Hygiene Tribune U.S. No. 2, 2013Hygiene Tribune U.S. No. 2, 2013Hygiene Tribune U.S. No. 2, 2013

Hygiene Tribune U.S. No. 2, 2013

Embrace it: Help your patients navigate orthodontics with ease / How hygienists can support patients’ overall body health / Commentary: Not all hand-held X-ray systems are created equal

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            [1] => 







HYGIENE TRIBUNE
The World’s Dental Hygiene Newspaper · U.S. Edition

MARCH 2013 — Vol. 6, No. 3

www.dental-tribune.com

Clinical

How hygienists can support
patients’ overall body health
Use the power of cross coding
By Marianne Harper

H

ave you lost the excitement?
Are you content with what
you might now perceive as
the same-old, same-old every day? Day after day you may be performing hygiene procedures over and
over again, all the while knowing you are
helping your patients but perhaps you
simply don’t feel as though you are truly
making a significant difference in their
overall health. If you feel that level of
frustration, or even if you don’t, but you
are interested in advancing your career,
then read on to discover some ways in
which you can make a significant difference in the health of your patients.
As you are aware, dentistry is becoming recognized as a medical discipline.
We in the dental field are in a unique
position to support our patients’ overall
body health. Our patients who maintain
their regular recare schedules are quite

Marianne Harper is the
CEO of The Art of Practice
Management. Her areas of
expertise include revenue
and collection systems,
business office systems and
the training of dental
practices in dental/medical
cross coding. Harper is a
well-respected consultant,
trainer, lecturer and author.
Her published works include “CrossWalking — A
Guide Through the Cross Walk of Dental to Medical
Coding” and her “Abra-Code-Dabra” series on
medical cross coding for sleep apnea, TMD and
trauma procedures.

probably seen by us more frequently
than they are seen by their primary care
providers. “Around 39 percent of adults
see their physicians in a year while 64
percent see their dentists, which means
we see 25 percent more patients than
they do.”1

Update recare forms
Hygienists can be key players in this opportunity. By thoroughly questioning
their new patients and by providing and
reviewing medical history forms that are
updated with the most current medical
questions, hygienists can begin an evaluation of their patients’ medical state.
In addition, our established patients
may have had a change in their medical
history since their last appointment, so a
recare update form is an efficient way to
inquire about their health. If your practice is not familiar with recare update
” See OVERALL, page D2

Fig. 1: Example photocopy of CMS-1500
health insurance claim for treatment of
sleep apnea, considered a medically
necessary dental procedure that qualifies for
coverage through health insurance. Many
other dental procedures and tests also can
qualify. But you need to know diagnosis and
procedure codes — and other nuances of the
process. Photos/Provided by Marianne Harper

Fig. 2: Blank, original CMS-1500 form, which
is printed in red ink, provides spaces for at
least four diagnosis codes and six procedure
codes. Codes within these code systems
provide further diagnostic information or
details on why a procedure might have been
modified. The complexity serves as fair
warning that cross coding is not an easy
system to implement.

Embrace it: Help your patients
navigate orthodontics with ease
Between 1982 and 2008, the number of
people getting braces in the U.S. increased
by 99 percent, according to the AAO Patient
Census Study conducted by the American
Association of Orthodontics. This dramatic
growth has resulted in a large number of
patients looking for information to prepare
for orthodontic treatment and guide them
through the often challenging process. To
address this growing need, Crest and Oral-B
have launched Embrace It! (www.embraceit.
com), a complete online resource for parents and patients preparing for or maintaining braces.
Embrace It! helps answer braces-related
questions, including: what to expect, how
to care for them, and how to address financial concerns. An “Ask-the-Expert” feature
even connects users with an oral care expert to answer their questions. Embrace
It! was designed with parents in mind, to
make the tooth-straightening process a
little less mysterious.
“After they leave the office, patients may
feel overwhelmed with questions about the
treatment and best products for their oral
health condition,” says Dr. Jennifer Salzer,

a New York-based orthodontist and
mother of four, who is featured on
the website. “Embraceit.com has a
wealth of information on orthodontic
treatment, presented in a user-friendly format to help patients and parents navigate
the braces experience and feel confident
with their mouths during the process.”
To ease the transition to braces, Crest and
Oral-B offer OrthoEssentials, the ideal collection of oral care products for someone
with braces including simple education
tools to guide proper use and produce results that exceed expectations. With OrthoEssentials, patients can steer clear of common problems such as gingivitis, tartar
and demineralization, which can result in
additional time and expense — and get the
most beautiful and healthy smile possible.
For patients in the tween age group particularly, getting braces is the perfect time
to re-establish proper oral care techniques
and routines to inspire confidence in having a healthy smile. To help tween patients
through this awkward phase, Crest and
Oral-B have updated their line of tweenfriendly Pro-Health FOR ME oral care prod-

Hinman
BOOTH
NO. 1507

ucts to include the Oral-B Pro-Health FOR
ME Electric Powered Toothbrush. With a
built in two-minute timer and multiple
brush heads for sensitive teeth and gums,
it enables patients can to power the gunk
away — something orthodontist can appreciate.
For more information on Embrace It!, you

Embrace It! (www.
embraceit.com), is a
complete online
resource for parents
and patients
preparing for or
maintaining braces.

can visit www.
Photo/Provided by
Crest Oral-B
embraceit.com.
To learn all about
OrthoEssentials
and Crest and Oral-B Pro-Health FOR ME
products, visit www.dentalcare.com.
(Sources: Crest and Oral-B)


[2] =>
D2

COMMENTARY

Commentary: Not all hand-held
X-ray systems are created equal
By Joel Gray, PhD

As a recent article on
[w w w. d en ta l - t r ib un e .
com] points out, there
are some safety issues
with hand-held X-ray
Joel Gray, PhD
units made in China and
Korea, as well as elsewhere outside of the United States. There
are two sources of radiation from an Xray system — leakage radiation from
the X-ray tube and scattered radiation
from the patient. The leakage radiation is
minimized by placing highly absorbing
material, such as lead, around the X-ray
tube. The major issue with the hand-held
X-ray units is the scattered radiation,
that is X-rays that are scattered from the
patient towards the operator.
In fact, about 20 to 30 percent of the
X-rays are scattered from the patient
toward the person holding the device.
The X-ray units from outside the United
States, which are under FDA scrutiny, do
not provide any protection from X-rays
scattered from the patient. These systems look like a large camera that you
hold with both hands.
There is no shielding provided by these
hand-held systems; that is, the user’s
hands are exposed to all of the X-rays

◊ OVERALL, page D1
forms, please check my website, www.
artofpracticemanagement.com, to obtain a copy. Again, thorough questioning
of all new and established patients is an
essential component to getting the full
picture of your patients’ health.
What is discovered from these questions can be a strong determining factor
in how each patient is handled. Patient
questioning should always be followed
by dental exams, X-rays, blood pressure
checks and clinical observations. For
those patients who may have a systemic
disorder, your practice should become
proactive by referring the patient back to
his or her primary care provider.
However, because dentistry has
evolved over the last decade, there are
more ways that the dental practice can
help make these determinations. With
the frequency of patients’ visits and the
availability of numerous cutting edge
diagnostic tools, we have the unique opportunity to administer different types
of disease testing that, in the past, were
performed only by medical practices.

Medical testing options
If you are unfamiliar with the types of
medical testing that are available for
dental practices to perform, then the following information can make a big difference in the quality of your practice’s
treatment, and it may help to make a
significant change in how you perceive
your career.
First of all, periodontal diseases and
caries are bacterial infections, but the
majority of dental practices diagnose
these conditions through the use of peri-

scattered from the paHinMAN
tient. Consequently, the
BOOTH
user’s hands are going
NO. 923
to receive a radiation
dose that will probably
exceed the radiationprotection limits for skin
and extremities. Therefore,
these units should not be
hand-held.
We evaluated one handheld X-ray unit manufactured in the United States
(Nomad, Aribex Inc.) and
compared staff doses with
those for the same staff using
conventional wall-mounted
systems prior to acquiring
The NOMAD handheld X-ray system.
the hand-held systems (Gray
Photos/Provided by Aribex
et al. 2012). This hand-held
system uses a proprietary
shielding material around
the X-ray tube, resulting in leakage rawall-mounted X-ray systems.
diation levels that are virtually immeaBuyers should be aware that not all
surable. In addition, it has an integral
hand-held X-ray systems are created
leaded-acrylic shield that protects the
equal and not all of those being sold on
user from radiation scattered from the
the web have been reviewed by the FDA.
patient.
Hand-held X-ray units should have
The results of our study indicated that
sufficient shielding to minimize leakthe users of the hand-held X-ray system
age radiation from the X-ray tube and an
received lower radiation doses than they
integral shield to protect from radiation
did when they were using conventional
scattered from the patient.

‘Dental-medical cross coding is a cutting-edge
insurance system whereby dental practices
can file a patient’s medically necessary dental
procedures with their medical plans.’
odontal probes and explorers. Have you
considered that medical practices would
never begin treatment without determining if they are treating bacteria or a
virus? In dentistry, we need to differentiate between aspirin sensitivity, blood
dyscrasias, other diseases, fungus, yeast
or a cyst; so bacteriologic tests should
be performed.2 Microscopic tests, DNA
tests, or bacteriologic tests should be
performed if periodontal infections are
apparent.
Tests that can be performed in a dental
practice:
• HgA1c for blood sugar
• C-reactive protein (CRP) for inflammation
• BANA for bacterial pathogens or their
byproducts
• DNA for the presence of specific
pathogens or for patient susceptibility to periodontal disease
• TOPAS for inflammatory markers
• Oral HPV testing
• Diabetes testing with a glucometer
— finger stick or blood sample taken
from a periodontal pocket
• Oral cancer screening (e.g. ViziLite)
• HIV testing
• Screening for cardiovascular disease
(e.g. HeartScore System)
• Saliva biomarker test — measures

three specific biomarkers that play
a role in cancer development in the
oral cavity
As you can see, these tests cover many
possible systemic conditions.
Your practice will have to determine
which staff members are allowed to administer these tests, because your state
makes regulations controlling this. Hygienists may be allowed and, if so, this
may make a difference in your career.
Even if hygienists are not allowed per
your state’s regulations, your encouragement in the practice to add these tests to
the practice’s procedure mix will be invaluable to the practice. In addition, hygienists need to realize the importance
of their observations and questioning of
the patients in helping to move these patients to better overall health. This puts a
new slant on the same-old, same-old.

The Power of cross coding
There is, however, another area in which
hygienists can make a significant difference in their practices. Dental-medical
cross coding is a cutting-edge insurance
system whereby dental practices can file
a patient’s medically necessary dental
” See OVERALL, page D3

Hygiene Tribune U.S. Edition | March 2012

HYGIENE TRIBUNE
Publisher & Chairman
Torsten Oemus t.oemus@dental-tribune.com
Chief Operating Officer
Eric Seid e.seid@dental-tribune.com
Group Editor & Designer
Robin Goodman r.goodman@dental-tribune.com
Editor in Chief Dental Tribune
Dr. David L. Hoexter feedback@dental-tribune.com
Editor in Chief Hygiene Tribune
Patricia Walsh, RDH feedback@dental-tribune.com
Managing Editor
Robert Selleck r.selleck@dental-tribune.com
Managing Editor Show Dailies
Kristine Colker k.colker@dental-tribune.com
Managing Editor
Fred Michmershuizen
f.michmershuizen@dental-tribune.com
Managing Editor
Sierra Rendon s.rendon@dental-tribune.com
Product/Account Manager
Mara Zimmerman
m.zimmerman@dental-tribune.com
Product/Account Manager
Charles Serra c.serra@dental-tribune.com
Marketing Director
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a.wlodarczyk@dental-tribune.com
Education Director
Christiane Ferret c.ferret@dtstudyclub.com
Accounting Coordinator
Nirmala Singh n.singh@dental-tribune.com
Tribune America, LLC
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New York, NY 10011
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Published by Tribune America
© 2012 Tribune America, LLC
All rights reserved.
Tribune America strives to maintain the utmost accuracy in its news and clinical reports. If you find a
factual error or content that requires clarification,
please contact Managing Editor Robert Selleck at
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Tribune America cannot assume responsibility for
the validity of product claims or for typographical
errors. The publisher also does not assume responsibility for product names or statements made by
advertisers. Opinions expressed by authors are their
own and may not reflect those of Tribune America.
Editorial Board
Dr. Joel Berg
Dr. L. Stephen Buchanan
Dr. Arnaldo Castellucci
Dr. Gorden Christensen
Dr. Rella Christensen
Dr. William Dickerson
Hugh Doherty
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Dr. Karl Leinfelder
Dr. Roger Levin
Dr. Carl E. Misch
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Dr. Jon Suzuki
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Dr. Dan Ward

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[3] =>
CLINICAL

Dental Tribune U.S. Edition | March 2013

◊ OVERALL, page D2
procedures with their medical plans.
Implementing cross coding creates
greater case acceptance resulting in increased patient affordability and practice profitability. Hygienists can play a
key role in the implementation of cross
coding.
Hygienists can be the communicators
for cross coding in their practices by
alerting the practice of patients whom
they believe are medically compromised. Such patients are excellent candidates for cross-coded claims.
As an example, hygienists can inquire
about conditions that might indicate
that a patient has sleep apnea (Fig. 1). For
those practices that treat sleep apnea,
the practice would then need to refer
the patient for a sleep study before commencing treatment. If the practice does
not treat sleep apnea, this referral would
at least get the ball rolling for treatment
by another provider.
Hygienists can also be the champions
for cross coding by encouraging that
their practices implement a cross-coding
system. In most practices, the business
office staff will need to play a significant
role, but the hygienists can spearhead
the process.

Dental, medical claims differences
There are significant differences between
dental and medical claims. The biggest
difference is that, at present, medical insurance is diagnosis driven while dental
insurance is not as of yet.
Medical insurance uses diagnosis
codes to explain why a procedure was
performed. Without at least one appropriate diagnosis code, a claim will not be
paid. The diagnosis codes are titled ICD9-CM. The procedure codes are titled CPT
codes.
At present, there are growing numbers of dentally related diagnosis codes,
which are very helpful when cross coding. However, it is not so easy to use the
CPT codes because there are so few dental CPT codes. This is the area that makes
cross coding more difficult. The medical
claim form is a bit different than the dental claim form. It is titled the CMS-1500
form and is printed in red ink (Fig. 2).
The form provides spaces for at least
four diagnosis codes and six procedure
codes. There are also other codes within
these code systems that are used to give
further diagnostic information or to provide information on why a procedure
might have been modified by a specific
circumstance.
As you can see, cross coding is not an
easy system to implement. The answer
to easing the difficulty with cross coding
is to take a good course on the topic. You
also can check out my website to see the
different tools available to help dental
practices implement cross coding.

Increased opportunities with
medical insurance
As mentioned already, the patient’s benefit from cross coding is that medically
necessary dental procedure can be made
more affordable.
It is possible to file the tests already
mentioned with a patient’s medical insurance plan. There are diagnosis and
procedure codes that apply to these tests,
but those are too involved for the scope
of this article to provide all of the codes
needed.

There is no guarantee that these tests
would be covered by the plan. According
to the Centers for Medicare and Medicaid
Services, “the existence of a code does
not, of itself, determine coverage or noncoverage.”3
It is certainly worth the effort of a
phone call to determine coverage. I always advise practices that cross code and
receive negative responses to encourage their patients to complain to their
employers. Insurance contracts are between the insurance company and the
employer, so dental practices have little
power to make any plan changes. However, the more that complaints are issued,
the more likely that medical insurance
carriers will begin to see the necessity for
including these types of procedures in
their plans.

More cross-coding procedures
The full scope of cross coding is much
more extensive than just these tests.

Dental practices should be cross coding
for the following:
• Trauma procedures
• Oral surgical procedures
• TMD procedures
• Sleep apnea procedures
• Medically necessary endodontic procedures
• Medically necessary implant and periodontal procedures
• Exams, radiographs and diagnostic
procedures for any medically necessary dental procedure

Postive changes to your career
Between implementing disease testing
and cross coding, a hygienist will significantly make positive changes to his
or her career. These hygienists will not
only help patients obtain optimal health,
but they can also help make procedures
more affordable.
Patients will be able to see that their
dental practice truly cares about their

D3
health and will have more confidence in
the practice. This is a true win-win situation. The dental practice will value the
contributions of these hygienists, and
hygienists will rarely face each day with
that “same-old, same-old” feeling.
Editorial note: This article is reprinted from
Vol. 1, No. 1, 2012, Hygiene C.E. magazine.
˙

References

1.

Dentists can help patients at risk of fatal
heart attack, www.drbicuspid.com/redirect
/redirect.asp?itemid=303206&wf=33ing,
accessed July 7, 2012.
Zaromb A, Chamberlain D, Schoor R, et al.
Periodontitis as a manifestation of chronic
benign neutropenia. J Periodontol.
2006;77:1921–1926.
Common Procedure Coding System
(HCPCS) Level II coding procedures. Centers for Medicare and Medicaid Services
website. Available at: www.cms.hhs.gov/
MedHCPCSGenInfoHealthcare/Downloads/
LevelIICoding Procedures113005.pdf, accessed Oct 24, 2006.

2.

3.

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