NHS:
2000 PCA(D)17
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NHS: |
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Health
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Dear Colleague Summary 1. This letter advises Primary Care Trusts, Island Health Boards and Practitioner Services Division of the preparation of guidance on the interpretation of the narrative of item 32 of the Statement of Dental Remuneration, of related items and clarification of procedures. Background 2. There is evidence of misinterpretation and potential abuse in relation to the narrative of item 32 and other item of service fees related to orthodontics, including items 1(a), 1(b) and 1 (c). There are also concerns that patients, particularly child patients, may be being put at unnecessary risk through repeat large radiograph exposures. Consequently, a Memorandum containing guidance has been prepared for issue to general dental practitioners. This is aimed at protecting patients and reducing misinterpretations and possible abuse of the system. The Scottish Executive wish to make clear to practitioners that we are aware that abuse is perpetrated only by a minority of general dental practitioners so a letter to that effect from the Chief Dental Officer has also been prepared to accompany the Memorandum. A Health Department Letter is also being issued for action by hospital and community dental services. This will require them to copy any radiograph of appropriate quality provided by a general dental practitioner when referring a patient for orthodontic or other assessment/treatment and return this immediately to the referring practitioner. Action 3. Primary Care Trusts, Island Health Boards and Practitioner Services Division are asked to note the guidance contained in the Memorandum to this letter. |
6 November 2000
Addressees For information Enquiries to: |
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4. Copies of the letter from the Chief Dental Officer and the Memorandum to this letter are being sent under separate cover for urgent distribution to all dentists on Primary Care Trust/Island Health Board lists. Yours sincerely
DR HAMISH WILSON
Dear Colleague MEMORANDUM TO
NHS 2000 PCA(D)17 - GUIDANCE ON INTERPRETATION OF If f you have any queries about the Memorandum, I should be grateful if you would discuss these in the first instance with Practitioner Services (Dental) who are tasked with monitoring the implementation of the guidance. Yours sincerely
MEMORANDUM
TO NHS DENTISTS ORTHODONTIC SERVICES
IN THE GENERAL DENTAL SERVICES -- 1. This Memorandum interprets the narrative of item 32 and related items of the Statement of Dental Remuneration and clarifies procedures relating to orthodontic treatment in the General Dental Services. Any enquiries arising from this Memorandum should be taken up with Practitioner Services (Dental) or the Chief Dental Officer. Introduction 2. This guidance is aimed it all practitioners undertaking general dental services (GDS), whether general or specialist. 3. It is important to ensure that there is a general understanding by dentists of the narrative of item 32 of the Statement of Dental Remuneration (SDR), and of related SDR items and procedures. Following the guidance below will allow orthodontic treatment to be provided in patients' best interests by specialist and non specialist practitioners and will allow practitioners to secure payment for orthodontic treatment undertaken. Practitioners should note that, where they fail to act in accordance with this guidance, the Scottish Dental Practice Board may exercise its discretion to refuse approval of payment of claims for remuneration under Regulation 10(2) of the Scottish Dental Practice Board Regulations 1997 and to refuse to authorise payments on account under Regulation 23(6) of the National Health Service (General Dental Services) (Scotland) Regulations 1996. Practitioner Services (Dental) acts on behalf of the Scottish Dental Practice Board. 4. For the purposes of this guidance, the term "children" is defined as those aged under 18 years. 5. For the purposes of this Guidance, "NHS" is defined as covering general (GDS), community (CDS) and hospital (HDS) dental services.
(i) Suitability for Appliance Treatment Background 6. In a number of cases, practitioners have undertaken orthodontic appliance treatment on unsuitable patients, some of whom have been self-referrals.
7. Practitioners arc reminded that children who have previously had a high caries level or poor oral hygiene should be stabilised for a reasonable period, ie not normally less than one year, before orthodontic appliance treatment begins. The referring dentists of children falling within these categories should provide, with the referrals, a signed letter stating that the patient has been under regular dental care and his/her oral health and oral health behaviours have improved and are now of a standard to allow treatment to commence. Practitioners should not initiate orthodontic appliance treatment for patients who are not under the care of an NHS or private dental practitioner for routine dental care. Where a practitioner is in doubt about the suitability of a case, they should contact the Practitioner Services (Dental). 8. Those practitioners who have indicated for dental list purposes to their Health Board or Primary Care NHS Trust that their practice is limited to orthodontics may not accept for orthodontic treatment patients who are self-referrals. Any exceptions must be agreed with Practitioner Services (Dental). All self-referrals should either register with a general dental practitioner or present themselves to a registered dental practitioner for routine care and active orthodontic appliance treatment should only be initiated in accordance with paragraph 7 above. (ii) Examination
and diagnosis Action 10. Where a routine examination within a capitation arrangement discloses a malocclusion, then an Item 1(a) examination fee would be payable on a GP17(0) after assessment and recording of that malocclusion. 11. When the dentist who will be providing the orthodontic treatment examines the patient for the first time and considers that active treatment will not be required for at least 6 months, then an item 1(b) examination fee would be payable on completion of a GP17(0), listing extensive clinical examination, advice, charting, report and the reasons why active orthodontic treatment is not being provided at this time. Item 1(b) should normally only be claimed once per patient. There is a timebar of 23 months between claims. 12. When the dentist who will be providing the active orthodontic treatment reviews the patient after the initial Item 1(b) examination and considers that the patient is not yet ready to commence appliance treatment, an Item 1(a) examination fee would be payable. Normal time bar rules will apply. 13. Where any practitioner submits claims for (i) item 1(a) examination fees consistently without an adequate clinical reason and these claims are not linked to subsequent orthodontic treatment by them or by another dentist, or (ii) item 1(b) examination fees consistently without an adequate clinical reason and these claims are not linked to subsequent orthodontic treatment by them, the Scottish Dental Practice Board may require an explanation from the dentist and, if dissatisfied with the explanation given, may use its discretionary power to refuse approval of payment of future claims and consider recovery action. Practitioners are asked to note that monitoring a dentition without a malocclusion does not justify an orthodontic examination fee. Under capitation arrangements, practitioners receive a monthly fee to provide each child patient with all the care and treatment necessary to secure and maintain oral hearth. There is no proviso in the Statement of Dental Remuneration which allows a fee for a routine examination to be claimed for child patients. 14. Where the dentist who is providing, the active orthodontic treatment completes a full diagnosis and a full treatment plan for appliance treatment, an item 1(c)(iii) examination fee would be payable on completion of the treatment. An interim payment may be claimed but approval of payment may be authorised only at the discretion of the Scottish Dental Practice Board. B. Radiographic Assessment Background 15. There has been a significant increase in the numbers of large X-rays normally associated with orthodontic assessment. Over the last 5 years, for example, there has been an increase in such exposures for children of around 50%. They include cephalometric radiographs and orthopantomographs. These are large radiographs which expose children to significant doses of radiation. This may put patients at unacceptable risk. The quality of radiographic exposures is variable and practitioners are reminded that, where their radiographs are of poor quality, this could constitute grounds for professional negligence and repeated patterns of poor quality control may result in a refusal to approve payment or referral for disciplinary proceedings.
16. Through good communication and co-operation, radiographs should be exchanged between specialist practitioners, general practitioners, community dentists and hospital-based specialists to limit the need for repeat exposures in children. We are issuing guidance to community and hospital dental services that, where a general practitioner provides a radiograph of an appropriate quality for a referred patient, this should be copied immediately and then returned to the referring practitioner to avoid duplicate exposures. We will also be discussing shortly with the SDPC an item of service fee for copying of radiographs by specialist practitioners and by those general dental practitioners who accept orthodontic referrals from other practitioners. 17. Cephalometric radiographs (Lateral Headplates): practitioners must be able to justify clinically any radiographic exposure and claims for cephalometric radiographs must be accompanied by an appropriate tracing and report. In order to minimise dosage, no more than 2 cephalometric radiographs should be taken for any patient. This number should include where possible any cephalometric radiographs taken in hospital, in the community service or by any other dental practitioner. Practitioners should note that they may be asked to justify taking cephalometric radiographs. Failure to provide an adequate reason may result in approval of payment being refused or in payments being recovered. 18. Othopantomographs (Panoral Radiographs): these are considered desirable in most cases but there is evidence of multiple orthopantomographs being taken for the same patient, with duplication between the referring dental practitioner, the specialist practitioner, the community dental service and the hospital service. Such practices expose the child to unnecessary radiation. In order to protect patients, practitioners are asked to note that no more than 2 panoral radiographs should be taken while the patient is under 18. This may be exceeded only where clinical necessity dictates and justification can be provided. Practitioners are reminded that there should be a gap of at least 3 years between panoral radiographs. The Practitioner Services (Dental) will monitor and control prescription of orthopantomographs. 19. Where oral or dental disease is identified by specialist practitioners, the patient and, in the case of a child patient, the parent or guardian should be informed and the patient referred back to the referring dentist for appropriate assessment, diagnosis and treatment. 20. Full radiographic assessment for caries (including bitewings) in addition to orthodontic radiographic assessment should only be undertaken by the orthodontist seeing patients on referral if there is a clear indication of a specific problem from initial radiographs. Remedial routine treatment should be undertaken by the referring dental practitioner prior to commencement of orthodontic appliance treatment. Where a specialist practitioner identifies a treatment need, the patient must be referred back to the referring dentist for further diagnosis and treatment as soon as possible. 21. Occlusal films: these are normally required to provide information not obtainable on the panoral radiograph or any other large film and are not normally required for routine orthodontic assessment. They should not be taken unless there is a sound clinical reason for doing so. C. Appliance Therapy Background 22. There have been cases where appliance therapy has been undertaken by a number of practitioners who have made inappropriate treatment plans. This has led to high relapse rates, re-treatments and also to very poor results ie where there is no beneficial, measurable change after treatment. Some practitioners have also submitted treatment plans which do not cover all stages of orthodontic treatment. This staged approach has been used in a number of cases to avoid submitting applications to the Practitioner Services (Dental) for prior approval. Action 23. Comprehensive orthodontic treatment plans must be submitted to the Practitioner Services (Dental) for prior approval covering initial and subsequent stages of treatment where the initial and all subsequent stages of treatment will individually, jointly or cumulatively exceed the prior approval by volume limit. 24. The comprehensive treatment plans must address the need for retention at the end of orthodontic treatment. Prior approval must be sought also from Practitioner Services (Dental) where a dentist intends to alter the approved orthodontic treatment plan where the initial and subsequent stages of treatment will individually, jointly or cumulatively exceed the prior approval by volume limit. 25. Where minor orthodontic treatment is proposed, prior approval is not required and practitioners do not have to submit comprehensive long term treatment plans. They should bear in mind, however, that some early treatments may be considered unnecessary. Such treatments will be monitored and authorisation of payment of fees may be withheld where practitioners cannot justify these treatments on sound clinical grounds. 26. The level of relapse and retreatments with some practitioners is outwith the norm. This may be due to an initial failure to identify the level of treatment needed to obtain a satisfactory outcome. It is desirable for all orthodontic treatment required to be identified at the outset. If this is not possible, the guidelines below must be followed:- a. In general, treatment involving sectional fixed appliance therapy will be expected, with retention, to last at least 18 months-2 years. b. Claims for fixed multiband appliance treatment will not be considered for payment if the duration of the active phase of treatment is less than one year. This should then be followed by at least 12 months retention. c. There will be exceptions to a. and b. Where these occur, practitioners should be able to provide sound clinical reasons for such exceptional cases and authorisation of payments may be delayed until proof of a stable result is shown. 27. It will be necessary to submit a second treatment plan for prior approval to the Practitioner Services (Dental) for all re-treatments or subsequent appliance treatments not specified in the original treatment plan where the initial and subsequent stages of treatment will individually, jointly or cumulatively exceed the prior approval by volume limit. 28. The Practitioner Services (Dental) will monitor all completed cases and will request study models where appropriate to determine that a satisfactory result has been achieved. In monitoring treatment, study models may be requested for cases which have been out of retention for a period of not less than 6 months to review the stability of the result. Where a pattern of significant numbers of relapses is identified, recovery of payment will he considered. 29. Where there is a pattern of cases where inappropriate treatment has been initiated but not completed or not completed satisfactorily, a discontinued fee may not be authorised where those cases have been referred to another practitioner or to a hospital consultant for completion of treatment. In these circumstances no claim should be made. 30. Where monitoring identifies an abnormal number of re-treatments, the Scottish Dental Practice Board may use its discretionary power to refuse approval of payment claims to that practice/practitioner for work of this type. The onus will then fall on the practitioner to demonstrate through continuing education or other means that he/she has developed the appropriate skills and expertise to provide this treatment satisfactorily. Where this is achieved, the Scottish Dental Practice Board may then use its discretionary power to approve payments. D. Repairs Background 31. Some practitioners are claiming a large number of item of service fees for repairs for each appliance. Action E. Headgear and Anchorage Background 33. Confusion has arisen over the claiming of extra oral traction. Some claims have been made where extra oral traction has not been used but has been included in the prior approval request as a basis for approval. Subsequently, however, the extra oral traction has not in fact been provided and, in a minority of cases, not deleted from the claim form. Additionally, more than 1 claim per patient has been made without clinical justification being provided. Action 34. Should extra oral traction and/or lingual arches be required, this should be included as part of the treatment plan for prior approval. This treatment must be provided or approval requested to modify the treatment plan. 35. Normally, no more than 1 claim for anchorage reinforcement per arch should be submitted. Any further such claims must be submitted with clinical observations for consideration. F. Retainers Background 36. There are cases where practitioners are using pressure-formed retainers inappropriately and a significant number of repairs and replacements are claimed. Action 37. Pressure-formed retainers should only be used where appropriate and will be expected to last for the duration of the retention which, in most cases, will be at least 6 months. Where pressure-formed retainers do not last for the entire retention period, dentists must be prepared to provide a sound explanation for this. Practitioners are reminded that, under paragraph 20 of Part IV of Schedule 1 (Terms of Service for Dentists) to the National Health Service (General Dental Services) (Scotland) Regulations 1996, dentists must use only materials which are suitable for the purpose for which they are used.
Background 38. We are aware
of a number of cases where several dentists in a practice have treated
the same patient during a single course of orthodontic treatment and have
claimed separate payments. These claims make it appear that there have
been several courses of treatment, rather than a single course of treatment. 39. Where a patient is receiving orthodontic treatment and more than one dentist in a practice is treating that patient during various stages of orthodontic treatment, this is classed is one course of treatment by the same dentist as defined in Section I of Determination Iof the Statement of Dental Remuneration, including for the purposes of prior approval. Separate claims should not be made and the Scottish Dental Practice Board may refuse to authorise such claims. The "same dentist" means:
G. Non-Completion of Treatment Background
Action 41. Orthodontic treatment must be viewed as a long term treatment. A practitioner must inform the Practitioner Services (Dental) when patients change practitioner while undergoing orthodontic care which the practitioner cannot fully complete. Under paragraph 14 of Schedule 1 (terms of service for dentists) to the National Health Service (General Dental Services) (Scotland) Regulations 1996, where a dentist is unable to complete any care and treatment which has been commenced under a continuing care arrangement or a capitation arrangement or treatment on referral, the dentist must notify Practitioner Services (Dental) in writing of the extent of the care and treatment or treatment on referral already provided and of the reason for his/her inability to complete the remainder. Authorisation of fees for discontinued treatment will be at the discretion of the Scottish Dental Practice Board in these circumstances.
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