Policy on Third-party Reimbursement for Management of Patients with Special Health Care Needs
The American Academy of Pediatric Dentistry (AAPD) recognizes that, because of improvements in medical care, the number of patients with special health care needs will continue to grow. Many of the formerly acute and fatal diagnoses have become chronic and manageable conditions. These patients require a dental team with special knowledge and skills and additional staff time to coordinate care and/or accommodate the patient’s unique circumstances. An increased appointment length often is necessary in order to treat the patient in a safe, effective, and high-quality manner. Such customized services have not been reimbursed by third-party payors. AAPD advocates reimbursement for measures that are necessary to manage the patient’s unique healthcare needs within the dental home.
This policy is a review of current dental and medical literature, sources of recognized professional expertise related to medical and dental reimbursement, and industry publications. An electronic search was conducted using the PubMed®/ MEDLINE database with the terms: special health care needs and access to care, special health care needs and reimbursement, disease management and managed care, disease management and insurance, disease management and reimbursement; fields: all; limits: within the last 20 years, humans, English, birth through age 99. The search found 1375 articles. Papers for review were chosen from this list and from the references within selected articles.
About 18 percent (12.5 million) of U.S. children have special health care needs, and numbers continue to rise.1 The AAPD defines special needs as “any physical, developmental, mental, sensory, behavioral, cognitive, or emotional impairment or limiting condition that requires medical management, health care intervention, and/or use of specialized services or programs.”2 The 2001 National Survey of Children with Special Health Care Needs (CSHCN) determined the dental care was the largest unmet need. More than eight percent of CSHCN were unable to obtain this service.3 This trend continued in the more recent 2005 National Survey.4 These patients face a multitude of barriers in accessing dental care. These barriers may be either environmental/system-centered or nonenvironmental.5 Environmental barriers to obtaining oral healthcare include difficulties in finding a dental office close to home that will accept the patient’s dental insurance and is able to accommodate the patient’s unique needs, in addition to the rising costs of healthcare. Non-environmental factors center around the patient: the patient is afraid of the dentist, orally defensive, or unable to cooperate for the dentist. Additionally, the patient’s medical condition may complicate dental treatment or the patient may have health care needs more urgent than dental care.5
Patients with special health care needs may require more provider time, particularly those with developmental disabilities, complex health care issues, behavioral issues, and dental fears.6 Many dentists often are unwilling to treat these individuals due to medical conditions, the additional time required to obtain a medical history or medical consultations and render treatment, poor reimbursement, and inadequate training in treatment of patients with special health care needs.7-10 Consequently, pediatric dentists provide a disproportionate amount of care to this population, but U.S. pediatric dentists are too few in number to meet the need.11 While the AAPD has obtained federal funding for expansion and creation of new pediatric dental residency positions, little has been done on the financial front by third-party payors.
Financing and reimbursement of dental care have been cited as common barriers for medically necessary oral health care in the special needs population.5,12-14 Eliminating or reducing the effect of this barrier may have lasting positive effects on oral health for patients with special health care needs. Patients with significant health histories require additional appointment time to take a thorough history, as well as additional time for medical consultation, documentation, and care coordination. Currently, there is a medical model that seeks to account for this increased time above the usual amount of time a practitioner would take to treat a non-complex patient.15,16 In the medical model, if the additional time that is spent is for counseling and/or coordination of care, then physicians are allowed to bill for evaluation and management (E/M; CPT codes 99201-99215) based on time. In doing this, physicians need to document the following information:
- total time of the visit,
- time or percent of the visit spent in counseling/coordination of care, and
- nature of the counseling/coordination of care.
Discussing referrals to other providers and ordering of tests meet the time criteria.16
Adequate reimbursement for the care coordination code (D9992)17 will more accurately identify patients with special health care needs and help alleviate the loss of income that dentists experience while treating these individuals. Care coordination offers the possibility of improving quality and controlling costs for patients with complex conditions.18
Many patients with special needs can be treated in the traditional clinical setting without the increased medical risk or additional cost of general anesthesia, but the provision of this care may take additional time and involve the use of additional personnel or use of advanced behavior management techniques. When physicians are faced with similar circumstances, they are able to use the prolonged service codes (CPT codes 99354 and 99356).16 In order to qualify for billing either code, the physician or other qualified healthcare professional must provide at least one hour of face-to-face patient contact, either outpatient or inpatient respectively, beyond the usual evaluation and management service. CPT codes 99355 and 99357 may be used if the prolonged service is increased by an additional 30 minute increment.16 The behavior management code (CDT code 9920) in Current Dental Terminology17 is most similar to the prolonged service code. Reimbursement for the behavior management code could reduce the need for costly general anesthesia and facilitate the delivery of medically necessary oral health care to which these patients are entitled.
Payment reform via implementation and reimbursement of these codes could allow the dental home to follow an important trend of the medical home. Care coordination activities could change from being mostly reactive to patients’ episodic needs to being more systematically proactive and comprehensive19 thereby reducing hospitalizations and avoiding emergency room visits.18
The AAPD recognizes that the population of people with special health care needs is increasing, and that additional time and skills are necessary to provide optimal care to those individuals in a dental home setting. Care coordination activities for patients with SHCN that are more systematically proactive, rather than reactive, and allow for comprehensive management could reduce hospitalizations and avoid emergency room visits. Furthermore, reimbursement for the use of additional personnel or advanced behavior management techniques could reduce the need for costly general anesthesia and facilitate the delivery of medically necessary oral health care to which these patients are entitled. Therefore, the AAPD advocates that third-party payors and managed care organizations review their capitation policies to provide adequate reimbursement for care coordination (CPT code D9992) and behavior management (CPT code D9920)
- Newacheck, PW, McManus M, Fox HB, Hung YY, Halfon N. Access to health care for children with special health care needs. Pediatrics 2000;105(4 Pt 1):760-6.
- American Academy of Pediatric Dentistry. Definition of special health care needs. Pediatr Dent 2017;39(6):16.
- U.S. Department of Health and Human Service, Health Resources and Service Administration, Maternal and Child Health Bureau. The National Survey of Children with Special Health Care Needs Chartbook 2001. Rockville, Md.; US DHHS; 2004. Available at: “https://mchb.hrsa.gov/chscn/pages/toc.htm”. Accessed June 30, 2017. (Archived by WebCite® at: “http://www.webcitation.org/6sio1Qzu9”)
- U.S. Department of Health and Human Service, Health Resources and Service Administration, Maternal and Child Health Bureau. The National Survey of Children with Special Health Care Needs Chartbook 2005-2006 Summary Tables. Rockville, Md.; US DHHS; 2008. Available at: “https://www.cdc.gov/nchs/data/slaits/summary_
tables_nscshcn_0506.pdf ”. Accessed August 7, 2017. (Archived by WebCite® at: “http://www.webcitation.org/6ta0sBiOn”)
- Nelson LP, Getzin A, Graham D, et al. Unmet dental needs and barriers to care for children with significant special health care needs. Pediatr Dent 2011;33(1):29-36.
- Hernandez PJR. Perspective of a parent and provider for children with special health care needs. Pediatr Dent 2007;29(2):105-7.
- Burtner AP, Jones JS, McNeal DR, Low DW. A survey of the availability of dental services to developmentally disabled persons residing in the community. Spec Care Dent 1990;10(6):182-4.
- Casamassimo PS, Seale NS, Ruehs K. General dentists’ perceptions of educational and treatment issues affecting access to care for children with special health care needs. J Dent Educ 2004;68(1):23-8.
- Edelstein BL. Conceptual frameworks for understanding system capacity in the care of people with special health care needs. Pediatr Dent 2007;29(2):108-16.
- Ferguson FS, Berentsen B, Richardson PS. Dentists’ willingness to provide care for patients with developmental disabilities. Spec Care Dentist 1991;11(6):234-7.
- Casamassimo PS. Children with special healthcare needs: Patient, professional and systems issues. In: Proceedings of the Interfaces Project, 2002. Children’s Dental Health Project, Washington, D.C. Available at: “http://www.oralhealthkansas.org/pdf/Casamassimo.pdf ”. Accessed August 7, 2017. (Archived by WebCite® at:
- Rouleau T, Harrington A, Brennan M, et al. Receipt of dental care and barriers encountered by persons with disabilities. Spec Care Dentist 2011;31(2):63-7.
- da Fonseca MA, Hong C. Improving oral health for individuals with special health care needs. Pediatr Dent 2007;29(2):98-104.
- Kastner T, American Academy of Pediatrics. Managed care and children with special healthcare needs. Clinical Report—Guidance for the clinician in rendering pediatric care. Pediatr 2004;114(12):1696-8.
- Dowling R. How physicians can get paid for time spent with patients: Billing E/M codes based on time. Medical Economics. July 24, 2014. Available at: “http://medicaleconomics.modernmedicine.com/medical-economics/content/tags/billing/how-physicians-can-get-paid-timespent-patients?page=full”. Accessed October 12, 2016. (Archived by WebCite® at: “http://www.webcitation.org/6sincJVqQ”)
- American Medical Association. Current Procedural Terminology professional edition: CPT: 2015. American Medical Association, Chicago, Ill.; 2014.
- American Dental Association. CDT 2017: Dental Procedure Codes. American Dental Association, Chicago, Ill.; 2016.
- Goodell S, Bodenheimer T, Berry-Millet R. The Synthesis Project. Care management of patients with complex health care needs. Policy Brief No. 19. Robert Wood Johnson Foundation. 2009. Available at: “http://www.rwjf.org/en/library/research/2009/12/care-management-ofpatients-with-complex-health-care-needs.html”. Accessed December 19, 2016. (Archived by WebCite® at: http://www.webcitation.org/6tkG3xTWl”)
- Van Cleave J, Boudreau AA, McAllister J, Cooley WC, Maxwell A, Kuhlthau K. Care coordination over time in medical homes for children with special health care needs. Pediatr 2015;35(6):1018-26.