Last Friday, the Health and Human Services Commission sent out a notice that it had “updated its Medicaid Medical and Dental Policy web page by posting stakeholder comments and HHSC responses for the THSteps Diagnostic Dental Services policy in development.”
TDMR had earlier promoted that providers should respond to the invitation to comment. The agency wrote it had received comments from MCNA Insurance Company, DentaQuest, and the Texas Dental Association
The odd thing about the update is that every suggestion and comment that was submitted to HHSC on the THSteps Diagnostic Dental Services Caries Risk Assessment was rejected with the phrasing of the HHSC’s responses rather cold and dismissive. The result leaves one to wonder if such responses are welcome and whether future invitations to comment on policy changes are worthwhile.
That being said, no comment is made on the rightness or wrongness of HHSC’s responses and they may be totally appropriate. It is suggested though that HHSC could seem more appreciative of the input given.
Rather than just have a link to the PDF file containing the comments and responses, which we do here, we are posting the full document in this article so everything is easy to review online.
Here it is:
THSteps Diagnostic Dental Services
Caries Risk Assessment comments
The 14-day comment period for the caries risk assessment (CRA) ended September 8, 2015. During this period, HHSC received comments from the following corporate stakeholders: MCNA Insurance Company, DentaQuest, and the Texas Dental Association. A summary of comments relating to the proposed policy changes and HHSC/DSHS responses follows.
Paragraph 24: Requiring the appendage of a CRA code to a dental examination procedure code
Comment: A commenter is concerned about updating Texas Health Steps (THSteps) Diagnostic Dental Services policy to require that CRA be documented in order for dental oral examination codes to be reimbursed.
Response: HHSC and DSHS decline to revise the policy in response to this comment. HHSC believes that appending the CRA code to the oral examination procedure codes is appropriate, given that it is standard practice that a dentist looks for evidence of caries, oral hygiene, and precursors to caries, among other concerns, while he or she is performing an oral examination.
Paragraph 24.1: Requiring documentation and maintenance of conditions justifying the risk assessment submitted
Comment: A commenter is concerned with certain risk assessment indicators on many of the tools currently utilized. The commenter is particularly concerned about the use of the socioeconomic status indicator. When selected, this indicator automatically places children in high-risk status. Consequently, many providers will select the high risk category for any child that is on Medicaid.
Response: HHSC and DSHS decline to revise the policy in response to this comment. Socioeconomic factors look at populations as a whole. HHSC and DSHS are encouraging dentists to evaluate their patients on a more individual basis looking at the biological and clinical factors to determine the caries risk status. HHSC is developing a THSteps training module that will address socioeconomic factors versus clinical and biological factors for determining caries risk. Adapted CRA tools for THSteps are based on nationally recognized tools in conjunction with feedback from leaders in the dental profession. HHSC and DSHS encourage providers to consider using these tools.
Comment: A commenter is similarly concerned that the use of the oral health of the mother/caregiver indicator is misleading. The commenter suggests that factors other than a mother’s or caregiver’s lack of concern for his or her oral health might lead to the mother’s or caregiver’s poor oral health. For example, the commenter says, the mother/caregiver might not be caring for his or her own oral health because Texas does not have an adult Medicaid dental benefit. By contrast, because there is a benefit plan for children, the mother/caregiver may very well be taking care of the child’s oral health.
Response: HHSC and DSHS decline to revise the policy in response to this comment. Nationally recognized research has shown that a child has a greater risk for having decay if their mother has decay regardless of insurance status. Consequently, HHSC and DSHS believe that including these indicators is consistent with dental best practices.
Paragraph 24.2: Providing a list of acceptable CRAs
Comment: Several commenters imply that paragraph 24.2 of the policy should require the use of a particular CRA tool, rather than providing dentists with a choice. In one commenter’s view, the lack of a specific tool requirement leaves the determination open to any number of factors leaving the designation subjective. Another commenter suggests that the use of uniform CRA tool for all providers will streamline the factors that determine each category of risk.
Response: HHSC and DSHS decline to revise the policy in response to these comments. The training that THSteps is providing will help minimize subjectivity. A certain amount of error is to be expected with any tool, and we will be monitoring that in our baseline year. In addition, a dentist should have the flexibility, using his or her professional judgment, to utilize the caries risk assessment tools with which the dentist is most comfortable.
Comment: A commenter voices concerns about the accuracy of the data obtained through the CRA. With First Dental Home, all dentists use the same CRA created by the Department of State Health Services Oral Health Program. However, with this draft policy change, dentists may use one of three approved CRA tools. Instead, the state should standardize the CRA tool so that the data collected is as cohesive as possible. This is important since the CRA is inherently a subjective tool with information gathered by interviewing the parent, primary care giver, or the
patient. Allowing dentists to use three different CRA tool adds to likelihood of inaccuracy in the data collected. As a result, the commenter continues, using data gathered from the CRAs for the Pay-For-Quality (P4Q) program could be detrimental as a result of the lack of consistency.
Response: HHSC and DSHS decline to revise the policy in response to this comment. All of the tools seek to find the same kind of information, specifically what events or conditions in a client’s life and environment might predispose them to risks for caries development. As previously stated, dentists have the right to utilize the caries risk assessment tool with which they are most comfortable. They need flexibility to exercise their own professional judgment. HHSC will monitor the reliability of the caries risk assessment data to ensure consistency for the P4Q program.
Comment: A commenter states that a CRA does not evaluate a patient’s oral health and does not predict a patient’s future oral health. Rather, the CRA is an educated guess at the probability of an individual to maintain his or her current level of oral health, experience deterioration in oral health, or realize improvement in oral health through appropriate interventions.
Response: HHSC and DSHS decline to revise the policy in response to this comment. A patient’s oral health is determined by assessing soft tissue as well as hard tissue (teeth). The CRA is a tool to predict the risk for future dental caries. From that assessment, a dentist can determine necessary interventions that will help to prevent future decay if the patient has an elevated risk. The P4Q program will be evaluating our Medicaid/CHIP patients with elevated risk for dental caries to determine if they are receiving sealants – an appropriate preventive
intervention.
Comment: A commenter questions the value of the CRA requirement. In the commenter’s view, while the future of dentistry will certainly include CRA as part of the overall delivery of dental care; the practice of dentistry and of health care in general is moving towards identifying each individual patient’s unique needs and designing a customized treatment plan for that patient. Although the state included in the summary that prevention of childhood caries is a fundamental part of preventive dental care, the draft proposal simply provides for the collection of data through a CRA and does not adjust benefits needed for effective chronic disease management. In the commenter’s view, the State is requiring dentists to collect data simply for the sake of collecting data and nothing else, when the State’s goal should be to prevent disease when possible and treat disease when present.
Response: HHSC and DSHS decline to revise the policy in response to this comment, although the agencies agree that the practice of dentistry is evolving and the CRA will be included in the overall delivery of care. Waiting for a future date to implement this quality tracking measure is inappropriate. Over the last decade, there has been increased support in the dental profession for utilizing CRA tools. Based on current literature and research, the CRA is recommended to be carried out at the child’s first dental visit with reassessments performed throughout childhood. The THSteps program initiated CRA over seven years ago for children under the age of three.
Since this assessment is now considered to be an integral part of all childhood dental examinations conducted by a dentist, the THSteps program expects that all dentists will understand the importance of these assessments as being best practice.
Comment: A commenter suggests that HHSC and DSHS have not considered CRA limitations or the negative outcomes that will occur from requiring measurements for measurement’s sake.
Response: HHSC and DSHS decline to revise the policy in response to this comment. The agencies disagree that the CRA measurements are being required simply for the sake of measuring. Rather, the results will be tracked and evaluated for future policy and benefit considerations. HHSC will be monitoring and will assess the reliability of the CRA data to assure consistency in the baseline year. The Texas Medicaid program adopted an adapted CRA tool
based on other nationally accepted tools. HHSC encourages providers to consider using our tool, with the understanding that dentists have the autonomy to utilize the CRA tools with which they are most comfortable, providing flexibility for a dentist to exercise their own professional judgment. According to a recent European journal listed on the American Dental Association (ADA) website: http://ebd.ada.org/en/evidence/evidence-by-topic/cariology-and-caries-management/cariesrisk-assessment-in-children-how-accurate-are-we
Based on the present summary of literature, it may be concluded: (1) a caries risk assessment should be carried out at the child’s first dental visit and reassessments should be done during childhood (D); (2) multivariate models
display a better accuracy than the use of single predictors and this is especially true for preschool children (C); (3) there is no clearly superior method to predict future caries and no evidence to support the use of one model, program, or technology before the other (C); and (4) the risk category should be linked to appropriate preventive care with recall intervals based on the individual need (C).
Comment: A commenter is concerned that providers are not adequately trained on utilization of these risk assessment tools and believes support staff might actually be the ones selecting the risk category.
Response: HHSC and DSHS decline to revise the policy in response to this comment. HHSC is developing a training that will be available via a Texas Health Steps Online Provider Education module that is accessible 24 hours a day, seven days per week, at http://www.txhealthsteps.com/cms/. A webcast will be posted initially on October 1, 2015, and a training module will be posted mid-November. Adjudication for the appending of the CRA codes to the oral evaluation claims will not be enforced until January 1, 2016.
Comment: Several commenters recommended that the CRA requirement be delayed for various reasons. One commenter recommends delaying any final policy decisions in terms of payment until after the training has occurred and the success can be gauged in terms of participation in the training opportunities and feedback given by the provider community. Additionally, a commenter suggested that the agencies delay the implementation of the CRA
tool until January 1, 2016, for the Dental Maintenance Organizations (DMOs). This would coincide with HHSC’s current plans to capture the risk assessment codes for the 2016 P4Q program, and prepare for the inclusion of the Dental Quality Alliance (DQA) measures that will be added in 2017. In addition, it would allow the commenter’s time to configure its claims processing system as well as allow for provider communications and education to be drafted,
approved by HHSC and mailed to the network to notify them of the new requirement.
Response: HHSC and DSHS agree with the comments, but believe that the policy as drafted is consistent with the comment. Policy changes will be effective October 1, 2015; however, data collection in conjunction with the enforcement of policy through claims adjudication will not be effective until January 1, 2016. This will allow dental providers time to adjust to the policy changes and to complete the necessary training.
Comment: A commenter strongly recommends delaying implementation of this policy until CRA can be paired with benefit changes that support clinical management protocols designed to assist in clinical decision-making with individualized preventive treatment modalities based on a specific patient’s risk.
Response: HHSC and DSHS decline to revise the policy in response to this comment. HHSC and DSHS will proceed to begin tracking caries risk effective January 1, 2016, making it consistent with the P4Q timeline. The data will be collected to provide information regarding the current overall oral health of Texas children and will be evaluated and used to provide a baseline for what the current dental needs are for these children in order to develop effective prevention programs and determine appropriate future dental benefit considerations. Reviews of recent literature involving children and CRAs demonstrate that a CRA should be conducted at the child’s first dental visit and reassessments should be completed throughout childhood. The DQA, led by the American Dental Association in collaboration with a variety of dental associations and dental stakeholders, support the importance of a CRA. This assessment is considered to be an integral part of all routine dental exams for children. As we move forward with the submission of CRA codes, if a dentist determines additional preventive treatment as medically necessary, the provider can submit for approval under those terms with sound documentation.
Comment: A commenter expressed concern that this policy change coincides with the effective date of ICD-10 and the timing may compound the issues for the provider community.
Response: HHSC and DSHS decline to revise the policy in response to this comment. Code on Dental Procedures and Nomenclature (CDT) codes are not changing. Very few dental procedure codes in Texas Medicaid will be impacted by the transition from ICD-9 to ICD-10. The ICD-10 implementation is effective October 1, 2015, while claims adjudication for the CRA codes will not be enforced until January 1, 2016.
Section 24.3: No reimbursement amount
Comment: A commenter opines that the proposed policy imposes the use of the CRA as an unfunded mandate for dentists. In the commenter’s view, if Texas truly values the CRA, it should reimburse dentists for it.
Response: HHSC and DSHS decline to revise the policy in response to this comment. In the agencies’ view, the assessment of caries risk is an integral part of any dental exam. It is standard of care and considered “best practice” by national experts.
Comment: Commenters expressed concern about the $0.01 billing standard implemented in the policy. One commenter indicated that it will be problematic for providers in terms of accounts receivable reconciliations. Another commenter also suggested that the billing standard will be administratively burdensome for dental offices. In the commenter’s view, a dental office should not have to “go through the hassle” of adjusting billing for every $0.01 entry because no reimbursement is given for CRA.
Response: HHSC and DSHS decline to revise the policy in response to these comments. Billing $0.01 is standard practice for all informational codes that lack a specific price assignment. See Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, § 5.5.1 (September 2015) (“All procedures, including the informational-only procedures, must have a billed amount associated with each procedure listed on the claim. Informational-only procedure codes must be billed in the amount of at least $.01.”) For this reason, the agencies do not believe the policy will be problematic for providers in terms of accounts receivable reconciliations or be administratively burdensome.
In general
Comment: A commenter is concerned that dentists may submit the CRA codes without actually performing an assessment in order to receive payment for the D0120, D0150, and D0145 codes. In the commenter’s view, even though the language requires that dentists use a valid risk assessment tool, there is no practical way of verifying that they did in fact did so before they assigned the risk status. On the other hand, the commenter points out that a dentist who submits a risk code without having conducted a CRA ultimately will be identified through the
utilization review process. Thus, according to the commenter, policing the process will fall on the DMO’s utilization review staff retrospectively to make sure providers actually complete a CRA form when doing an exam and submitting the risk assessment code.
Response: HHSC and DSHS decline to revise the policy in response to this comment. HHSC expects the DMOs to monitor utilization of CRA codes, track utilization patterns, and identify potential fraud, waste, or abuse as part of the existing operational requirements set out in in sections 8.1.9 and 8.1.13 of the dental services managed care contract.
Comment: A commenter suggests that the policy, if implemented, may result in increased legal exposure for the State. If the CRA is required, the State will have data identifying and categorizing certain patients as “high-risk” for caries, but the State will not have made necessary benefit changes to address those patients’ needs. The commenter advocates pairing CRA with management protocols, individualized patient interventions, and anticipatory
guidance.
Response: HHSC and DSHS decline to revise the policy in response to this comment. For a child whose medical and dental needs exceeds the allowances in the THSteps policies, the Comprehensive Care Program is available to Medicaid clients from birth through 20 years of age to meet the child’s medically necessary medical and dental needs. The DQA, led by the ADA in collaboration with a variety of dental associations and dental stakeholders, support the importance of a CRA. This assessment is considered to be an integral part of all routine dental
exams for children. As we move forward with the submission of CRA codes, if a dentist determines additional preventive treatment as medically necessary, the provider can submit for approval under those terms with sound documentation.
Out of scope of this policy change
Comment: A commenter suggested that the requirement in section 19.3 that a dental home provider keep supporting documentation for a primary caregiver’s oral health in the client’s medical record may be interpreted to mean that the dentist completed an examination and diagnosed the primary care giver’s oral health. According to the commenter, this is not part of a CRA, and the policy should clearly state that the dentist is not making a diagnosis but only collecting verbal affirmation from the parent/primary caregiver as to whether he or she has active caries.
Response: HHSC and DSHS decline to revise the policy in response to this comment. This section of the policy is not proposed for amendment at this time.
Comment: With respect to section 23, a commenter stated that the claims should not be subjected to retrospective payment review with possible recoupment. The state and the dental plans must build an edit into the electronic claims processing system that prevents the dentist from submitting the claim until medical necessity has been documented.
Response: HHSC and DSHS decline to revise the policy in response to this comment. This section of the policy is not proposed for amendment at this time.
Comment: A commenter suggested that sections 38-44 should be deleted or rewritten as duplicative.
Response: HHSC and DSHS decline to revise the policy in response to this comment. This section of the policy is not proposed for amendment at this time.
Comment: With respect to section 45, a commenter recommends that HHSC strike the code D0145 because it does not apply to the age group identified. Rather, it applies to children aged 6 months to 35 months.
Response: HHSC and DSHS decline to revise the policy in response to this comment. This section of the policy is not proposed for amendment at this time.