Teledentistry

Teledentistry, according to the ADA’s Comprehensive Policy Statement on Teledentistry, refers to the use of telehealth systems and methodologies in dentistry. Teledentistry can include patient care and education delivery using, but not limited to, the following modalities:

• Live video (synchronous): Live, two-way interaction between a person (patient, caregiver or provider) and a provider using audiovisual telecommunications technology.
• 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.
• 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.
• 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).

Refer to ADA Guide to Understanding and Documenting Teledentistry Events

Yes. In 2016, the Missouri legislature enacted a statute that helped increase telehealth access by increasing eligible healthcare providers and settings. This action allowed for teledentistry (HB 1617). In 2018, the Missouri Dental Board revised the Patient of Record rule that changed the patient of record definition to allow for full scope of teledentistry services.

Refer to: Teledentistry Bill Language and Teledentistry Rule Language (page 3)

This response is related only to the time period of the COVID-19 pandemic.

An inquiry with Missouri Dental Insurance Services and their research indicates that as long as the dentist is doing teledentistry in accordance with guidelines set out by the state, there should be no issues with seeing patients of record. For example, triaging patients would be an example of this. However, seeing an existing or new patient for a full “exam” and calling it an exam may be pushing the limits, especially for new patients where no initial exam or healthy history exists.

Doctors should contact their malpractice provider to make them aware they are doing teledentistry from their practice and discuss any questions/concerns. Please note, not all malpractice carriers may allow coverage for teledentistry, therefore it is suggested you check with them to confirm.

Document the method for obtaining data, and the specifics of the appointment to include, pain assessment, patient expectations, and contraindications in medical history. Detail and specificity is extremely important; this will help the doctor with the treatment planning process. Four key things are needed:

1. Time and Date: Most teledentistry regulations require that a teledentistry visit is completed within a certain period of time. This helps identify time and date of the originating assessment in conjunctions with the examination.
2. Data Collection Method: It’s important to list what was used to collect data during an assessment. These items will vary from radiography (how many, what type), photographs (intra-oral, extra-oral), dental instruments and services rendered.
3. Location of Originating and Distance Site: Per regulations, the location and time that a patient receives service via a telecommunications system must be documented as the originating site. The distance site where the exam actually occurs must be documented.
4. Name of Case Facilitator/Presenter: A facilitator/presenter has the responsibility to facilitate or present teledentistry cases to the exam provider. This may vary based on who collects data. In traditional teledentistry it is usually a dental hygienist. If you are doing limited evaluations with the patient directly, the presenter would be the patient.

 Refer to State Telehealth Laws & Reimbursement Policies

The Office for Civil Rights (OCR) at the Department of Health and Human Services (HHS) is responsible for enforcing certain regulations issued under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), as amended by the Health Information Technology for Economic and Clinical Health (HITECH) Act, to protect the privacy and security of protected health information, namely the HIPAA Privacy, Security and Breach Notification Rules (the HIPAA Rules).

During the COVID-19 national emergency, which also constitutes a nationwide public health emergency, covered health care providers subject to the HIPAA Rules may seek to communicate with patients, and provide telehealth services, through remote communications technologies. Some of these technologies, and the manner in which they are used by HIPAA covered health care providers, may not fully comply with the requirements of the HIPAA Rules.

OCR will exercise its enforcement discretion and will not impose penalties for noncompliance with the regulatory requirements under the HIPAA Rules against covered health care providers in connection with the good faith provision of telehealth during the COVID-19 nationwide public health emergency. This notification is effective immediately.

Refer to: Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency

Imaging in some form is required. It is recommended to have the patient send you a photo or series of photos for asynchronous exams. Video conferencing does not require an image because it is inherent in how that technology works.

Refer to ADA Guide to Understanding and Documenting Teledentistry Events

Synchronous teledentistry (D9995) is 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.

Asynchronous teledentistry (D9996) is different, as 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.

Refer to ADA Guide to Understanding and Documenting Teledentistry Events

Teledentistry evaluations are reimbursable by many of the major insurance companies. You also are able to bill patients directly via fee for service. ADA has released guidelines, which are being continually updated.

Refer to ADA Guide to Understanding and Documenting Teledentistry Events

No, you will need an image or documented video conference.

Refer to ADA Guide to Understanding and Documenting Teledentistry Events

Initiate a medical history and dental history screening before engaging in a teledentistry exam. If you would like to use a third-party service you can use certain online programs to send forms to the patient. For example, Google Forms, Formstack, and Survey Monkey allow you to build forms that the patient can fill out and send to you via email. These can then be printed or scanned into your patient record at a later time.

The author is Nathan Suter, DDS. Dr. Suter is CEO of Access Teledentistry and owner of Green Leaf Dental Care in House Springs, Mo.

​A graduate of the University of Missouri-Kansas City (UMKC) School of Dentistry with a Doctorate of Dental Surgery degree, Dr. Nathan Suter also has a Bachelor of Science degree in Business Administration from Webster University in St. Louis.

Dr. Suter was instrumental in two pieces of legislative advocacy efforts in the State of Missouri. He presented the concept of teledentistry to the Missouri Dental Board and gathered the dental organizations to push the Missouri legislature to enact a statute that helped increase telehealth access.

Dr. Suter joined the Missouri Coalition for Oral Health in 2014 and is currently serving as the Chair on its board of directors. Dr. Suter implemented the first teledentistry program in the state of Missouri, increasing access to dental care for over 1,200 patients in the first year of operation. Recently, awarded with Missouri Dentist of the Year for his contributions to teledentistry advocacy.