The current state of the tele-dentistry industry is ever expanding amidst the COVID-19 crisis
Reliance on hospital emergency departments (ED) for non-urgent or preventable medical conditions has been a growing public health concern in the United States well before the arrival of the novel coronavirus (COVID-19). According to the health Policy Institute of the American Dental Association (ADA), dental-related ED visits have increased in the U.S. exponentially while patients could instead be seen in more appropriate settings. (One study reported that approximately 2 million dental patients present to EDs per year for non-emergent cases alone.1) Today, as the number of COVID-19 cases in this country swells to more than 140,000, these “more appropriate settings” are more likely to be the homes of dentists and patients alike through the use of tele-dentistry technologies.
The use of tele-dentistry is gaining increasing support from the ADA and other professional organizations in the industry. According to the ADA, most dentists will potentially be leveraging telecommunication technology to provide limited-scope interactions with patients.2 And as the COVID-19 pandemic raises more questions than it provides answers, those in the dental community are facing uncertainty as to how to proceed about conducting tele-health visits as well as the subsequent, coding, documentation, and billing. Officials with the ADA and the American Association of Dental Boards (AADB) have come forth with some guidelines to help providers navigate this unpredictable time.
Functions of Dental Tele-Health
The ADA promotes tele-dentistry for such services as problem-focused evaluations and reevaluations, performing triage, and planning for in-person interactions that could become medically necessary.2 As the surge of COVID-19 patients puts some hospitals in compromising positions where the virus is most prominent in terms of available personal protective equipment (PPE) and staff, and threatens to do so in other locales, the dental community and other allied staffs across the continuum will be increasingly hard pressed to help diminish the intake throughout EDs country-wide.
The past few weeks have brought stay-at-home orders and other tactics be government officials to help slow the spread, and organizations like the U.S. Department of Health & Human Services and the Centers for Medicare & Medicaid Services have initiated measures to help the medical community manage the persistence of the spread, including HIPAA waivers that relax penalties for privacy and security infractions while expanding the scope of patients who can be seen via tele-health. Still, the ADA and the AADB urge that individual providers and practices defer to state law before expanding on any tele-services they’re conducting beyond what they already may have been offering prior to the pandemic, including whether or not it is permissible to tele-care for a patient across state lines.
In a recently prepared statement, the AADB suggests that “at this time, it is crucial for the dental profession to follow the guidelines set forth by their respective state boards … and consult their dental boards and use best judgment in triaging patients and minimizing the number of exposures. They must utilize every precaution for the safety of patients, staff, and themselves, employing the most current guidelines for infection control.”3
Applicable Tele-Health Programs and Devices
The ADA also suggests utilizing commercially available applications through cell phones, tablets, laptops, computers, and personal digital assistants, such as Zoom, Apple FaceTime, and Skype.2 Having both an audio and visual (video or photograph) component is also considered necessary to appropriately conduct a problem-focused dental evaluation. Prior to introducing such platforms to patients, providers should retrieve informed consent – meaning that specific information be given as to the nature of the device being used, whether it is provider-owned or employer-owned, and the program being used. Patients who are not familiar with a specific platform should be educated on its functionality and the entire conversation should be documented.
Telephones that have audio and video capabilities are said to be appropriate for virtual evaluations.
HIPAA & Telecommunication Technology
The federal government has indicated that it will waive penalties against providers who serve patients in good faith through certain non-public facing everyday applications. CMS and the Office for Civil Rights (OCR) have issued certain guidance regarding HIPAA and the use of tele-health remote communications during the COVID-19 emergency, which includes:2
- No penalties for noncompliance with HIPAA in connection with the good faith provision of tele-health using non-public facing audio or video communication products.
- Such platforms as Facebook Live, Twitch, TikTok, and similar video communication applications that are public facing should not be used.
- Private and public third-party payers may have additional guidelines to determine reimbursable payment.
- 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” that are available by contacting the ADA at email@example.com
Responsibility and liability is also determined by state law. Concerns should also be discussed with one’s personal legal counsel and insurance advisor to determine whether existing liability insurance policies cover any risks. Additional personal, professional, and practice insurance coverage may be needed to address any coverage gaps at this time, the ADA advises.
While what follows is not a comprehensive list, ADA officials have referenced a couple codes that can be used for the reporting of tele-health:2
D9995 tele-dentistry – synchronous – real-time encounter – Reported in addition to other procedures delivered to the patient on the date of service.
D9996 tele-dentistry – asynchronous – Information stored and forwarded to dentist for subsequent review – Reported in addition to other procedures delivered to the patient on the date of service.
- Sun BC, Chi DL, Schwarz E, et al. Emergency Department Visits for Nontraumatic Dental Problems: A Mixed-Methods Study. Am J Public Health.2015; 105(5):947–55.
- COVID-19 Coding and Billing Interim Guidance. ADA. 2020. Accessed online: https://success.ada.org/~/media/CPS/Files/COVID/ADA_COVID_Coding_and_Billing_Guidance.pdf?utm_source=adaorg&utm_medium=covid-resources-lp&utm_content=cv-coding-and-billing-guidance&utm_campaign=covid-19&_ga=2.195363244.1202894608.1585153844-576526950.1578318483
- Zena R. AADB. 2020. Accessed online: https://dentalboards.org/wp-content/uploads/2020/03/AADB-Position-Statement.pdf