the dentist for diagnosis, evaluation and treatment planning at a later time, and possibly at a different location. This dentist has no live vocal or visual interaction with the individual or hygienist during information collection.

The following procedure codes are reported, as applicable, for each individual who received the services described above.

D0191 assessment of a patient

D0350 2D oral/facial photographic image obtained intra-orally or extra-orally

D0351 3D photographic image

Note: The types of diagnostic image (2-D or 3-D), as well as the number of separate images captured would be determined by the clinical condition being documented.

D01xx (oral evaluation CDT Code – determined and reported by the dentist – or by another oral health or general health practitioner in accordance with applicable state law)

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

Note: D9996 is reported once for each individual to document the type of teledentistry interaction in this setting on the date of service.


Appendix 1

Special Claim Completion Instructions – Coding a Teledentistry Event

A teledentistry event claim or encounter submission involves reporting the appropriate Place of Service (POS) code and CDT Code.

• POS code 02 (Telehealth – the location where health services and health related services are provided or received, through telecommunication technology) was added to that code set effective January 1, 2017.

• CDT Codes D9995 and D9996 became effective January 1, 2018. These codes are reported in addition to other services (e.g., diagnostic) reported separately when the patient presents for care. They document services provided by the dentist, or other practitioner providing care, who is not in direct contact with the patient at the time of the encounter.

These instructions apply only to the ADA Dental Claim Form. Please contact your practice management system vendor for guidance when reporting D9995 or D9996 on the HIPAA standard electronic dental claim (837D v 5010).

POS code 02 is recorded in Item # 38 on the claim form.

Note: POS is at the Claim level for dental services, which means it pertains to all services reported on the claim submission.

D9995 or D9996 is recorded on any unused line (1 through 10) in the ‘Record of Services Provided' section of the form. The applicable teledentistry code is always reported on a separate service, in addition to those used for reporting all other procedures delivered during a virtual evaluation.

The following special instructions for Items 24 - 31 apply to the service line on which D9995 or D9996 is reported.

24. Procedure Date (MM/DD/CCYY): Enter date the dental procedures delivered in the teledentistry encounter were performed. The date must have two digits for the month, two for the day, and four for the year.

25. Area of Oral Cavity: Not Used


26. Tooth System: Not Used

27. Tooth Number(s) or Letter(s): Not Used

28. Tooth Surface: Not Used

29. Procedure Code: Enter D9995 or D9996 as applicable. Only one type of teledentistry service may be reported for the encounter.

29a Diagnosis Code Pointer: Not Used

29b Quantity: Cannot be greater than “1”

30. Description: Enter “Teledentistry – Synchronous” or “Teledentistry – Asynchronous” as applicable.

31. Fee: Enter the full fee for the reported teledentistry procedure that is related to the other procedures delivered in the encounter.

Note: The full fee is an amount that the dentist determines covers the costs associated with the tools and technology needed to enable remote communication.

In addition to the above, for teledentistry encounters Item # 56 in the claim’s “Treating Dentist and Treatment Location” block the address is the dentist’s practice location, not the patient’s address.

56. Address, City, State, Zip Code: For teledentistry encounters the treatment location is the dentist’s practice location, not the patient’s location. Must be a street address, not a Post Office Box.


Questions or Assistance?

Call 800-621-8099 or send an email to [email protected]

Notes:

• This document includes content from the ADA publication – Current Dental Terminology (CDT) ©2019 American Dental Association (ADA). All rights reserved.

• This document includes content from the ADA publication – ADA Dental Claim Form ©2019 American Dental Association (ADA). All rights reserved.

• Version History

Date Version Remarks – Change Summary

07/17/2017 1 Initial publication

03/31/2020 2 Clarification of claim completion instructions in Q&A #11, in Coding Scenarios 1 & 2, and in Appendix 1


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