payment models in the medical office - it works… · clean your baby’s gums before teeth come...
TRANSCRIPT
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, [email protected] Thomas J. Maroon, MD, Chapter Oral Health Advocate – 724- 832-0850, [email protected] Bonnie Magliochetti, Project Coordinator 484-446-3059, [email protected]
Additional Help or Information
Questions?