Teledentistry

“Teledentistry is the use of electronic information, imaging and communication technologies, including interactive audio, video, data communications as well as store and forward technologies, to provide and support dental care delivery, diagnosis, consultation, treatment, transfer of dental information and education.” 1

There are four different modalities of teledentistry:

  • Live video (synchronous): Live, two-way interaction between a person (patient, caregiver, or provider) and a provider using audiovisual telecommunications technology. 2
  • Store-and-forward (asynchronous): Transmission of recorded health information (for example, radiographs, photographs, video, digital impressions and photomicrographs of patients) through a secure electronic communications system to a practitioner, who uses the information to evaluate a patient’s condition or render a service outside of a real-time or live interaction. 2
  • Remote patient monitoring (RPM): Personal health and medical data collection from an individual in one location via electronic communication technologies, which is transmitted to a provider (sometimes via a data processing service) in a different location for use in care and related support of care. 2
  • Mobile health (mHealth): Health care and public health practice and education supported by mobile communication devices such as cell phones, tablet computers, and personal digital assistants (PDA). 2

Remote patient monitoring and mobile health can be conducted synchronously or asynchronously. In all teledentistry events there is an originating site and a distant site.

Distant site is the “site at which a licensed health care provider is located while providing health care services or consultations by means of telemedicine.” 2

Originating site means “a site including, but not limited to, a health care facility at which a patient is located at the time health care services are provided to the patient by means of telemedicine.” 2

Teledentistry Equipment

Technology needs will depend on the type of services provided and where they are provided.

For Synchronous Teledentistry the patient at the originating site will need to have a computing device like a smart phone or computer capable of video conferencing, internet access, consent form and a secure video conferencing platform like Microsoft Teams. Digital photos would also be beneficial. The dental provider at the distant site will need a computing device capable of video conferencing, a secure video conferencing platform like Microsoft Teams, internet access and dental software to enter the patient health information and document the visit.

Originating Site  Distant Site
Computing Device: laptop, computer, cellphone with video and sound capability.Computing Device: laptop, computer with video and sound capability.
Quality Internet ConnectionQuality Internet Connection
Link to secure video conferencing: Microsoft Teams or other HIPAA compliant secure system.Link to secure video conferencing: Microsoft Teams or other HIPAA compliant secure system.
Informed consent: This could be a digitally sign able consent form allowing for the visit.Dental software: Eaglesoft, Open Dental, Dentrix, ect.
Directions: Directions on how to upload pictures, sign consent and logon to the visit. 

For Asynchronous Teledentistry the provider (Dt/ADT/DH) at the originating site will need a patient, a computing device like a laptop, internet access, dental software to enter the patient information and document the patient encounter, intraoral camera and ability to capture x-rays. The dentist at the distant site will need a computing device, internet access and dental software.

Originating SiteDistant Site
Computer or Laptop: laptop is preferred due to easy of travel.Computer or laptop
Dental software: Eaglesoft, Open Dental, Dentrix, etc.Dental software: Eaglesoft, Open Dental, Dentrix, etc.
Quality Internet ConnectionQuality Internet Connection
Intraoral Camera: High quality images are essential for diagnosis 
X-ray device: Digital sensors are essential for ease of sending and viewing x-rays.  

Portable x-ray systems are a great investment for teledentistry as they allow for exposure of radiographs without the need for a large and stationary x-ray tube head. When portable x-ray systems are combined with digital sensors acquisition of x-rays for immediate viewing is simple and does not require x-ray film processing systems.

Billing and Coding for Teledentistry

In 2015 Minnesota Pass the Minnesota telemedicine Act. This parity law made reimbursement for telemedicine services by Medicaid, Minnesota Health Care Programs and private insurers mandatory in Minnesota. The telemedicine law includes coverage for dental services. Insurers are required to cover both synchronous and asynchronous teledentistry encounters in the same manner that they would cover in-person visits. Dental office fee for teledentistry services must be equal to the fees charged in face-to-face visits. 3 4 5

CDT Codes for Teledentistry

Current Dental Terminology (CDT) codes are published by the American Dental Association (ADA). They are procedural codes for documentation of services and submission to insurance companies. The collection of codes is updated and published yearly. Using correct codes is critical for insurance reimbursement and for proper documentation. Dental providers should look for the yearly updates to make sure they are using the correct codes. There are two CDT codes used in teledentistry. Teledentistry codes cannot be submitted alone. Teledentistry codes are always submitted in addition to other procedures delivered to the patient on the date of service. This can include diagnostic and preventative services. 2

D9995 teledentistry – synchronous

This is a real time encounter, delivered on the day of service. It involves the delivery of patient care and education where there is live, two-way interaction between a person or persons (e.g., patient; dental, medical or health caregiver) at one physical location, and an overseeing supervising or consulting dentist or dental provider at another location. The communication is real-time and continuous between all participants who are working together as a group. Use of audiovisual telecommunications technology means that all involved persons are able to see what is happening and talk about it in a natural manner.

The dental provider who conducts the synchronous event submits the code D9995 in addition to the type of exam given. 2

Example

A patient with tooth pain had a virtual dental visit through a secure video platform. The dentist consults with the patient in real time. Through the symptoms and photos, the patient sends of the tooth the dentist makes a diagnosis and referral to a specialist as well as prescribes antibiotics for the dental infection.

The dentist submits codes for:

  • Teledentistry synchronous (D9995)
  • Problem focused exam (D0170)

D9996 teledentistry – asynchronous

Information is stored and forwarded to a dentist for later review. There is no real-time, live, continuous interaction with anyone who is not at the same physical location as the patient. Also known as store-and-forward, asynchronous teledentistry involves transmission of recorded health information (e.g., radiographs, photographs, video, digital impressions and photomicrographs of patients) through a secure electronic communications system to another practitioner for use at a later time. 2

For code D9996 the dentist who receives the stored health information, reviews and creates a treatment plan is the person who submits the teledentistry code. The code can only be used once per patient encounter. 2

Example

An established adult patient is seen by a collaborative dental hygienist in an off-sit setting. Consent, health history, charting of oral cavity conditions, periodontal probing, x-rays, intraoral images, caries risk assessment and chart notes are completed.  The hygienist forwards all stored information from this appointment to the consulting dentist using secured encryption technology. The dentist reviews the information, completes an exam, diagnosis and treatment plan for the patient.

The hygienist submits codes:

  • Diagnostic service codes
  • X-rays codes (Full mouth series of x-rays D0120 or 4BWX D0124)
  • Preventative services provided (prophy D1110, fluoride 1206, ect.)

The dentist submits codes for

  • Exam
  • Asynchronous teledentistry (D9996)

Further information on teledentistry billing can be found at the ADA guide to understanding and documentation teledentistry events (2021) To view to full document please use the link here:

ADA guide to Understanding and documenting teledentistry event
Synchronous Teledentistry Animated Appointment Walkthrough

What is a Collaborative Management Agreement?


A collaborative management agreement (CMA) is a formal written document that outlines the committed collaborative relationship between a dentist and a licensed dental hygienist, licensed dental therapist (DT), or advanced dental therapists (ADT). A collaborative management agreement provides a path for a patient to be seen by a DH, DT/ADT without the dentist first seeing the patient and without the dentist being physically present onsite. Due to differences in the scope of practice between dental hygienists and DT/ADT’s their CMA’s require different information. 5

CMA’s for Dental Therapists

CMA can include the delegated duties outlined in the DT/ADT scope of practice. Note that having a CMA does not allow a DT to preform duties that require indirect supervision without a dentist being present onsite. Only ADT may perform all delegated duties under general supervision. 5

Link to DT/ADT Delegated Duties In Minnesota

CMA for a DT/ADT must include:

  1. Practice settings where services may be provided and the populations to be served.
  2. Any limitations on the services that may be provided by the dental therapist, including the level of supervision required by the collaborating dentist.
  3. Age- and procedure-specific practice protocols, including case selection criteria, assessment guidelines, and imaging frequency.
  4. A procedure for creating and maintaining dental records for the patients that are treated by the dental therapist.
  5. A plan to manage medical emergencies in each practice setting where the dental therapist provides care.
  6. A quality assurance plan for monitoring care provided by the dental therapist, including patient care review, referral follow-up, and a quality assurance chart review.
  7. Protocols for administering and dispensing medications authorized under subdivision 5, and section 150A.106, including the specific conditions and circumstance under which these medications are to be dispensed and administered
  8. Criteria relating to the provision of care to patients with specific medical conditions or complex medication histories, including requirements for consultation prior to the initiation of care.
  9. Supervision criteria of dental assistants; and
  10. A plan for the provision of clinical resources and referrals in situations which are beyond the capabilities of the DT/ADT. 5 6

A dentist entering into a CMA with a DT/ADT

  1. Must be licensed and practicing in Minnesota.
  2. The collaborating dentist shall accept responsibility for all services authorized and performed by the dental therapist pursuant to the management agreement. Any licensed dentist who permits a dental therapist to perform a dental service other than those authorized under this section or by the board, or any dental therapist who performs an unauthorized service, violates sections 150A.01 to 150A.12.
  3. Collaborative management agreements must be signed and maintained by the collaborating dentist and the dental therapist. Agreements must be reviewed, updated, and submitted to the Minnesota board of Dentistry on an annual basis.
  4. A dentist can enter into collaborative management agreements with up to five DT/ADT at one time. 5

Further information on dental therapy scope of practice can be found on the State Legislature website under statue 150A.105 DENTAL THERAPIST. Website link: https://www.revisor.mn.gov/statutes/cite/150A.105

CMA’s for dental hygienists

A dental hygienist working with a CMA must be employed by a Minnesota State Health Care Program enrolled group. These included: health care facilities, programs such as Head Start and non-profit organizations. Dental hygienists are limited to providing delegated duties that can be preformed under general supervision under a CMA. 7

Link to Dental Hygienist Delegated Duties in Minnesota

CMA for a collaborative dental hygiene practice must include:

  1. Consideration for medically compromised patients and medical conditions for which a dental evaluation and treatment plan must occur prior to the provision of dental hygiene services.
  2. Age- and procedure-specific standard collaborative practice protocols, including recommended intervals for the performance of dental hygiene services and a period of time in which an examination by a dentist should occur.
  3. Copies of consent to treatment form provided to the patient by the dental hygienist.
  4. specific protocols for the placement of pit and fissure sealants and requirements for follow-up care to assure the efficacy of the sealants after application.
  5. The procedure for creating and maintaining dental records for patients who are treated by the dental hygienist under Minnesota Rules, part 3100.9600, including specifying where records will be located. 7

A dentist entering into a CMA with a DH 

  1. The dentist must be licensed and practicing in Minnesota.
  2. The collaborative agreement must be signed and maintained by the dentist, the dental hygienist, and the facility, program, or organization.
  3. The CMA must be reviewed annually by the collaborating dentist and dental hygienist and must be made available to the Minnesota Board of Dentistry upon request.
  4. A dentist may enter into a CMA with up to 4 dental hygienists at one time. 7

Further information on collaborative dental hygiene practice can be found on the Minnesota State Legislature website under statute 150A.10 ALLIED DENTAL PERSONNEL. Website link: https://www.revisor.mn.gov/statutes/cite/150A.10

The Minnesota Board of Dentistry has a template for CMA’s with dental hygienists. This can be found on their website:

Collaborative Practice Authorization for Dental Hygienists Template

References:

1. Teledentistry facts. American Teledentistry Association. (2020, March 19). Retrieved April 9, 2022, from https://www.americanteledentistry.org/facts-about-teledentistry/

2. American Dental Association. (2020, March 27). D9995 and D9996 – Ada Guide to understanding and documenting Teledentistry Events.. Mouthwatch. Retrieved April 9, 2022, from https://www.mouthhealthy.org/~/media/ADA/Publications/Files/CDT_D9995D9996-GuideTo_v1_2017Jul17.pdf

3. MN House Research Committee. (2020, July). Telemedicine laws in Minnesota – 83rd Minnesota legislature. Retrieved April 9, 2022, from https://www.house.leg.state.mn.us/hrd/pubs/telemed.pdf

4. American Dental Educators Association . (2021, September). Compilation of state laws and regulations … – adea.org. Retrieved April 13, 2022, from https://adea.org/uploadedFiles/ADEA/Download/ADEA-Compilation-of-State-Teledentistry-Laws-and-Regulations-StatesK-N.pdf

5. Office of the revisor of statutes. Sec. 150A.106 MN Statutes.. Retrieved April 15, 2022, from https://www.revisor.mn.gov/statutes/cite/150A.106

6. Office of the revisor of statutes. Sec. 150A.105 MN Statutes. Retrieved April 15, 2022, from https://www.revisor.mn.gov/statutes/cite/150A.105

7. Office of the revivor of statutes. Chapter 58 – MN Laws. Retrieved April 15, 2022, from https://www.revisor.mn.gov/laws/2017/0/58/Allied Dental Professionals  MN CMA statute for allied dental professionals  https://www.revisor.mn.gov/statutes/cite/150A.10