In the spring of 2020, telehealth became a necessary utility in the medical and dental fields. According to a recent survey, about one-third of consumers had a telehealth appointment during the COVID-19 pandemic, with more than half of that cohort saying they had never had a telehealth visit until the pandemic began. Now, teledentistry has been adopted by some practitioners as a way to separate themselves from others in the field. To thrive in the general practice, these dentists are embracing technology and providing convenience to patients.

“We live in a time when everything happens right now,” said Dr. Susan McMahon, author, lecturer and expert in cosmetic dentistry, with a dental practice in Pittsburgh. “If you want groceries, you can get them on Instacart and they’re delivered the same day. If you place an order on Amazon, it can be at your door the next day, if not the same day. People have that expectation about their medical and dental care now. Fortunately, the whole range of technology — same-day milling, 3D printing, CT scans — makes that possible for us, so patients don’t have to go out to other offices to get all the information they need. And teledentistry is a big part of that. They’re getting immediate contact with the doctor and immediate information.”

In March 2020, Medicare began to cover telemedicine for all enrolled patients, which opened the door to new opportunities for patients and dentists alike. “It used to only be for people who lived in remote areas, but thankfully, Medicare expanded that to accommodate the entire country,” said Joseph Pinkava, director of employee development at Pristine Medical Billing, which regularly handles telemedicine insurance claims. “After recognizing that, we notified our clients, and several implemented it into their practice. Interestingly, many offices continue to do it because of how time efficient it is.”

People want immediate answers to their dental questions. With teledentistry, a cosmetic consultation that in the past would have taken at least three days to book for an in-office visit now can be completed within the same day. For example, patients may be seen by the end of the business day or within 24 hours of their initial call.

“We do telehealth smile consultations because it satisfies the patient’s need to get in and know their treatment plan right away,” Dr. McMahon said. “For every person who calls up for a consultation in our office, we ask, ‘Would you like to do a Zoom consult with the doctor today?’ About 35% to 40% of patients agree because they want the information right away.

“That has generated a lot of cosmetic work for us. My patient coordinator talks to the patient first, just like she would during a regular appointment. We charge $75 for a teledentistry visit, versus our regular in-office consultation of $150. The patient coordinator sets up a meeting and determines what the patient has in mind — what they don’t like about their smile. And then she asks them to get very close to their camera on their laptop or device, and she captures three or four close-up screenshots of their teeth.”

The screenshots are uploaded right onto Dr. McMahon’s phone or computer. She reviews them, and then meets the patient via Zoom to discuss the patient’s options. “I would say to the patient, ‘I can’t know with certainty until we see you in person and we take X-rays or a CT scan, or evaluate your bite, but here’s what I’m thinking for you as far as cosmetics go,’” she said. “And the teledentistry assessment is accurate most of the time — it’s what I definitively end up diagnosing for them. The benefit is that we can give them a right-then-and-there tentative treatment plan, and a tentative fee.”

Generally, patients are much more comfortable in their home with their computer or phone cameras discussing what they don’t like about their smile than they are during an in-office consultation. And they are comfortable and willing to talk to the patient care coordinator. “Being in the comfort of their home makes the treatment hurdle smaller,” Dr. McMahon said.

When patients arrive at the office, they already have a relationship with the practice. They have a good idea of the fees, and they are prepared for treatment. Often, the in-person visit simply documents the case for their record via a full exam (i.e., CTs and X-rays, digital scans), and then the patient is ready for treatment.

For Dr. McMahon, teledentistry provides a convenient route for new patients to reach her. “The window is small, really,” she said. “If patients are interested in cosmetic dentistry, for example, they’re interested now and they want to know now. If we don’t respond, then they may just keep on searching until someone does respond to them.”

Patients with sleep-disordered breathing may also be ideal candidates for teledentistry. The survey linked above noted a strong willingness from participants to use telehealth for future sleep-related concerns, with 58% of respondents reporting they’d be willing to try a telehealth visit.

For practitioners, it’s a straightforward process to identify at-risk patients via a teledentistry visit and, using the provisional mandibular advancement device (PMAD) protocol, provide treatment. “PMAD therapy lends itself really well to telehealth because it allows for a quick step into the process of sleep dentistry,” said Dr. Bradley Eli, orofacial pain specialist and expert in the treatment of sleep-disordered breathing, with a practice based in Encinitas, California. “If the patient has never been sleep tested, and has an initial complaint of snoring or excessive daytime sleepiness that they want to treat, there may be a lag between the time that the patient is interested in being treated and the time that a definitive diagnosis can be obtained through a sleep physician. A provisional device allows for a person who has an interest and symptoms to engage in an initial step.”

Once patients are diagnosed with sleep apnea, a telehealth conversation can occur about the diagnosis. Dr. Eli explained: “I discuss the patient’s diagnosis with them. I review the results of the sleep test, in case that hadn’t been done with the physician, which is common. I allow patients to ask any questions that they have regarding the diagnosis.” From there, a decision can be made to either continue with the appliance that was prescribed provisionally or use another device.

Dental procedures may be converted into billable telehealth services, allowing doctors to bill for more services than traditional visits. “When you take a medical office approach to dental office procedures, these procedures can effectively be billed as telehealth services,” Dr. Eli said. “In dentistry, to use telemedicine, you have to start seeing all of the procedural steps as separate steps because there is an opportunity for the dental provider to determine which steps can be done by video conference.

“There is a tremendous number of codes for everything from an emergency examination, to a periodic examination, to home care instruction, to tobacco cessation consultation. Those codes are all available because they describe a service. So you have to go through it and say, ‘For this date, I am going to complete these things, which do not require that the person is actually in my presence in order to provide the service.’ Note that any billing process should be reviewed with billing staff or experts prior to use to avoid incorrect billing issues.”

For medical billing, procedure codes and charge amounts go along with each service. “Sometimes a modifier, which is like an addendum, will be added to the procedure code,” Pinkava said. “For example, if procedure code 99203 means an initial evaluation for a patient, modifier 95 may be added to it. This essentially means the procedure was done via telemedicine.

“For sleep therapy, for example, instead of just putting all the fees into the oral appliance, you can bill them separately — the oral appliance fees and consultation fees. And then you have the telemedicine consultation fees, which is separate. For follow-up visits, instead of using code 99203, for example, it’s 99213 — just one number is changed. With emergency procedures, for example, the billing guidelines wouldn’t change for in-person versus telemedicine visits. But for telemedicine, the service would include the modifier 95.”

Dentists who are experienced at performing medical services should be somewhat familiar with the procedure coding. Practitioners who are new to it may choose to partner with a medical billing company to either train them or use them as a service.

Dentists often wonder if telemedicine rates are similar to in-office rates for patients with medical insurance. To determine whether or not rates are different, Pinkava compared about 50 telemedicine payments to payments for patients who visited the office, and he found there were no recognizable differences. The only variability resulted from different plans paying differently (e.g., HMOs having different rates compared to PPOs). Importantly, this was the case for both contracted and non-contracted dentists.

For contracted providers, dentists should receive the same rates as they do for in-office visits. Practitioners should review their contracts to verify rates.

For out-of-network providers, dentists receive about 100% to 120% of the Medicare rate, which is consistent with commercial payers. For a 45-minute new patient consultation, it’s around $120 to $140. For a 15-minute follow-up visit, it’s $80 to $100. Place-of-service codes and modifiers include the following:

• Public insurers (e.g., TRICARE and Medicaid): Place-of-service code 02 and modifier GT
• Private insurers (e.g., BCBS and Aetna): Normal place-of-service code 11 and modifier 95

Chair time may be reduced by incorporating teledentistry into the practice, and a good place to start is within the hygiene department. For example, Dr. Eli suggested saying the following to staff members: “Starting next week, for all patients scheduled for Monday, Tuesday and Wednesday, I’d like you to call and update their health history and overall health status before they come into the office.” For the teledentistry visit, staff can provide a video link to review home care instructions, such as how to properly brush and floss, and ask if patients have any questions regarding oral health. Then, take 10 minutes off the typical appointment that is routinely scheduled for these patients, so when they come into the office, none of the processes that occurred via telehealth get repeated.

“You purposely shorten the visit,” Dr. Eli said, “so the hygiene department doesn’t fall into the trap of, ‘We’ve always done it a certain way; therefore, we’re going to continue to do it a certain way.’ You have to create a bit of a change, and shortening the in-office appointment is motivation to change.”

Teledentistry has provided benefits to both patients and providers, such as convenience, improved communication, time savings, and expanded billing and reimbursement options. In addition, it has been a valuable component to same-day dentistry, designed to address a patient’s request for immediate care.

“Early on, the thing that surprised me the most about teledentistry was how comfortable patients are talking about themselves and their desires about their teeth, and how comfortable they are showing them to me on a screen,” Dr. McMahon said. “I thought it would be a much less informative session for me when we first started doing it, but I realized right off the bat: People love this! Teledentistry was brand new for us a year ago. I had never thought about using it before. Now that I see how easy it is and how beneficial it is to make that connection with people early, we’ll continue to use it.”

For doctors looking to treat patients as quickly as possible for the betterment of patient health, teledentistry services may be a suitable option to explore. “Adopting telemedicine is a way to save chair time and entertain medical treatments that can help enhance people’s lives,” Pinkava said. “If dentists begin to implement telemedicine to their practice, they will likely be shocked at how much more efficient they become.”

To discover the provisional mandibular advancement device (PMAD) protocol, which may be integrated into a teledentistry appointment, visit glidewell.com/pmad.