We all know that treatment plans are a list of proposed procedures and treatments that must be presented to patients in a way they understand and agree to. Usually, the dentist or hygienist introduces the clinical reasoning behind the recommended treatment, and it is left for the administrative team to get a financial agreement and a commitment on the schedule from the patient.
After presenting a treatment plan for scaling and root planing (SRP) to a patient for the first time, you may get a variety of reactions. Sometimes, patients experience remorse, denial, anger, or guilt.
It isn't easy to tell a new patient or an existing patient that they now have periodontal disease. To lessen the sting of reality, trivializing the treatment only lessens its value and makes it more difficult for the patient to see the urgency of the issue. Using terms such as "deep cleaning" and phrases like "we'll get you a 'little numb'" for the procedure sends the wrong message as to what the procedure entails and its importance.
If an existing patient hasn't followed your oral hygiene care recommendations, they may have all kinds of excuses for their dental health decline. Getting the care now is a step closer to maintaining dental health and a motivator for patients to move forward. Illustrating the process and creating a dental treatment prescription brings professional importance to the treatment and the need for urgency.
If the practice is in network with the patient's insurance plan, the patient will want to know if there is some coverage for the treatment. Showing compelling evidence and providing dental benefits to help pay for the services is usually a win-win situation. Many practices experience conflict with the clinical team, the front office, and the patient regarding the proposed treatment.
An example
Take the story of Dr. Drake (a fictitious name), his hygienist, and his administrator. In an email stating, Dr. Drake's administrator writes the following:
"We hired a new hygienist who is very aggressive in treatment planning, and she wants to do SRPs on many patients who don't think they need it. They have never needed it before. She takes too many x-rays, which the plans won't cover. Dr. Drake says to schedule them with her so she can do what she wants. First, filling the schedule with stuff we are not getting paid for is ridiculous, but the bigger picture is the trust issue with patients. When they get their EOBs, which say the procedures are not a covered benefit, we must write it off depending on the contract. It creates terrible feelings with patients. What should I do?" -- Mary G., dental administrator
It starts with proper documentation from the clinical team so that the administrator has evidence to talk to the patient and subsequently file a claim on their behalf.
According to the American Academy of Periodontology, a patient is a periodontitis case in the context of clinical care if one of the following are present:
- The interdental clinical attachment level (CAL) is detectable at ≥2 nonadjacent teeth, or
- There is buccal or oral CAL of ≥3 mm with pocketing and >3 mm is detectable at ≥2 teeth
The observed CAL cannot be ascribed to nonperiodontal causes, such as the following
- The gingival recession of traumatic origin
- Dental caries extending in the cervical area of the tooth
- The presence of CAL on the distal aspect of a second molar and associated with malposition or extraction of a third molar
- An endodontic lesion draining through the marginal periodontium
- The occurrence of a vertical root fracture
According to the ADA's evidence-based clinical recommendations for patients with chronic periodontitis, i.e., with the clinical indicators noted above, clinicians should consider SRP as the initial definitive treatment.
The importance of treatment prescriptions
Treatment prescriptions written by the dentist help eliminate communication issues with this common dental office dilemma. Please see the following example for a sample prescription:
Diagnosis: K05.322 Chronic periodontitis, generalized, moderate
Indication: The patient presents with periodontitis, classified stage II, grade B.
Documented by SOAP notes: _________ radiographs, six-point periodontal charting, and (other)
Treatment plan: D4341 periodontal scaling and root planing -- four or more teeth per quadrant (coded computer printout will accompany)
Areas: URQ, LRQ, ULQ, LLQ
Est. appointment time in minutes: 120 minutes
Anesthetic options (as required) name, strength, and amount:
Sedation options (if applicable or required by the situation of fear, anxiety, or medical condition):
Follow-up care: Periodontal maintenance visits (scheduled) three to four months or as determined by the clinician to continue monitoring the patient's periodontal status and oral health
Home care: Custom oral hygiene instructions
______________________________________________
Doctor's signature and license No.
_______________________________________________
Date of prescription
Informed consent reminders
The informed consent form must be signed by the patient or guardian before treatment. It shows that the patient has been educated about the pros and cons of the proposed treatment and understands the risks and benefits.
Informed refusal happens when the patient does not agree to treatment and doesn't want to continue. The patient and the dentist should sign the informed refusal form. It should be clear that the disease has been diagnosed, treatment options have been recommended, and the patient has refused treatment despite being made aware of the risks and benefits. The patient is choosing not to treat the disease at that time. It also must be made clear (both verbally and in writing) that any other hygiene procedures performed will not address the disease.
A new system of prescribing the proposed treatment rather than listing it on a form can remove barriers to communication with the clinical and administrative team.
Editor's note: References available upon request.
Estela Vargas, CRDH, is the founder and CEO of Remote Sourcing, a dental insurance billing and revenue recovery service. She is a graduate of Miami Dade College's dental hygiene program. Vargas' extensive background in the clinical arena of dentistry is coupled with her experience as a practice administrator and business executive.
The comments and observations expressed herein do not necessarily reflect the opinions of DrBicuspid.com, nor should they be construed as an endorsement or admonishment of any particular idea, vendor, or organization.
