Patti DiGangi, RDH, BS, believes dentistry is no longer just about fixing teeth. Dentistry is oral medÂ­icine. Her work helps dental professionals embrace the opportunities and understand the metrics that accurate insurance coding provides. The ADA recognized her expertise by inviting her to write a chapter in its CDT 2017 Companion book and again for its CDT 2018 Companion. She is the author of the DentalCodeology series of easy-to-read, bite-size books. Her latest book, "Teledentistry: Pathway to Pathology" was co-written with Cindy Purdy, RDH, BS. She can be reached at patti@dentalcodeology.com.

Patti DiGangi, RDH, BS

Millennials are natural entrepreneurs and are not much satisfied with status quo. The 

 crisis has brought to light the need for proper personal protective equipment and procedures. Yet there needs to be funds to pay for it. The 

 needs to be more than a nebulous idea. A 

 recognizes the consequences of their production numbers and wants to know.

In the traditional dental hygiene model, compensation is based on some vague per hour, per day or “going rate” idea. Practice management consultants say 

 should be no more than 1/3 of production (though none say why this is an accurate figure). MMHs know it’s time to reevaluate the entire game and look at employment from an entrepreneurial point of view.

You have probably heard, “work smarter not harder.” What does that mean? No one ever says what working smarter really means. Most all of us work hard already even to the extent that you may find that you haven’t even taken a bathroom break for half or even the entire day. We are already smart though we can all get smarter. Perhaps what is needed is to be more deliberate and use measurable systems.

Shirley created a numbers tracking tool for her 

1. To have a way to truly see how you’re managing your time

2. To prove you’re practicing your beliefs rather that only what others expect from you

3. To show the value you bring to the patients and practice

4. To create an increased compensation plan

This tracking tool has one purpose: to help you to focus. You can see on a daily, weekly, and/or monthly basis if you’re meeting your goals. If you are thinking, “I can’t get the numbers,” we call that 

. Be creative … you know what is being done in your chair. Which answers the next question: Should the dentist exam/evaluation and radiographs be counted in your production? Absolutely yes! If the care was performed in your chair, that means you couldn’t be performing other care. Besides, the hygienist generally performs the majority of both of these procedures. Don’t mix payment for procedures and politics with what your treatment room produced because you are in that room.

Additional learning opportunity:	How to manage hypersensitivity in your dental patients

That fourth purpose of tracking your numbers is 

. First, you need to decide what compensation means to you. Don’t start with everyone else’s definition, figure out your own. Dream big! There are no limitations in this part of the exercise except what you put on it. What’s the ROI (return on investment) you want for your work? So you decide $1 million. Is this possible? Why not? Yet compensation does not mean $$ only. Compensation may mean health benefits. It may mean having the practice pay for something like a personal item like 

. It may be schedule flexibility. MMHs don’t just think in the traditional ways. When you track your numbers, you have the ammunition to make reasoned arguments. Oh, we don’t like that word “argument” because it means disharmony, disagreement and negative thinking, right? Not really. An argument is a logical, well-structured discussion of business facts and figures.

Dental hygiene is on a precipice of amazing opportunity. MMHs look ahead to see and help to create those changes. When an MMH learns to help direct the “sails” of change, he or she can also create “sales” for themselves. That is the way of the entrepreneur … and that is the way of the millennials.

Next time, we will be talking about the three reasons why an MMH does NOT perio chart.

	Check Out Business Podcasts at Blog Talk Radio with 

Articles

Millennials are natural entrepreneurs and are not much satisfied with status quo. The Ebola crisis has brought to light the need for proper personal protective equipment and procedures. Yet there needs to be funds to pay for it. The cost of doing business needs to be more than a nebulous idea.

4 reasons that Modern Millennial Hygienists should track their production numbers

	Author Robin Hobb wrote “One must plan for the future and anticipate the future without fearing the future.” At the recent 

 a few trends emerged that help us to plan for the shifting dental benefit landscape.

Related reading: Why are some insurance companies excluding dental care? 

Dental industry watchers have always taken note of changes in medical plan design and now must include observations on the impact of 

 – kept us repeating the words “we don’t know.” This is in response to questions that we all have: what will dental benefits look like in ten years? Will the ACA be repealed? Will employers move away from stand-alone dental plans? The response to all of these and more is quite frankly “we don’t know.” Ms. Pearson did a great job discussing the ways employers will seek to keep dental plan costs low.

Other themes included network improvement and analytics. The use of narrow networks has taken hold on the medical side of health care and we are starting to see their increased usage in dentistry. Narrow networks refer to the utilization of smaller panels of providers in an effort to reduce cost. Many of these plans that utilize narrow networks do not provide benefits outside of the network providers.

Trending article: Antidepressant drug linked to dental implant failure

Data collection and analysis companies were well represented on the exhibit floor. Companies seek to not only control costs but to identify providers that abuse coding practices. The ability to identify outlier patterns is helped by the increased communication of patient data via 

EHR, as well as the Affordable Care Act, is moving our healthcare system toward more structured data. A standard EHR and interoperable national health information infrastructure requires the use of uniform health information standards, including a common language. Data must be collected and maintained in a standardized format, using uniform definitions, in order to link data within an EHR system or share health information among systems.

The conference concluded with a panel discussion on the future of dental benefits. The outlook was cautiously optimistic that employers would continue to provide dental benefits to our patients. The challenge will be to keep these benefits affordable for both the purchaser and the employee.          

5 facts you should know about dental insurance coverage

Editor's note: We caught up with Teresa Duncan at the ADA Annual Session in San Antonio and asked her about what was coming in insurance and what dental professionals needed to know. See our exclusive video interview below...

, is a clinician, speaker, author and coach. She is an ADA Evidence Based Champion and holds a publishing license with the American Dental Association for Current Dental Terminology. She is the author of the DentalCodeology series of mini-books. She was awarded the 2014 Sunstar Award of Distinction, 2014 CE Leaders Recognition and 2013 Sonicare Mentor of Distinction.

, is an international speaker who focuses on revenue & management issues. She is a Fellow of the American Assn of Dental Office Managers. Her memberships include the American Academy of Dental Consultants, National Speakers Association and the Academy of Dental Management Consultants. She was recently named one of the 

 Teresa received her Master’s Degree in Healthcare Management. 

 Author Robin Hobb wrote “One must plan for the future and anticipate the future without fearing the future.” At the recent 2014 Converge Session of the National Association of Dental Plans a few trends emerged that help us to plan for the shifting dental benefit landscape.

What does the future hold for dental insurance? [VIDEO]

, we introduced the idea of the Modern Millennial Hygienist (MMH). MMH challenges our brains to use higher level revolutionary thinking. Growth and change can 

 return on investment (ROI) and profitability for the practice AND the hygienist. This issue, we will look at how a MMH uses the opportunities downtime provides.

One of the tenants of the millennials we can learn from is they don’t work off the clock. In the world the pre-millennials created, people struggle with 

. An entire industry cropped up over it. 

This time of year, moving into fall, can be downtime in our offices. There’s a limit to how many times you can organize a drawer. The number of patients may be down and the no-show/broken appointments may be up for a number of reasons … but that doesn’t mean you can’t be productive.

Here are five revolutionary ideas you can do to make your job more secure and help the practice serve patients better.

 When’s the last time that happened? What usually happens in protocol development is that someone thinks this new product or procedure would work great and it’s added in. Take advantage of the time in September to see if things really are working by printing off the codes and matching them to the perio charts of the patients. Are they getting better?

Additional reading:	The Perio Percentage KPI ... how does your dental practice stack up?

Create or reconstruct your caries management protocol.

 protocols? Are your patients on prescription fluoride experiencing less decay? How does that compare to patients on using remineralization therapies?

Evaluate your head and neck oral cancer screening processes.

 How many suspicious soft-tissue lesions did you refer out for evaluation in the first half of the year? According 

, a normal practice will see about one or two potentially cancerous lesions a week. If your practice doesn’t, what could you do better?

Start a protocol that identifies tongue ties. 

Have the patient open his or her mouth as wide as possible, then lift the tongue to the palate. How much does the mouth close to accommodate? Check out this link to 

. This is the true research you need to do to find out if products are going to work and how. Set up the search feature to look only for human studies and you’ll be off to the races. Find free full articles too. Once you’re signed in, a link in the upper right area (at this writing) will appear to choose showing only free full articles.

Set a team meeting for the hygiene department to compare notes and figure out:

· what changes could benefit the practice most

· calibrate with other hygienists and dentists

· set a strategy for the next slow month (February)

In this time of high hygiene unemployment, a MMH knows making the best use of time is critical. Going home is not a good option for most paychecks, but filing charts or cold calling patients is not a good option for the practice bottom line. Applying the MMH strategies above prove you are a keeping yourself employable and retainable.

Next time, we will look at how MMH weigh the pros and cons of juggling many responsibilities at once.

	Check Out Health Podcasts at Blog Talk Radio with 


	Patti DiGangi, RDH, BS, and Shirley Gutkowski RDH, BSDH, are known for bringing their Midwestern sensibility to today’s health issues with an eye towards the future. With decades of experience in clinical dental hygiene, writing about it, speaking on it, and pondering over all aspects of it, Patti and Shirley challenge dental hygienists to reach higher levels of revolutionary thinking to meet 21st century patient needs, wants and expectations. Beware their infectious excitement, it can be catchy.
	
	Patti is the author of the fast selling 

 books and webinars and popular speaker. Shirley is the coach and primary cheerleader at 

In our previous article, we introduced the idea of the Modern Millennial Hygienist (MMH). MMH challenges our brains to use higher level revolutionary thinking. Growth and change can warp-speed return on investment (ROI) and profitability for the practice AND the hygienist. This issue, we will look at how a MMH uses the opportunities downtime provides.

5 downtime activities to show you are an indispensable Modern Millennial Hygienist

Dentistry is now serving four or more generations with two or three generations working in the practice. All of us are aging and, as we age, the real danger is thinking old. For dental hygiene professionals to succeed in the 21st century, it is essential to become a modern millennial hygienist (MMH). It is not age-based, it’s attitude-based. MMH challenges our brains to use higher level revolutionary thinking. Growth and change can 

 return on investment (ROI) and profitability for the practice AND the hygienist.

Railroads played a large role in the development of the United States. Trains were supreme at the same time as horses and buggies. In the early years of the 20

 century with the advent of motor driven vehicles, it was quickly no place for slow-moving horses pulling flimsy carriages mixed in with cars, taxis, fire trucks, and buses

When trucks combined with the Interstate system, freight traffic for the trains became obsolete and changed the game.

SPEAKING OF THE PAST...	Did this common weed have some great oral health benefits for our ancestors?

The dental hygiene game is also at the precipice of major change. Dental hygiene has very successfully taught the public the habit of coming in routinely. We taught the public to expect to hear about flossing almost to the extent where they hear us say it even when we don’t. The routines and habits of the past are comfortable. Expectations are met and that’s about it. Production stays the same. Insurance is easy to file.

century, it makes little sense to think that the same routine care based on 40- to 50-year-old philosophies should remain the unchanged. In the 21

 century, it makes sense to focus clinical energy on oral-systemic science. Thinking a prophy can remove infectious agents that contribute to 

may be an interesting add-on to the normal mix of procedures offered by the dental hygiene department. Patients want and expect more. When doing an oral cancer screening, they want information on their airway, tongue tie, skin tag, etc.

Just as the world of transportation changed, so has oral health care. The very horse we rode to get here may no longer serve. We certainly don’t use buggy whips like we used to, getting around requires a key not spurs.

21st century problem and your role with it:	Spotting and preventing domestic abuse

Demographic studies are showing the population between ages 19-64 (the majority in most of our practices) is trending down in the number of visits (Figure 1, below). 21

 century consumers are just saying “no,” affecting practice incomes. They are showing their dissatisfaction through their feet. They no longer value the routine care as they once might have. They see other ways and spend their time, energy, and money. New improved trends open up a world of possibilities for a modern millennial revolutionary thinking hygienist.

ADDITIONAL READING:	The perio percentage KPI: How does your practice stack up?

Practicing as a MMH means an attitude adjustment not changing a single product, procedure, technology, or technique. It may mean working outside of a clinical practice. It involves finances in ways many hygienists have previously not considered. There is no reason to invest the time, energy, and sweat-equity unless there is a warp speed return on investment for the patient, practice, AND the MMH. This series of articles will introduce the concepts of MMH. Next time, we will look at 

Five Downtime Activities to Make You an Indispensable MMH.

: Percentage of the Population with a Dental Visit in the Year, 2000-2011

Listen below to the authors talk about this article
	and the launch of this new series...

	Editor's Note: Check Out Health Podcasts at Blog Talk Radio with 


	Patti DiGangi, RDH, BS and Shirley Gutkowski RDH, BSDH are known for bringing their Midwestern sensibility to today’s health issues with an eye towards the future. With decades of experience in clinical dental hygiene, writing about it, speaking on it, and pondering over all aspects of it, Patti and Shirley challenge dental hygienists to reach higher levels of revolutionary thinking to meet 21st century patient needs, wants and expectations. Beware their infectious excitement, it can be catchy.
	
	Patti is the author of the fast selling 

Dentistry is now serving four or more generations with two or three generations working in the practice. All of us are aging and, as we age, the real danger is thinking old. For dental hygiene professionals to succeed in the 21st century, it is essential to become a modern millennial hygienist (MMH). It is not age-based, it’s attitude-based. MMH challenges our brains to use higher level revolutionary thinking.

The Modern Millennial Hygienist: Managing risks through revolutionary thinking

If your patient is experiencing their dental hygiene care as a prophy, a brush and floss lecture and quick dentist check at the end, then you are NOT getting the most out of the most powerful 5 ½ minutes in your hygiene appointment.

You want to have patients accept your best recommendations, don’t you?  They usually come to the office prepared to accept our recommendation.  But patients don’t start buying 

 dentistry until they stop getting cavities, believe you are knowledgeable and know they won’t be sorry. 

Practicing dentistry is successful when the dental hygienist becomes a risk factor preventive specialist and the dentist diagnoses dentistry for whole body health.

Rules are everywhere and most of us try very hard not to break the rules. But rules in dentistry keep us in the commodity business.

		Basic rule #1: keep your focus only on teeth and gums (under pain of death).

 wasted exercise. This narrow focus misses the consequences seeing how dentistry impacts whole body health.

The 80-20 rule, or Pareto Principle, is the idea that a relatively small percentage of any cause (20%) creates most of the subsequent effects (80%). In dentistry, teeth make up only 20% of the surface area of the mouth, with the other 80% including interproximal spaces, the dorsum of the tongue and cheeks, and below the gum line. Yet this still misses a lot.

We are moving beyond the purely mechanistic/treatment view of oral health because the mechanical model of dentistry keeps us in the tooth and gums fixing business. The natural progression of our profession is plotting a course for risk based/diagnostic centered model of health. It’s time to break some of the old and create some new rules.

Percentage of the population with a dental visit from 2000 to 2011.

Bringing patients into our practices has remained the same for all these years. Maybe (through a CE course here and there) you added or subtracted a step or two.

But, whether patients enter through the dentist or hygienists’ chair, the pattern remains the same … fill out a health history, gather oral data, take some x-rays, and have a prophylaxis before the dentist comes in and ‘looks around’. This has been the old equation for productivity. But that equation doesn’t work as well as it once did, people want (expect) more.

Demographic studies are showing the population between ages 19-64 (the majority in most of our practices) is trending down in the number of visits (Figure 1).  Where are they being seen? The trend line for the younger adults, ages 21-34, has sharply increased over recent years and they are seeking care at emergency departments of hospitals (Figure 2).  Oh, that’s just the economy or because they have no dental benefits.

Dental emergency department visits as a percent of total dental visits in the United States. 

Those answers can feel comfortable to us, yet a deeper look shows many are looking for alternative health care possibilities.  Dentist’s income trends are also being affected by these shifts (Figure 3).

Market dynamics in the dental care system.

The facts are … that 30% of the American population is recycling and going green, and 30 – 40% is pursuing alternative health care.  These numbers are just too big to ignore anymore.  There were more patient visits to Naturopaths, Chiropractors and alternative medicine providers than there were to traditional medicine providers in 2013.   

 Lifestyles of Health and Sustainability (LOHAS)

. This is the biggest market you’ve never heard of.  And profits will suffer the longer you ignore this market.  Go ahead and google it and break the rules. There is a HUGE opportunity here.

The innovative dental team is evolving right along with the new research and science. And the nice part of this evolution is that it is effortless. We already have the education and most of the equipment to increase the effectiveness of helping our patients and our business bottom line. Think of it as progress in 

Working Together with the 7 Diagnostic Disciplines

 hygiene check as a rule must be broken.  And we break this rule by understanding that whole body health is more than just teeth and gums. Risk assessment and co-diagnosis with an emphasis on the 7 Diagnostic Disciplines (see table 1) gives patients what they are looking for and improves patient care. You and your team will be more productive and this translates into greater personal, financial and professional satisfaction.

Patti DiGangi, RDH, BS is a clinician, speaker, author and coach. She is an ADA Evidence Based Champion and holds a publishing license with the American Dental Association for Current Dental Terminology. She is the author of the 

 series of mini-books. She was awarded the 2014 Sunstar Award of Distinction, 2014 CE Leaders Recognition and 2013 Sonicare Mentor of Distinction.

Dr. Peter Evans is a practitioner, author, speaker, and inter-nationally known dental coach. He is an active member of the American Association for Oral Systemic Health, Academy of General Dentistry, American Dental Association, International Academy of Oral Medicine and Toxicology, International Association of Mercury Free Dentists, and Holistic Dental Association. They join their strengths to offer their course - 

. For information, contact Kristin Church 

Untapped Power in 5½ Minutes If your patient is experiencing their dental hygiene care as a prophy, a brush and floss lecture and quick dentist check at the end, then you are NOT getting the most out of the most powerful 5 ½ minutes in your hygiene appointment.

Untapped power in 5½ minutes of a dental hygiene appointment

Most practices are seeking ways to get patients to accept treatment, to be paid in a complete and timely manner, get more patient referrals of friends and family, have improved collegial relationships with physicians, and receive compliments from patients and the feeling of a job well-done. This requires ongoing training for the entire team. Spending any money when the schedule is slow can seem just plain stupid, yet how can your practice stay relevant in a changing world without essential learning? Learning is much more than fanny time it has to be practical and applicable.

Taking the necessary steps to provide your entire team the needed tools that will move you into the wellness model is the basis of success and, more importantly, profitability. Courses, webinars, seminars, academies, books, articles, and videos abound with costs ranging from free to thousands of dollars. What is the return on investment (ROI)? The answer is often unfortunately not what is hoped. The difference is the delivery of data versus creating useable information. Data is raw, unorganized facts that need to be processed by the individual. Data can be random and useless until the individual knows how to organize it. When the individual processes, organizes, and structures data for the needs and direction of your wellness practice, it becomes “information.”

Many procedures performed in the dental office may qualify for wellness benefits through medical insurance. Medical may reimburse for oral disease complications or causes of other medical problems. Dentists can and should bill for all services performed with the understanding that each state has a statute specifying that medical insurers cannot deny a claim based solely on a provider’s degree and license if the care is within the scope of practice and the treatment is a medical necessary. In other words, the oral cavity is our scope of practice. For example, the ADA Council on Dental Care does not define implants as routine, therefore you should file implants to medical first if the diagnosis is medical in nature. Both TMD and implants have previously put us into the “no insurance coverage zone.” However, many states have added laws that do not allow jawbone and/or jaw joint treatment to be excluded if bones and joints in other parts of the body are covered.

Coding involves the entire team because the answer to nearly every benefit coding question is diagnosis and dental-medical necessity. 

No one in the practice can be hands-off with coding. 

Christine has been consulting on medical cross-coding for many years. The biggest problem she finds is that information is 

. A whole team system for data collection and documentation is needed for determining dental-medical necessity.

Medical-dental necessity isn’t as complicated as it might first appear. Our weapons for identifying the clues to the most accurate dental-medical necessity are:

Diagnosis is consistent with the symptoms

Treatment is consistent with the diagnosis

Treatment is not primarily for the convenience of the patient or provider

Treatment is good dental-medical practice

The idea of dental-medical necessity shouldn’t be foreign to dental professionals. It’s simply requires documenting the reason a procedure is needed.

, have watched the Sherlock Holmes movies, or seen the recent TV show 

. The object is to bring together different ways of thinking to provide the answer. Every case is different just as every patient is different.

Which one of the several suspects did it?

In the insurance game, we need to answer these questions:

What condition is putting them this patient at risk?

Where in overall system are there conditions and diseases affecting oral health?

What weapons are needed to assess risk, perform the right tests, and gather all the clues to make the diagnosis?

In real criminal cases, we treat everyone as if they are guilty until we prove they are not. In a wellness practice, we also treat everyone as if they qualify for medical coverage until we prove they do not.

We have created books and courses that are going to rock the dental world with the simple steps. We play a detective game starting with why and the detective role each team member (including the dentist) plays on billing. We end up with how-to dental-medical billing for TMD, sleep apnea, implants, periodontal risk patients, pediatric, trauma, and more. Learning the practical, applicable steps to fill out the forms leads to making life easier and more profitable with a team excited about the future. That’s ROI on every level.

Editor's Note: For more information on these authors, check out their book, 

DentalCodeology: Jump Start Diagnostic Coding

Changing data into profitable information for the dental practice

Creating codes to embrace new technologies, materials, and procedures can lead to earlier arrest and prevention of oral disease and positively influence systemic health. For the past decade, the CDT codes were updated every two years. To facilitate a fast-moving world, CDT is now updated every year. The existence of code does not mean a patient has coverage under a policy, yet without a code, no coverage could be offered.

Part of the Affordable Care Act is aimed at improving the quality, efficiency, and overall value of health care. Reimbursements will be tied to outcomes in the future. Having a code gives opportunity to measure outcome data. CDT 2014 has changes in all 12 sections showing a shift with the addition of codes for regenerative procedures and stages of care.

Three new caries risk assessments and documentation codes were added to CDT 2014. The description for all three codes: “Using recognized assessment tools.” Because the code contains the word 

writing the dental/medical necessity in this case the method of determining caries risk is needed.

These caries risk codes ARE NOT codes for specific treatments; they are to determine risk. They should be submitted 

 other codes. The new codes are: D0601 caries risk assessment and documentation, with a finding of low risk, D0602 moderate risk and D0603 high risk. Reimbursement for these codes should not be expected since they do not describe actual provided treatment.

Diagnostic Imaging (formerly Radiographs) section contained the greatest number of changes in CDT 2013 particularly adding numerous codes for cone beam computed tomography (CBCT). This pattern was refined by adding more description to the codes plus adding new codes.  The new codes enable clinicians to describe the process of image capture, reconstruction and interpretation with more versatility than was previously available. CBCT images can assist in making a definitive diagnosis, help with treatment planning and follow-up care, and result in precise and favorable outcomes.

There is always a code. It doesn’t sound right to many, but it is true. All 12 sections of CDT contained a 

 code D_999 unspecified __ procedure, by report as the last code in each section except in the Preventive Section. The new code D1999 unspecified preventive procedure, by report was added to CDT 2014.

Atraumatic/alternative restorative treatment (ART) is a procedure involving the removal of soft, demineralized tooth tissue using hand instrument alone, followed by restoration of the tooth with an adhesive restorative material, routinely glass ionomer. ART is endorsed by the World Health Organization. Interim therapeutic restoration (ITR) more accurately reflects the procedure as practiced in the U.S. creating the need for the new code D2941 interim therapeutic restoration primary dentition.

Crown buildup code D2950 was modified to express that the addition of coronal structure should not be used to eliminate undercuts, box cuts or concave irregularity. The new code D2949 more accurately describes the addition of foundational structure for the purposes listed above.

This section now has a subcategory to describe pulpal regeneration procedures. For offices that only had pulpal exposure, limited pulpal regeneration and apexification codes to choose from this new subcategory offers much more descriptive codes. This subcategory also includes descriptors that include bone grafting and biologic material so be careful to not confuse them with similar existing codes in the periodontal category.

Gingival irrigation is an important part periodontal therapy protocol in many offices yet there has not been a specific code. D4999 unspecified periodontal procedure was submitted more than 500,000 times in 2012. There has not been support of the code in the past by some code committee members because they question the clinical efficacy of one-time irrigation. Like many procedures in clinical practice, there is a gap between what science supports and what is routinely performed.

The National Dental-Practice Based Research Network

 is seeking close these gaps and to enroll more practitioners to contribute to their scientific endeavors. The new code is D4921 gingival irrigation per quadrant is now available for practices using this therapy. This will help many offices who have been irrigating with chlorhexidine or another medicament but have never had a code to adequately describe the procedure.

Codes are not product-specific. Some procedures do not seem to have a code that accurately fits. An example of gaining an accurate code is for the minimally invasive procedure using Perio Protect trays. The Perio Protect Method tray is a prescription medical device that places medication in the sulcus or periodontal pocket.

It is not co-packaged with any medication. It is simply an effective tool for subgingival delivery to address biofilm infections, inflammation, root caries or recession-induced sensitivity. The trays have customized seals and extensions fabricated along the interior periphery to prevent medication from leaking and provide positive pressure to direct medication deep into the sulcus and periodontal pocket. Perio Protect Method trays are classified as prescription medical devices, they require a doctor’s script and must be fabricated in a dental laboratory registered with FDA and trained by Perio Protect LLC.

The only code previously available for the procedure was D5991 topical medicament carrier which did not accurately describe the procedure. The new code is D5994 periodontal medicament carrier with peripheral seal laboratory processed.

Offices have struggled for years with how to code mini-implants and finally we have a code that is appropriate. Previously mini-implants that were permanently placed were coded with D6010. However the price for a mini-implant is usually lower than the cost of a traditional implant. This was hard for offices to track so the addition of code D6013 to denote permanent placement of a mini-implant is very helpful. Don’t forget that any implant placed temporarily regardless of size  is to be coded with D6012.

Offices who uncover implants after they have been placed at another office finally have a code to describe this procedure. Code D6011 describes the surgical access to an implant for placement of a healing cap or to prepare for abutment placement. Offices that were providing this service had no accurate code prior to 2014.

It is important to understand the revision of code D6080 implant maintenance procedures when prostheses are removed and reinserted, including cleansing of prostheses and abutments. This code is NOT for routine prophylactic care of implant supported prostheses. It is for very specific complex situations. In order to use this code, the prostheses MUST be removed.  This is an important distinction as many offices previously used the code when several implants were present along with natural dentition.

The new sales tax code D9985 will not be a reimbursable code. However several states require dentists to charge sales tax on sales of items such as toothpaste, toothbrushes and mouthwashes. Check with your accountant to see if you are in one of the states that requires the reporting of such a tax.

Staying current on coding is a continuous process. 

 plans to release and modify new codes every year and it will be up to each office to remain current. The use of outdated CDT codes on your claim forms can delay payment or even cause the denial of a claim.

DentalCodeology: CDT 2014 shifts and coding tips that every dental practice should know

Dental practitioners have been hearing stories of paperless requirements in place by 2014 or 2015. Minnesota policymakers recently upped the ante when they voted to require dentists, oral surgeons, and orthodontists to adopt a certified, interoperable electronic health record (EHR) system, like their medical counterparts, by 2015.

Dr. Charles Mayo nearly 100 years ago said dentistry is a branch of medicine. Interoperable EHR will join medicine to dentistry in ways we have never experienced. Routine determination and documentation of medical-dental necessity 

 can only bring benefit to our patients and our practice.

, “Ready are you? What know you of ready? You must unlearn what you have learned.” 

Dentistry continues to evolve as the crossover evidence between medicine and dentistry emerges. Dentistry is no longer fixing teeth. It is dental medicine. To medically manage oral disease in our EHR world means determining medical-dental necessity, which is the responsibiliy of clinicians. Clinicians may find that EHR provides valuable data from patients medical conditions, history of prescription medicines, and potential drug interactions that had previously depended on patient self reporting.

In medicine, both procedural and diagnostic codes are used. Current Procedural Terminology (CPT) describes medical, surgical, and diagnostic services equivalent in dentistry to Current Dental Terminology (CDT) codes, except that dentistry does not yet have codes for diagnoses. In medicine, International Classification of Diseases (ICD) is used to code signs, symptoms, injuries, diseases, and conditions.

The critical relationship between an ICD code and a CPT code is that the diagnosis supports the medical necessity of the procedure.

 This is where dentistry is going with EHR interoperability. In dentistry, the ICD equivalent has not yet been decided but does not limit the determination of medical-dental necessity.

Medical-dental necessity isn’t as complicated as it might first appear. It is defined as:

Treatment is good medical/dental practice

The idea of medical-dental necessity shouldn’t be foreign to dental clinicians. It simply requires documenting the reason a procedure is needed. For example, in the general description for the radiographic imaging section of CDT 2013, it states that radiographs, “should only be taken for clinical reasons determined by the dentist...”

A list that works in concert with this description is provided in the updated 2012 ADA/FDA work 

The Selection of Patients for Dental Radiographic Examinations 

 Currently, radiographs are often taken as part of a routine office visit. This is not a medical-dentally necessity (Yoda’s: You must unlearn what you have learned). A medical-dental necessity for a dental radiographic image can be as simple as previous periodontal or endodontic treatment. The reason the radiograph was taken must be documented.

Benefit carriers can request the reason for radiographs. An excerpt from a 2013 Delta Dental letter to a Rhode Island dental practice illustrates this point, “The number of X-rays your practice takes per patient is not only well above that of your peers but also contrary to ADA/FDA recommendations for radiographic examinations.” A documented medical-dental reason is all that is needed.

Dental clinicians must provide consistent methodical documentation of medical-dental necessity for coding. Coding is not limited to codes for insurance. Codes are the language of EHR. The time is now.

What you need to know about medical-dental necessity

“As the evidence mounts in the area of oral-systemic links, the dental profession will need to become more involved in sorting out the relevant clinical information and determine what is appropriate for dental practice. In this article, Patti DiGangi explores an interesting theory.”
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	The first decade of this century gave the dental profession a massive amount of research, articles and continuing education programs about the oral-systemic link. Yet has this knowledge changed the way most dentists practice day-to-day? The changes have been slow, but the good news is all it takes is a few simple steps for dental professionals to immediately incorporate up-to-date oral-systemic information into their practices.

	In July 2009, the American Journal of Cardiology and the Journal of Periodontology simultaneously published an Editor’s Consensus Paper on Periodontitis and Atherosclerotic Cardiovascular Disease (available at 

. This consensus paper clearly shows the evidence supporting inflammation as the oral-systemic connection. This document not only provides health professionals with a better understanding of the links between CVD and periodontitis, it also assists in reducing the risk factors. There are numerous non-oral risk factors strongly associated with an increased risk for periodontitis as well as disease severity, such as being overweight/obese. This non-oral risk factor is recognized as a major problem in the United States for both adults and children.

	Is obesity an oral bacteria disease? This fascinating question was the basis of research The Forsyth Institute published in the June 2009 Journal of Dental Research.

 Dr. J. Max Goodson, senior author of the study, said, “There has been a world-wide explosion of obesity, with many contributing factors. However, the inflammatory nature of the disease is also recognized. This led me to question potential unknown contributing causes of obesity. Could it be an epidemic involving an infectious agent?”

	This study demonstrates that the salivary bacterial composition of overweight women differs from non-overweight women. The data suggests that the bacterial species could serve as a biologic indicator of developing an overweight condition. These results will lead to future research on whether oral bacteria may participate in the pathology that leads to obesity.

	Previous studies show how fat adds to the overall inflammatory burden and is an important risk factor to consider.

 Metabolic syndrome is a group of risk factors that occur together and increases the risk for coronary artery disease, stroke, type 2 diabetes and other diseases related to plaque buildup in artery walls. Risk factors include being overweight/obese, lack of physical activity and genetics. Metabolic syndrome affects more than 50 million Americans.

	There are five conditions that signal a patient may have metabolic syndrome. Patients can develop any one risk factor by itself, but they tend to occur together. Patients who demonstrate at least three of these risk factors should be diagnosed with metabolic syndrome.

	It’s important to note that drug therapy is an alternate indicator for four of the five criteria. When you review a patient’s medication history, look for medications developed to manage high triglycerides, reduced HDL cholesterol, high blood pressure and elevated glucose levels. This is key to recognizing metabolic syndrome. Waist circumference and body mass index (BMI) also are important criteria. At the clinical level, individual patients with metabolic syndrome should be recognized so their multiple risk factors can be addressed and reduced.

	Think about the many patients in your practice who qualify as high risk for metabolic syndrome, heart disease, type 2 diabetes and periodontal disease. Each one of these risk factors may become a volatile multi-directional component in the inflammatory cascade.

 THE SET-UP  “As the evidence mounts in the area of oral-systemic links, the dental profession will need to become more involved in sorting out the relevant clinical information and determine what is appropriate for dental practice. In this article, Patti DiGangi explores an interesting theory.” -Dr. Peter Cabrera, Team Lead