Payment Models in the Medical Office It works

Payment Models in the Medical Office It works

C Eve J Kimball, MD Chapter Oral Health Advocate PA Chapter, American Academy of Pediatrics Disclosure Information 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.

Four Groups Collaborating for Children s Dental Health in Pennsylvania 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

TOPICS THEY TACKLE! 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

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 )

ABC s 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 1 st to 3 rd 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!

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

Early Childhood Caries (ECC) is the most prevalent chronic disease in U.S. children, increasing in parallel with obesity Sugar + Calories Obesity + Teeth/oral flora Cavities Sugar

5 Key Oral Health Messages 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.

MODERATE HIGH RISK A SIMPLE ECC Risk Assessment Summary LOW RISK 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 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**

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

CSHCN Patient Factors 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 Provider Actions 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

Fluoride Varnish Application

Referral to a Dental Home

Goals for 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

Dental Referral Lists 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

PCPS can REFER: Risk Assessment Examination of the teeth Fluoride varnish application Education of parents and child Referral to dental home Repeat all steps every 3 months!

Making it Work for YOU

Medical Office Oral Health Implementation Patient calls for appt. Patient Arrives, Insurance verified Office Champion MA rooms patient MA gives patient info about OHRA MA puts varnish and educational materials in room Patient leaves Educational materials and list of Dentists Given Fluoride varnish applied if mod/high risk (by OHRA) Provider does screening Provider with patient

Coding and Reimbursement 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 For Medical Offices 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

Pearls for Medical Providers 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

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?

Professional Resources 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

A special thank you to Paul Westerberg, DMD David Kelley, MD

Professional Resources 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/ttasystem/health/health/oral%20health Information re laws about fluoride in water: http://www.fluidlaw.org

Additional Help or Information Eve Kimball, MD, Chapter Oral Health Advocate 610-463-8775, ekimball@aacpp.com Thomas J. Maroon, MD, Chapter Oral Health Advocate 724-832-0850, thomasmaroon1@gmail.com Bonnie Magliochetti, Project Coordinator 484-446-3059, hthc@paaap.org

Questions?