Interactive Presentation - Is 60 Minutes Enough Time? What is the Standard of Care? - Washington State Dental Association
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Is 60 Minutes Enough Time?
What is the Standard of Care?
Presenter: Kathy S. Forbes, RDH, BS
June 23, 2018
8:30-11:30
Interactive Presentation
1
If you could have as much time as you
want to complete all the dental hygiene
procedures you believe are necessary for
your patients, how much time would you
schedule?
It all started in June of 2015 . .
October 2015
Issue
2
Dental Hygiene in 1972
1972
What was the prevailing theory for the
cause of periodontal infections?
How did we treat patients who needed
more than one appointment to complete
their “cleaning”?
How were these appointments billed to
patients as well as “insurance”
companies?
3
Today we will examine:
• The 60-minute Hygiene Appt –
*1972 vs 2018
*What is expected of hygienists
as licensed dental professionals?
*What is in the best interest of
the patient?
*How can we manage a 60
minute appointment?
Classification/Case Types
of Periodontal Diseases
(Based on 1989 World Workshop in Periodontics)
Formerly AAP Classification System
Case Type I – Early/Chronic Gingivitis
Case Type II – Established
Gingivitis/Early Periodontitis
Case Type III –
Moderate/Chronic Periodontitis
Case Type IV – Advanced Periodontitis
Case Type V – Refractory Periodontitis
4
General Guidelines
Extent Severity
Localized = 30% or less Slight =
of sites are involved LOA/CAL 1-2 mm
Generalized = more than Moderate =
30% of sites are involved LOA/CAL 3-4 mm
Severe =
LOA/CAL 5+ mm
LOA = Loss of Attachment
CAL = Clinical Attachment Loss
Does your dentist perform a complete
periodontal charting on new patients at the
first appointment?
Does s/he determine AAP classification?
Does s/he create the dental hygiene
treatment plan for that patient? (which
procedures to be performed)
Does s/he discuss his/her findings with
you and collaborate on this classification?
5
Do you perform complete periodontal
charting on a new patient at first
appointment?
Do you determine AAP classification?
Do you determine the dental hygiene
treatment plan for that patient?
Do you discuss your findings with dentist
and collaborate on this classification?
Development of a Classification System
for Periodontal Diseases and Conditions
Annals of
Periodontology
December, 1999
www.perio.org
6
AAP Classification of Periodontal
Diseases and Conditions
(Based on 1999 International Workshop)
Gingival Diseases
Chronic Periodontitis
Aggressive Periodontitis
Periodontitis as a Manifestation of
Systemic Diseases
Necrotizing Periodontal Diseases
Abscesses of the Periodontium
Periodontitis Associated with
Endodontic Lesions
Developmental or Acquired
Deformities and Conditions
Gingival A. Plaque 1. Associated
Diseases induced with dental
plaque only
2. Modified by
systemic
factors
3. Modified by
medications
4. Modified by
malnutrition
B. Non-plaque 1. Bacterial,
induced viral, fungal,
allergic,
genetic, etc.
7Chronic A. 1. Modified by
Periodontitis Localized systemic factors
≤ 30% 2. Modified by
medications
3. Modified by
malnutrition
B. 1. Modified by
Generalized systemic factors
≥ 30% 2. Modified by
medications
3. Modified by
malnutrition
Update will
commence in 2017
to review:
• Attachment level
• Chronic versus
aggressive
periodontitis
• Localized versus
generalized
periodontitis
8Who determines how much time
you will need to complete the
necessary dental hygiene
treatment?
Should dental hygienists know the benefits
which may be paid (or not paid) for their
patients who have dental insurance?
Why is it important for dental hygienists to
understand what dental “insurance” is and
what it is not?
9Insurance:
Protection against the
occurrence of an
infrequent, catastrophic
event.
Dentistry:
Involves the frequent
occurrence of
non-catastrophic
events.
10Dental “Insurance”
Not really insurance but a
Dental Benefit
or
Healthcare Financing
But I don’t have time to document
everything!
11S.O.A.P.
– Subjective Findings (what patient says)
– Objective Findings (what you see)
– Assessment (dental diagnosis)
– Plan (what treatment needed)
A.D.P.I.E.
– Assessment (subjective data and objective
data)
– Diagnosis (what is the problem)
– Plan (recommended treatment)
– Interventions (procedures completed that day)
– Evaluation (did plan work)
12WAC 246-817-305
Patient Record Content (4-17-16)
This is only a partial listing of requirements:
For each clinical record entry note, the signature,
initials, or electronic verification of the individual
making the entry note.
For each clinical record entry note, identify who
provided treatment if treatment was provided.
The physical examination findings documented by
subjective complaints, objective findings, an
assessment or diagnosis of the patient’s
condition, and plan.
WAC 246-817-305
Patient Record Content (4-17-16)
Up-to-date dental and medical history that may affect
dental treatment.
Notation of communication to or from the patient or
patient’s parent or guardian including:
– Notation of informed consent discussion. This is a
discussion of potential risk(s) and benefit(s) of
proposed treatment, recommended tests, and
alternative to treatment, including no treatment or
tests.
– Notation of posttreatment instruction or reference to an
instruction pamphlet give to the patient.
– Notation regarding patient complaints or concerns
obtained in person, by phone call, email, mail or text
13How much do you pay each year
for Malpractice Insurance?
What are the Limits of Liability?
RDH Magazine
November 2013
Top Reasons Hygienists Are Sued
Strategies for Avoiding Malpractice Claims
Author:
Dianne Glasscoe Watterson, RDH, BS, MBA
14Informed Consent
Revised Code of Washington
RCW 7.70.060 (updated 2012)
Consent form – Contents –
Prima facie evidence – Shared
decision making - Patient
decision aid - Failure to use.
15(a) A description, in language the patient could
reasonably be expected to understand, of:
(i) The nature and character of the
proposed treatment;
(ii) The anticipated results of the
proposed treatment;
(iii) The recognized possible alternative
forms of treatment; and
(iv) The recognized serious possible risks,
complications, and anticipated
benefits involved in the treatment and
in the recognized possible alternative
forms of treatment, including non-
treatment;
(b) Or as an alternative, a statement that the
patient elects not to be informed of the
elements set forth in (a) of this subsection.
Examples of Fraud
Billing for services not performed.
Upcoding (AKA “remapping”) – billing for one
procedure when you actually performed
another
Misrepresenting patient identities
Waiver of co-payments and/or deductibles
Not informing dental carrier you’ve billed
medical carrier also.
16Example of Fraud
Unbundling Codes – separating dental
procedures so the benefits of the
component parts total more than the
procedures as defined would normally be
reimbursed.
From
Insurance Solutions
Newsletter:
March-April 2014 Issue
Part 1
May-June 2014 Issue
Part 2
17Current Dental Terminology
Jan. 1, 2018 – Dec. 31, 2018
Where do we start?
18Periodic Oral Evaluation –
established patient
CDT 2018, p. 5: D0120
An evaluation performed on a patient of
record to determine any changes in the
patient’s dental and medical health status
since a previous comprehensive or periodic
evaluation. This includes an oral cancer
evaluation and periodontal screening where
indicated and may require interpretation of
information acquired through additional
diagnostic procedures.
Comprehensive Oral Evaluation –
New or Established Patient
CDT 2018, p. 6: D0150
Typically used by a general dentist and/or
specialist when evaluating a patient
comprehensively. This applies to
• new patients;
• established patients who have had a
significant change in health
conditions or other unusual
circumstances, by report, or
• established patients who have been
absent from active treatment for three or
more years. > > >>>>>
19Comprehensive Oral Evaluation –
New or Established Patient
Evaluate and record:
An evaluation for oral cancer where
indicated
Extra-oral and intra-oral hard and soft
tissues
Dental history
Medical history
A general health assessment
>>>>>>>
Comprehensive Oral Evaluation –
New or Established Patient
Dental caries, missing or unerupted teeth
Restorations
Existing prostheses
Occlusal relationships
Periodontal conditions, including
periodontal screening and/or periodontal
charting
Hard and soft tissue anomalies
20Comprehensive Periodontal Evaluation
– New or Established Patient
CDT 2018, p. 7: D0180
This procedure is indicated for patients showing
signs or symptoms of periodontal disease and for
patients with risk factors such as smoking or
diabetes. It includes evaluation of periodontal
conditions, probing and charting, evaluation and
recording of the patient’s dental and medical
history and general health assessment. It may
include the evaluation and recording of dental
caries, missing or unerupted teeth, restorations,
occlusal relationships and oral cancer evaluation.
What is the difference in the definitions?
Comprehensive Oral Evaluation Comprehensive Perio Evaluation
Evaluation of oral cancer Oral cancer evaluation
Extra-oral/intra-oral hard/soft tissues NOT INCLUDED
Dental history Dental history
Medical history Medical history
General health assessment General health assessment
Dental caries, missing or unerupted Dental caries, missing or unerupted
teeth teeth
Restorations Restorations
Existing prosthesis NOT INCLUDED
Occlusal relationships Occlusal relationships
Periodontal conditions including Periodontal conditions including
periodontal screening and/or periodontal charting
charting
Hard and soft tissue anomalies NOT INCLUDED
21Assessment of a Patient
CDT 2018, p. 7: D0191
A limited clinical inspection that is
performed to identify possible signs of
oral or systemic disease, malformation,
or injury, and the potential need for
referral for diagnosis and treatment.
From:
Coding with Confidence
(published by Dr. Charles Blair and Associates)
Recommend the following be included:
Review/documentation of the patient’s medical
and dental history
Limited clinical examination including but not
limited to:
– Recording dental restorations and conditions such as
Hard and soft tissue abnormalities
Plaque and debris levels
Dental caries
Oral injuries
Tooth eruption
Tooth loss
Etc.
– Collection of other oral health data
22From:
Coding with Confidence
(published by Dr. Charles Blair and Associates)
A dental assessment involves a limited
clinical examination, typically by an
independent hygienist or other mid-level
provider acting within the scope of his/her
state license.
March 2014
Issue
23Caries risk assessment and documentation, with a
finding of low risk.
Using recognized assessment tools
CDT 2018, p. 11: D0601
Caries risk assessment and documentation, with a
finding of moderate risk.
Using recognized assessment tools
CDT 2018, p. 11: D0602
Caries risk assessment and documentation, with a
finding of high risk.
Using recognized assessment tools
CDT 2018, p. 11: D0603
“Evaluation of caries susceptibility”
Caries Risk Assessment Forms for
–Age 0 to 6 years and
–>6 years
www.ada.org
Search, enter:
“caries risk assessment forms”
24Fluoride Treatment
(Office Procedure)
Prescription strength
fluoride product designed
solely for use in the dental
office, delivered to the
dentition under the direct
supervision of a dental
professional. Fluoride must
be applied separately from
prophylaxis paste.
*Factors increasing risk for caries may
include but are not limited to:
High level of caries experience or
demineralization
History of recurrent caries
High titers of cariogenic bacteria
Existing restoration(s) of poor
quality
Poor oral hygiene
Inadequate fluoride exposure
Prolonged nursing (bottle or breast)
Poor family dental health >>>>>>>
25*Factors increasing risk for caries may
include but are not limited to:
Developmental or acquired
enamel defects
Developmental or acquired
disability
Xerostomia
Genetic abnormality of teeth
Many multisurface
restorations
Chemo/radiation therapy
Eating disorders
*ADA Guidelines
Drug/alcohol abuse
July 2004
Irregular dental care
Topical application of fluoride varnish
CDT 2018, p. 15: D1206
Topical application of fluoride –
excluding varnish
CDT 2018, p. 15: D1208
Interim caries arresting medicament
application – per tooth
CDT 2018, p. 16: D1354
26Documentation for Radiographs
Guidelines for Prescribing
Dental Radiographs
From: American Dental Association and
U.S. Food & Drug Administration
2004, then Updated 2012
www.ada/org/prof/resources/topics/radiography.asp
www.fda.gov/cdrh/radhlth/adaxray.html
27Guidelines for Prescribing
Dental Radiography, 2012
Page 3 of Report
Radiographic screening for the purpose
of detecting disease before clinical
examination should not be performed.
A thorough clinical examination,
consideration of the patient history,
review of any prior radiographs, caries
risk assessment and consideration of
both the dental and the general health
needs of the patient should precede
radiographic examination.
ADA Clinical Indicators
for Dental Radiographs
A. Positive Historical Findings
1. Previous periodontal or
endodontic therapy.
2. History of pain or trauma.
3. Family history of dental
anomalies.
4. Postoperative evaluation of
healing.
5. Remineralization monitoring
6. Presence of implants or evaluation
of implant placement.
28ADA Clinical Indicators
for Dental Radiographs
B. Positive Clinical Signs and Symptoms
1. Clinical evidence of periodontal 13. Evidence of foreign objects
disease 14. Pain and/or dysfunction of the
2. Large or deep restorations TMJ
3. Deep carious lesions 15. Facial asymmetry
4. Malposed or clinically impacted
teeth 16. Abutment teeth for fixed or
5. Swelling removable partial prosthesis
6. Evidence of dental/facial trauma 17. Unexplained bleeding
7. Mobility of teeth 18. Unexplained sensitivity of
8. Sinus tract (“fistula”) teeth.
9. Clinically suspected sinus 19. Unusual eruption, spacing or
pathology migration of teeth
10. Growth abnormalities 20. Unusual tooth morphology,
11. Oral involvement in known or calcification or color
suspected systemic disease 21. Missing teeth with unknown
12. Positive neurologic findings in reason
the head and neck 22. Clinical erosion
Prophylaxis – Child
CDT 2018, p. 15: D1120
Removal of plaque, calculus and stains
from the tooth structures in the primary
and transitional dentition. It is intended
to control local and irritational factors.
Prophylaxis – Adult
CDT 2018, p. 15: D1110
Removal of plaque, calculus and stains
from the tooth structures in the
permanent and transitional dentition.
It is intended to control local and
irritational factors.
29Scaling in the presence of generalized
moderate or severe gingival inflammation
– full mouth, after oral evaluation.
CDT 2018, p. 39: D4346
The removal of plaque, calculus and stains from
supra- and sub-gingival tooth surfaces when there
is generalized moderate or severe gingival
inflammation in the absence of periodontitis. It is
indicated for patients who have swollen, inflamed
gingiva, generalized suprabony pockets and
moderate to severe bleeding on probing. Should
not be reported in conjunction with prophylaxis,
scaling and root planning, or debridement
procedures.
www.ada.org
CDT 2018
pp. 288-298
30Full mouth debridement to enable
comprehensive evaluation
and diagnosis on a subsequent visit
CDT 2018, p. 39: D4355
Full mouth debridement involves the
preliminary removal of plaque and calculus
that interferes with the ability of the dentist
to perform a comprehensive oral
evaluation. Not to be completed on the
same day as D0150, D0160,or D0180.
Scaling and Root Planing
CDT 2018, p. 39: D4341/D4342
This procedure involves instrumentation of the
crown and root surfaces of the teeth to remove
plaque and calculus from these surfaces. It is
indicated for patients with periodontal disease
and is therapeutic, not prophylactic, in nature.
Root planing is the definitive procedure designed
for the removal of cementum and dentin that is
rough, and/or permeated by calculus or
contaminated with toxins or microorganisms.
Some soft tissue removal occurs. This procedure
may be used as a definitive treatment in some
stages of periodontal disease and/or as a part of
pre-surgical procedures in others.
31Periodontal Periodontal
Scaling and Root Scaling and Root
Planing – Planing –
four or more one to three
teeth, per teeth, per
quadrant quadrant
CDT 2018, p. 39: D4341 CDT 2018, p. 39: D4342
Periodontal Maintenance Procedures
CDT 2018, p. 40: D4910
This procedure is instituted following
periodontal therapy and continues at
varying intervals determined by the clinical
evaluation of the dentist,
for the life of the dentition or any implant
replacements. It includes removal of
bacterial plaque and calculus from
supragingival and subgingival regions, site
specific scaling and root planing where
indicated, and polishing the teeth.
If new or recurring periodontal disease
appears, additional diagnostic and treatment
procedures must be considered.
32Comprehensive Periodontal Therapy:
A Statement by the American Academy
of Periodontology
• Health Professionals
• Clinical/Scientific Resources
• Scroll to Academy Statements
• Comp Perio Therapy
(from jop, July 2011)
Report sets forth the scope, objective and
procedures that constitute periodontal
therapy:
Scope of Periodontal Therapy
Periodontal Evaluation
Establishing a Diagnosis, Prognosis and
Treatment Plan
Informed Consent and Patient Records
Treatment Procedures
Evaluation of Therapy
Factors Modifying Results
Periodontal Maintenance Therapy
33Standard of Care
Ethical or legal duty of a professional to
exercise the level of care, diligence, and skill
prescribed in the code of practice of his or her
profession, or as other professionals in the same
discipline would in the same or similar
circumstances.
Our responsibility to our patients:
We inform.
We document.
We all share the same culture in
the office.
We all have the same “Standard
of Care”.
We have a team on board serving
the patients’ perio and restorative
treatment needs.
34What is ICD-10-CM?
International Classification of Diseases,
Tenth Revision, Clinical Modification
Contains 68,000 codes.
October 1, 2015 was the
compliance date to transition
to ICD-10 code sets.
From:
Diagnostic Coding for Dental Claim Submission
(published by Dr. Charles Blair and Associates)
Examples of three diagnosis codes in ICD-
10-CM:
• Z01.20 Encounter for dental examination
and cleaning without abnormal findings
• Z01.21 Encounter for dental examination
and cleaning with abnormal findings (use
additional code to identify abnormal
findings)
• Z13.84 Encounter for screening for dental
disorders.
35From:
Diagnostic Coding for Dental Claim Submission
(published by Dr. Charles Blair and Associates)
Diseases of the Teeth and Gums
• KO2.9 Dental caries, unspecified
• K02.62 Dental caries, extending into dentin
• K02.63 Dental caries, extending into pulp
• K02.3 Arrested dental caries
• K02.51 Dental caries pit and fissure
(subcategories)
• K02.61 Dental caries of smooth surface
(subcategories)
• K02.7 Dental caries of root surface
Dental Hygiene in 2018
36What has changed since 1972?
1992 – Washington State
“Standards of Dental Hygiene
Conduct or Practice”
2001 - AAP released position paper
“Guidelines for Periodontal Therapy”
2008 - ADHA adopted “Standards
for Clinical Hygiene Practice” updated
2016
What has changed since 1972?
2011 – “Comprehensive Periodontal
Therapy: A Statement by the
American Academy of
Periodontology”
2016 – “Dental Hygiene Diagnosis:
An ADHA White Paper”
37The 60 Minute
Dental Hygiene Appointment
How?
38Contact info:
Kathy S. Forbes, RDH, BS
Phone: 253-670-3704
FAX: 866-669-9308
Email:
prodentseminars@gmail.com
Professional Dental Seminars, Inc.
1702 Valley Oak Ct.
Castle Rock, CO 80104
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