Wednesday, April 3, 2013

Vertical Bitewings

Every state or national dental meeting has multiple practice management programs on the agenda. Inevitably, these are among the most well-attended seminars at the meeting. The common themes at these courses include improving your recall system, your case presentations, follow-up systems, phone skills, scheduling and marketing. While dentists and their teams leave most of these programs excited for all of the changes they are going to make, the excitement and the follow-through wane over time. Perhaps that is because you don’t leave these programs with any concrete changes to implement or true idea of the financial implications of the suggestions.

The best systems in the world are only as effective as the diagnosis about which the patient was educated. Even the best office manager or schedule coordinator cannot put patients on the books for treatment that wasn’t diagnosed. The goal of this series of posts is to open doctors’ and staff’s eyes to all the dentistry that is right in front of them. The amount of dentistry that is available to do on your current patient pool and the underutilized treatment procedures/codes is astounding. In each post of this series, I will discuss one or two treatments or practice management suggestions that you can utilize the second you put down the article. We will look at the financial implications of each and extrapolate the results over the typical dental career.

Each of the tips will be accompanied by clinical photos or case reports to support the concept. The goal is that every idea turns into a win-win situation. It is amazing how thorough, thoughtful dentistry not only turns out to be best for the patient, but also adds to the production of the practice. I will discuss concepts that benefit the patient, protects the dentistry you perform, and enhances everyone’s quality of life by decreasing patient chair time and adding to your bottom line.

Let us begin with your hygiene department and available treatment that can be produced. In the vast majority of practices in the United States, patients receive prophylaxes twice a year. In the typical practice, dentists perform radiographs once a year. What form do these radiographs take? If yours is like most practices, you perform four horizontal bitewings that look something like this:

This is the classic four bitewing series, ADA code D0274 . What do you notice as you look, however, at this next series of radiographs?

Here we see anterior teeth and we can see much further apically. This is the seven vertical bitewing series. This series not only helps us examine the upper and lower anterior teeth, but also shows us the crestal bone in much greater depth and detail. Compare the vertical bitewing of the #3 and #30 areas to the horizontal radiographs of the same area. It is clear how deep the periodontal defect is. You cannot appreciate this on the horizontal bitewing.

This series of radiographs is better for the patient, as it gives us more diagnostic information. It turns out that we can charge (and insurance pays) more for this series of radiographs. This is the definition of a win-win situation: better diagnostic information benefits the patient’s oral health and a greater fee benefits the practice. Let us examine the immediate impact of the implementation of seven vertical bitewings on your practice.

My calculation is based on the following assumptions: eight hygiene patients a day (we will assume ½ of the patients in a typical day are due for radiographs), 200 hygiene days a year, and a fee difference between four bitewings and seven vertical bitewings of $30. You can, of course, plug your own numbers into this equation:

4 (one half number of hygiene patients a day)
x 200 (hygiene days a year)
x $30 (fee difference between 7 VBWs and 4 BWs)
$24,000 increased production by converting to 7 vertical bitewings

By simply changing your recall protocol so that you take seven vertical bitewings instead of four bitewings, you can easily generate an extra $24,000 in production per year, based on this example. This doesn’t even take into consideration the difference in diagnostic information and increased treatment you will find during your exams. This calculation is based on conservative assumptions. For many of you, the increased production can be much greater. Extrapolated over the average 35-year career of a dentist, this could result in an extra $840,000 in production. This is certainly a nice start for a comfortable retirement.

This is the first of a number of suggestions that I will present over the coming series of posts. Next month, we will step back and start where all patient relationships begin: the new patient experience. We will discuss how to maximize this critical event and make it more financially productive by decreasing the lost overhead of new patient no-shows. As we progress through the series, I will speak about specific treatments, under-utilized ADA codes, and missed diagnoses that will add production and profitability.

Until next time, open your eyes to the possibilities.

Christopher J. Perry MS, DMD, FAGD


Tom said...

Hi Dr. Perry. Thank you for your blog.
I agree with you about the benefits of vertical bitewings and we started doing them when we switched to digitial radiographs in 2007. There is an insurance pitfall that you should be careful of though. Typically we do a full series of radiographs every 5 years and typically insurance will cover that frequency. After about a year of using the vertical bitewing code we found that many of our full series radiographs were being rejected by insurance companies. They consider the seven vertical radiographs the same as a full series of radiographs (18 images)so anyone who had vertical bitewings were not eligible for a full series.
We still continue to do vertical bitewings but we code them and charge for 4 bitewings.


Dr. Chris Perry said...

Tom: Thanks for responding. You are exactly right about the concern of frequency issues. A couple of things I would suggest: 1: Always code for what you do. While doing 7 BW's is a better service; doing seven and charging for 4 BW's may find you on a slippery insurance slope (though it makes no sense that it should. 2: You'd be amazed how many employers have contracted with their insurance company to cover 7 VBW's, usually with the disclaimer that 8 or more radiographs constitutes an FMX. Amazingly enough, many, many employers (and remember to emphasize to your patients that it's the employer that determines the benefit companies will cover whatever you pay a premium for) have contracted with insurance companies to actually cover bitewings twice in a year. 3: There are terrific programs out there that will allow you to have the answer to frequency and coding questions in seconds. Here in Texas (and Oklahoma and Louisiana) we have access to a program called "Insurance Answers Plus" and we just type in the employer and have coverages in seconds. They update the program daily and ask a lot of the questions that we want answers to: how often can you take BW's, is there a missing tooth clause, do they have implant or ortho coverage, do they have occlusal therapy and/or splint coverage, etc. Another program around the country is Trojan. If you ever have a company tell you that 7 images are an FMX, then fight them, because the CDT specifically says that 7 VBW's is not an FMX.
Hope that was helpful. A long answer to your comment. :-) Chris Perry

Rex said...

Subjecting every patient to excess radiation over a 35 year career isn't following the guidelines of ALARP. I have no problem with vertical bitewings when warranted, but doing them on every single patient with good bone levels and no clinical indications is poor practice IMHO.

Dr. Chris Perry said...

Rex: Thanks so much for your comment and I very much appreciate the ALARP concept. I hope you can appreciate the ALARP is based on the clinician's perspective of what is reasonable. In my opinion, the information garnered from vertical bitewings is worth the minimal additional exposure which I'm sure you can appreciate is greatly below levels of background exposure. As I stated in the blog, every suggestion I make is based on a patient-centered practice. By not ignoring the anterior teeth radiographically, I feel I am serving the best interest of the patient. There are many times that I will pick up early lesions that I could not see clinically, whether due to stain, overlap, old restorative material etc. I am also very conservative and prefer a longitudinal view of these lesions when present so that I don't treat arrested lesions. There is absolutely, "no dentistry better than no dentistry" and I prefer not to touch a tooth if I don't absolutely have to. To that end, I wish there was a better way that patients could maintain their radiographic history so that we could have more historical perspective on their dentition. Every new patient is asked if they have x-rays from their previous dentist, both so that they are not overexposed and so that we can get some historical perspective on their disease status. It is rare that a patient has or can obtain that historical record.
Also, I find that I have performed many fewer full mouth series of radiographs, as the vertical BW, including the anterior's, gives me more than enough information so as not to need to subject the patient to 18-20 extra radiographs. I would say that that, in and of itself, is a wash in terms of radiation exposure.
Again, I totally appreciate and agree with the idea of ALARP, and hope you can see my perspective on the issue.
Now, if we would really like to open up a thread of discussion focused on "doctor do no harm", let's start talking about sealants and orthodontics and how both have become over-used and detrimental to generations of kids. But that is a discussion for another day and one in which I would love to engage (if you are in Nashville, you can hear me address it a bit in my course).
Again, Thanks so much for you input. Chris Perry

Mike M said...

Thank you for the information regarding dental insurance. I too have been taking all vertical bitewings and ran into the issues with insurance not covering the full series. It is incredible the limitations on some patients plans.


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