Teledentistry update: Navigating teledentistry during the COVID-19 pandemic (United States)

As part of its efforts to mitigate the spread of the coronavirus disease 2019 (COVID-19) pandemic, on March 18, 2020, the American Dental Association (ADA) provided essential guidance on (i) emergency vs. nonemergency dental care and (ii) the use of teledentistry. In response to the current health crisis, teledentistry is emerging as a viable care option in an effort to help “flatten the curve” of the COVID-19 pandemic.

The ADA defines teledentistry as “the use of telehealth systems and methodologies in dentistry,” which includes “a broad variety of technologies and tactics to deliver virtual medical, health and education services.” Such technologies and tactics include the following:

• Live video (synchronous): Live video between patients and providers using audiovisual telecommunications technology.
• Store-and-forward (asynchronous): Transmission of recorded health information (e.g., a patient’s radiographs, photographs, digital impressions, etc.) 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 in a different location for use in care and related support of care.
• Mobile health (mHealth): Healthcare and public health practice and education supported by mobile communication devices such as cell phones, tablet computers and personal digital assistants (PDA).

Emergency vs. non-emergency distinctions

In order to alleviate the burden that dental emergencies would place on hospital emergency departments and front-line providers, and in an effort to stymie the spread of COVID-19, the ADA advised dentists nationwide to postpone elective procedures and all non-emergency dental care. The ADA’s guide on dental emergencies defines dental emergencies as those that are “potentially life threatening and require immediate treatment to stop ongoing tissue bleeding [or to] alleviate severe pain or infection.” Dental emergencies include:

• Uncontrolled bleeding;
• Cellulitis or a diffuse soft tissue bacterial infection with intra-oral or extra-oral swelling that potentially compromises the patient’s airway; and
• Trauma involving facial bones, potentially compromising the patient’s airway. 

In addition to dental emergencies, urgent dental care includes conditions that require immediate attention to relieve severe pain and/or risk of infection. Some examples of urgent dental care treatments, which should be treated as minimally invasively as possible, include:

• Severe dental pain from pulpal inflammation;
• Pericoronitis or third-molar pain;
• Surgical post-operative osteitis, dry socket dressing changes;
• Abscess or localized bacterial infection resulting in localized pain and swelling;
• Tooth fracture resulting in pain or causing soft tissue trauma;
• Dental trauma with avulsion/luxation;
• Dental treatment required prior to critical medical procedures;
• Final crown/bridge cementation if the temporary restoration is lost, broken or causing gingival irritation; and
• Biopsy of abnormal tissue.

On the other hand, non-emergency dental procedures include, but are not limited to:

• Initial or periodic oral examinations and recall visits, including routine radiographs;
• Routine dental cleaning and preventive therapies;
• Orthodontic procedures other than those to address acute issues;
• Extraction of asymptomatic teeth;
• Restorative dentistry including treatment of asymptomatic carious lesions; and
• Aesthetic dental procedures.

In its March 18 letter, the ADA asked dentists nationwide to postpone such non-emergency or elective procedures and only treat emergency and urgent dental care cases over the next three weeks. This request preceded the closing of many non-essential businesses nationwide due to increased risk of contamination when working in the oral cavity. As a result, many dentists have begun to explore the possibilities of continuing their practices via teledentistry.

Regulatory considerations for teledentistry

Multiple federal agencies have issued regulatory waivers with respect to telehealth services and have relaxed telemedicine rules, as further detailed in DLA Piper’s comprehensive telehealth waiver update. With respect to telecommunication technology and the regulatory requirements under HIPAA, the Department of Health and Human Services Office for Civil Rights (OCR) will not impose penalties on dentists for noncompliance with HIPAA in connection with the good faith provision of teledentistry during the COVID-19 pandemic. The OCR has clarified that the appropriate videoconferencing services for providing teledentistry (and telehealth in general) include Apple FaceTime, Facebook Messenger video chat, Google Hangouts video or Skype. Public-facing technologies such as Facebook Live, TikTok and Twitch should not be used to provide telehealth services.

The ADA has also provided guidance on its teledentistry policies and further considerations to protect a patient’s private health information. As with in-person treatment, the treatment of patients who receive services via teledentistry must be properly documented, and patients should receive a summary of all services provided by the dentist or allied dental personnel. Furthermore, dentists and allied dental personnel who deliver services through teledentistry modalities must be licensed or credentialed in accordance with the laws of the state in which the patient receives services, unless a particular state has issued a licensure waiver relating to the practice of dentistry during the pandemic.

ADA’s guidance on billing and coding for teledentistry

The ADA has published billing and coding guidance for dentists providing teledentistry services during the current public health emergency. If you are a dentist using telecommunication technology to render dental services or offer evaluations to determine if a situation is urgent or emergent, then the following codes should be used to document and report the services:

• D0140 limited oral evaluation – problem focused
• D0170 re-evaluation – limited, problem focused (established patient; not post-operative visit)
• D0171 re-evaluation – post-operative office visit
• D9992 dental case management – care coordination

If you are a dentist providing services in a teledentistry environment, you should report one or the other of the following codes in addition to those cited above:

• D9995 teledentistry – synchronous; real-time encounter
• D9996 teledentistry – asynchronous; information stored and forwarded to dentist for subsequent review

Synchronous teledentistry (CDT Code D9995) is the delivery of patient care and education where there is a live, two-way interaction between the patient at one location and the dentist or dental provider at another location using audiovisual telecommunications technology. Whereas, asynchronous teledentistry (CDT Code D9996), also known as “store-and-forward,” involves transmission of recorded health information (e.g., radiographs, photographs, video, digital impressions and photomicrographs of patients) through a secure electronic communications system to a dentist who uses the information to evaluate a patient’s condition or render a service outside of a real-time or live interaction.

The complete guide for teledentistry billing and coding is available here. A COVID-19 interim guide for coding and billing is available here. The ADA is in the process of compiling third-party payor policies with regard to payment for telehealth services and making the information available in the COVID-19 interim guide. The ADA also notes that it has been following guidance issued by CMS de-regulating telehealth and offering benefits for virtual check-in as a means to support primary care and is exploring if this guidance applies to dental care.

DLA Piper continues to closely monitor federal and state waivers and other governmental actions as this situation unfolds. For information on other ways COVID-19 is changing the healthcare industry and how your company can help serve patients, please contact your DLA Piper relationship partner or any member of our healthcare industry group.

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