Dr. Dean JensenCouncil on Orthodontic Health Care

Dr. Dean Jensen

At the direction of the AAO Board of Trustees, the Council on Orthodontic Health Care submitted codes for Temporary Anchorage Devices (TAD), Retainer Repair and Comprehensive Orthodontic Evaluations to the ADA to be considered for inclusion in the CDT-2007 code manual. The AAO submitted codes are scheduled for evaluation along with other Batch 3 codes at the February, 2006 meeting.

On January 9, 2006, the COHC Code Subcommittee met via teleconference with Dr. Alan Friedel, Chairman of the ADA Code Review Committee. The purpose of the call was to gain a better understanding of the code submission process in an effort to represent AAO as effectively as possible with respect to the management of codes. Dr. Friedel offered several coding recommendations to the AAO and are as follows:

  • Try and work covertly with other specialties to coordinate coding efforts and requests in order to stay "under the payer radar"; coding coordination effort may help keep the payer community from being aware that a specific procedure is orthodontic in nature and to avoid benefit deductions from orthodontic benefits.
  • Contact representative orthodontists on the ADA Dental Benefit Plans Council for help and support in any future coding issues and for introducing codes; Drs. Steve Simpson (Ohio) and James Haight (Tennessee) are the current orthodontists serving on the Council; the Council meets twice per year in April and November and is composed of the following components:
  • Code section
  • Dental Benefits Information Service (DBIS)- handles complaints
  • Medical Quality Assurance-keeps dental offices "state of the art"
  • Contact ADA staff (Frank Pokorny) and work through him for coding requests and coding issues.

The Council voted unanimously to support Dr. Friedel's recommendations and subsequently is recommending rescission of the codes that address TAD's, retainer repair and comprehensive orthodontic evaluations. A complete report on the Council's philosophy for coding efforts follows:

"Council on Orthodontic Health Care - January 2006

  1. The COHC is the most knowledgeable AAO representative for the code process.
  2. The COHC code representatives are cooperating with interrelated disciplines.
  3. The code process has changed dramatically since 2002 and requires our constant oversight.
  4. The AAO does not have the control over codes it had in the past.
  5. Codes effecting orthodontics may be submitted without time for proper review by the AAO.
  6. The code submission process is a negotiation between dentistry and the insurance industry. The Insurance half of the code revision committee is adversarial to dental claimants.
  7. The existence of a code does not solve inherent problems with payment for the procedure.
  8. Codes frequently work to the disadvantage of the dentist and the claimant.
  9. The AAO has no bargaining, lobbying, or negotiating ability with the insurance payers.
  10. Changes to codes and new code submissions that are not subjected to due diligence may be counter productive. COHC needs time to review and make sound recommendations.
  11. Results of a 2005 survey reveal over 80% of AAO members are satisfied with the existing codes.
  12. The survey also found 75% of our members have problems with Insurance payment.
  13. COHC has been advised by knowledgeable sources to remove the 3 TAD codes because TAD codes proposed by orthodontists will be deducted from the lifetime orthodontic benefit.
  14. The ADA will not recognize a code for a comprehensive specialist's examination. Comprehensive exams can be unbundled by using existing codes D0150 or D0160.
  15. Existing Retainer codes D8691, D8692, D8210, or D8999 adequately cover the needs of our members. No new retention codes are needed at this time.
  16. COHC desires to protect the limited orthodontic benefit from unwarranted invasion and work to expand benefits by encouraging use of existing dental codes.
  17. COHC voted unanimously to remove all orthodontic code requests for 2006.
  18. COHC also requests the Dr. Gary Wiser and Dr. John Harrison represent the AAO at the Code Revision Committee Meeting, February 17 - 19 in Chicago.

Attempting to formulate a consistent philosophy for diagnostic and treatment codes to be employed by the orthodontic profession, the American Association of Orthodontists, and its Board of Trustees to which the Council on Orthodontic Health Care is responsible, the following comments, observations, and experiences are respectfully presented.

In July 2005, a few weeks before the American Dental Association Code Revision Committee Meeting in Chicago, the Board of Trustees initiated a series of events resulting in the Council on Orthodontic Health Care to initiate an extensive internal examination and inquiry of code issues effecting the orthodontic profession. The Council on Orthodontic Health Care code subcommittee has subsequently enjoyed the advantage of highly experienced code mentors; Dr. Pamela Porembski, the American Dental Association Administrator of Dental Codes; Dr. Porembski's assistant, Mr. Frank Pokorny; Dr. Alan Friedel, chairman of the American Dental Association Code Revision Committee, Dr. Charles Cuttino, AAMOS representative to the American Dental Association Code Revision Committee and Dr. Jerry Zackin, AAP representative to the American Dental Association Code Revision Committee. Each of these professionals has graciously provided our subcommittee with an intensive code education. The subcommittee expects to continue to expand our code education by actively interacting with the two orthodontists who serve on the American Dental Association Dental Benefits Committee; Dr. Steven Simpson (Ohio) and Dr. James Haight (Tennessee). In addition, a specialists-only code meeting has been scheduled for the morning prior to the Code Revision Committee meeting in Chicago on February 17, 2006, for the interrelated specialty disciplines to assist each other in maximizing patient claims benefits and minimizing unintended patient/doctor consequences.

Historically, dental insurance code utilization and regulation changed dramatically in 2002 following a legal battle between the American Dental Association and Delta Dental. As a result of the legal settlement, dental codes became the proprietary property of the American Dental Association who is solely designated and recognized as the national standard by third-party payers for processing insurance claims and addressing related administrative matters. Code manuals are revised and published every two years by the American Dental Association to communicate accurate information on dental procedures and services for the utilization of the insurance companies adjudicating the claims.

The American Dental Association sponsors a Code Review Committee of general dentists and the recognized dental specialties, which meets annually to make revisions, deletions, or additions to codes for acceptance, rejection, or modification. The American Dental Association Code Committee is divided equally between provider dentists and third party payer members. At the present time, there is no existing pathway to lobby third party representatives in order for us to gain a sympathetic ear to a reasonable proposal. The existence of a code does not mean the procedure will be reimbursed, as evidenced by the insurance industry's denial to reimburse any of the 38 implant codes currently listed in the manual. Not only are the insurance carriers able to deny codes and claims arbitrarily, they have the authority to establish fees for the procedures they deny, thereby establishing fees more advantageous to their own economic interests.

Orthodontists have enjoyed an enviable position relative to code usage because of the relatively few (18) codes applicable to us. Historically, the Council on Orthodontic Health Care has been reluctant to add additional codes because they create difficulties for our patients and opportunities for the insurance carriers to delay or deny payment. In many areas of the country, orthodontic patients are experiencing difficulty in affording the increasing fees for orthodontic services because of the diminution of their lifetime orthodontic benefits from third party payers. As seen in our last survey, our patients' lifetime benefit for orthodontic treatment is often reduced because of payments for procedures such as serial extraction of primary teeth, extractions of permanent teeth, surgical exposure of impacted teeth.

At the August 2005 American Dental Association Code Revision Committee Meeting in Chicago the Board of Trustees of the American Association of Orthodontists directed the submission of three (3) codes for temporary anchorage devices against the advice of the Council on Orthodontic Health Care code subcommittee members, the chair of the CRC and the Oral Surgery and Periodontics representatives. It was strongly suggested by Dr. Friedel that any code for temporary anchorage devices be a single code and that it not be proposed by representatives of the American Association of Orthodontists. The third party payers in attendance know the codes are applicable to orthodontic treatment and if accepted would be deducted from the lifetime orthodontic benefit if implants are ever covered. This is unfair to our patients who already have the most reduced benefit in dentistry. The Council on Orthodontic Health Care believes its mission is to protect the orthodontic benefit, for its members. At its January 14, 2006 meeting, the Council on Orthodontic Health Care unanimously voted to request the Board of Trustees to rescind the three (3) temporary anchorage device codes prior to the February 17 - 19, 2006 meeting in Chicago. As previously stated, there are 38 non-reimbursed implant codes. What purpose would be served by having 41 non-reimbursed codes?

During the January 9, 2006 conference call between Dr. Freidel and members of the Council on Orthodontic Health Care we were informed that the newly submitted code for 'Comprehensive Orthodontic Evaluation by a Specialist' will not be accepted by the Code Revision Committee. The American Dental Association does not recognize a distinction between generalists and specialists performing orthodontic evaluations. Orthodontic diagnosis and treatment is open to every licensed dentist, therefore, a specialty-only designation is not acceptable. Codes D0150 and D0160 clearly meet the need for a comprehensive evaluation code. At its January 14, 2006 meeting, the Council on Orthodontic Health Care unanimously resolved to request the Board of Trustees to rescind this code.

The direction of the Board of Trustees, code applications for repair to retainers (removable or fixed), replacement of retainers, and for post orthodontic retention visits beyond the term of the contract were submitted to the Code Revision Committee. The response received by the COHC code subcommittee is that codes currently exist for repair of an orthodontic appliance (D8691) and replacement of a lost retainer (D8692). Retention visits beyond the contract term most often have an exhausted orthodontic benefit. A redefinition of code D8670-periodic orthodontic treatment visit part of contract by eliminating the words "part of contract" will achieve the requested objective without adding any additional codes. The Council on Orthodontic Health Care unanimously voted to request the Board of Trustees to rescind these newly submitted codes.

The January 2006 published survey of the American Association of Orthodontists membership demonstrated three salient points: (1) 72% of the responding orthodontists believe the present codes provide for good insurance practice management, (2) 83% of the responding orthodontists stated no new codes are needed to improve the insurance benefits for their patients, and (3) the codes our surveyed responders did request to be implemented demonstrates the need to further educate our members in the usage of existing codes for them to understand the consequences of adding new codes randomly.

The Council on Orthodontic Health Care meeting held on January 14, 2006 resulted in a unanimous resolution for the Board of Trustees to reconsider the American Association of Orthodontists representatives to the Code Revision Committee meeting in Chicago February 17 - 19, 2006 by appointing Dr. Gary Wiser, chairman of the Council on Orthodontic Health Care code committee to replace Dr. Rod Dubois who has not shared the vigorous code submission learning curve with Dr. Harrison and Dr. Wiser. Dr. John Buzzatto, the Board of Trustees liaison to the Council should be consulted on this proposal.

The Council on Orthodontic Health Care is proposing to the Board of Trustees the eighteen (18) orthodontic codes currently in the manual be reviewed annually for streamlining, simplifying, and satisfying the needs of the members of the American Association of Orthodontists. The code subcommittee should be required to review any and all of the dental codes in the manual on an ongoing basis to best educate the membership for the most beneficial application of insurance codes. The Council on Orthodontic Health Care welcomes direction from the Board of Trustees and desires to work in harmony to produce a sound and unified code philosophy. Code issues are too vital for the members of the American Association of Orthodontists to be submitted to the American Dental Association Code Review Committee in the absence of thoughtful consideration and diligent analysis."

The COHC Code Subcommittee will undertake a review of all CDT-2005 codes prior to the Council's July 15, 2006 meeting. Based on the code review findings, COHC will make appropriate coding recommendations to the AAO Board of Trustees.

Payer Meetings

To address the following portion of the resolution, "RESOLVED, that the AAO request the American Dental Association (ADA) to direct the appropriate ADA council of agency to meet with third party payers to discuss and review the deduction of charges of ancillary orthodontic procedures from the benefits designated 'orthodontic benefits'," the Council asked AAO staff to approach the American Association of Periodontists (AAP) and the American Association of Oral & Maxillofacial Surgeons (AAOMS) in an effort to join ranks in their biannual interface meetings with payer groups. Neither group is interested in partnering with the AAO with respect to the meetings. The AAP already is engaged in a partnership with the Endodontic specialty; AAOMS representatives stated that their organization has a great deal of issues to address with the payers and simply do not want to dilute their efforts by sharing meeting time and space.

Dr. Alan Friedel also addressed suggestions for AAO/payer relations during the January 9, 2006 conference call. He recommended that the AAO dialog with insurance payers using the ADA Council on Dental Benefit Plans (CDBP) as a resource for obtaining a list of major industry "players." He further recommends that the AAO work with the ADA to leverage any negotiations with the payers.

Access to Oral Health Care

After the 2005 House of Delegates approved the AAO endorsement of The Virginia Brown Community Orthodontic Partnership (VBCOP) also known as the Smiles Change Lives (SCL) Program, great progress has been made to make AAO members aware of not only the program, but the opportunity to participate in the delivery of orthodontic care to the children of the "working poor." Articles describing the program appeared in last month's issues of The Bulletin and Straight Off the WireŽ. The program also targeted AAO members residing in potential program growth areas to receive a letter announcing the program and offering the opportunity to lend professional support to the program.

LeAnn Smith, Director of Programs and Tom Brown, Chairman of the Virginia Brown Partnership Board recently contacted COHC to announce that the program is expanding into the St. Louis area. Saint Louis University (SLU) has not only agreed to host SCL as their local program screening site, they have also offered to treat between 20-30 children a year. SLU has additionally agreed to treat the more difficult cases seen in the St. Louis area.

Ms. Smith, Mr. Brown and Dr. Kelly Toombs met with the Council during their January 14, 2006 meeting to brief the Council on program status and expansion efforts. Their presentation included in-depth information about the program and its administration and the discussion outline follows:

Program expansion:
  • Planned expansion into at least three new regions per year with the first international program expected to be located in Calgary, Alberta, Canada
  • Current staffing levels offer the ability to launch up to 10 new programs per year
  • Expansion into the St. Louis area is well underway
  • Next program is expected to be launched in Minneapolis; local publicity is expected to begin about May, 2006
Program financials:
  • Accounting controls are in place to prevent fraud; includes use of fiduciary agent
  • Program boasts an administrative cost of 11.5%
  • The limitation to growth at this time is financial resources. Each new area costs an average of $20,000 to get up and running
  • VBCOP is asking the AAO to help support community programs by providing start-up capital; if start-up capital is not received, expansion will continue, just not as quickly
Program governance:
  • Governed by a National Advisory Board consisting of nine members with eventual growth to thirteen members
  • National Advisory Board members have no term limits
  • Local programs governed by Advisory Boards; a stated goal is that each local Advisory Board should have one dentist, one media person and two orthodontists as part of its makeup
  • All Board members must make a commitment of personal time
  • The VBCOP would welcome the appointment of an AAO member to the National Advisory Board
Program facts:
  • VBCOP has been advised that they cannot limit provider membership in the program to AAO members; the provider network is already limited to licensed specialists or residents
  • The program works well in rural areas as demonstrated in the Wichita, KS area; patient families are willing to drive to seek the orthodontic treatment
Program publicity:
  • Information to be posted on the AAO member and public websites
  • Press releases in St. Louis, MO to announce the SCL program expansion into the local area
  • Press releases in Wichita, KS to educate the public and recruit new providers
  • AJO-DO editorial and cover photo to outline the SCL program
  • Feature article in The Bulletin on Dr. Kelly Toombs, an AAO member and his involvement and participation in the program
  • House advertisements in The Bulletin to encourage AAO member support and participation as a program provider
  • Companion articles published on Straight Off the WireŽ that coincide with articles published in The Bulletin

COHC is pleased with the program's direction and will continue to coordinate publicity efforts and monitor the program's progress.

With respect to the 2004 House of Delegate's mandate regarding access to care in rural areas, COHC concluded that the access to care issue is a difficult issue to address, especially in orthodontics. Additionally, the access to care issue contains two facets: care for indigents who cannot afford care; and people living in rural areas that can afford care but must commit to traveling to receive the care. Further complicating the issue is that in some areas, populations are transient and the lack of continuity in care often leads to the decision that if the case is not severe, orthodontic treatment can be performed at a later time. COHC noted that the AAO endorsement of the Virginia Brown Community Orthodontic Partnership DBA Smiles Change Lives will serve to provide access to care in urban as well as rural areas when the program has expanded more fully.

In order to address access to care in the broadest possible terms, the council continues to feel that the Give Kids a Smile Program sponsored by the ADA holds the greatest potential for reaching most sections of the population.

With respect to access to care in rural areas, the council debated a myriad of ideas for addressing the situation including:

  • Mobile van clinics driven to rural areas for provision of care
  • Federal and state tax incentives to patient families for travel to receive orthodontic care
  • Federal and state tax incentives to patient families for travel to receive orthodontic care
  • Federal and state tax incentives or subsidies to providers for creating satellite practices or provision of care in rural areas
  • "Coat-tail" on national advocacy groups and professional associations to use their resources to accomplish the AAO objectives

Several of the suggestions were eliminated due to practicality and/or invasion of the orthodontic profession by care being rendered by non-specialists. A recommendation is being forwarded to the Board outlining COHC's proposed initiatives.

COHC Survey

COHC completed a survey conducted by the AAO Research Family Group. Issues polled were:

  • Practice Management/Third Party Payer Issues
  • Electronic Data Interchange claims submission
  • Additional resources for the AAO Member Hotline
  • Access to Care
  • CDT Coding

The Council is quite pleased with the results and has begun to use responses to better address AAO member and association needs and to provide better professional advocacy.

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