What’s in a number?

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Why the removal of two periodontal items from the Dental Schedule in March created tension between the ADA and affiliated periodontal professional groups. By Sue Nelson

The Dental Schedule of Services is sacrosanct to the profession, describing services delivered by dentists, dental specialists and affiliated professionals. The item numbers contained in the Schedule are important not only to dental professionals but also to patients and, of course, the health funds that use the items to determine rebates.

The Schedule is administered by the Australian Dental Association (ADA), and is reviewed every four to five years to ensure that the items it contains continue to effectively describe the treatments dentists provide. In reviewing the Schedule, the ADA’s Schedule Committee takes notice of any queries and feedback from interested parties.

“We log all the enquiries we get, whether they be from practitioners, the health funds or the public,” says Dr Carmelo Bonanno, interim chair of the Schedule Committee as well as a past chair, who has been on the committee for 19 years. “And we look to see which numbers are problematic. Then we invite submissions from stakeholders. And that could be societies, specialist groups, health funds—anybody who has a stake in the items.”

Earlier this year, the ADA removed the two items relating to periodontal treatment and care—items 281 and 282—from the Schedule. The ADA had received feedback about confusion surrounding the use of these items, which related to the treatment of moderate to advanced periodontal disease. These two items were used mainly by periodontal specialists, but also by general dental practitioners and dental hygienists.

“While we found that a lot of people were happy with the numbers, it became clear that the description of the numbers and the way they should be used was a little bit ambiguous—and how the extent of periodontal disease was to be defined was ambiguous as well,” says Dr Bonanno.

“We did find that people were probably misusing the item numbers, not in a dishonest sense, but in the sense of not understanding their application. There was a fair amount of discussion and a view in some areas that the procedures described in the items could be described using the other existing item numbers.”

“We look to see which numbers are problematic. Then we invite submissions from stakeholders.”—Dr Carmelo Bonanno, interim chair, Schedule Committee, ADA

At the time, periodontist groups including the Australian and New Zealand Academy of Periodontists (ANZAP) and the Australian Society of Periodontology (ASP) raised strong concerns about the removal of the items, saying the absence of these descriptors of their service would have a huge impact on specialist periodontal practice.

Dr Rachel Garraway, spokesperson for ANZAP and the ASP—and a key player in the discussions between the ADA and the periodontists—said in April: “Without 281 and 282, we don’t have the item numbers to explain or describe the treatments we provide for periodontal disease.”

A key issue for periodontists and general practitioner dentists working in the area was that there was no practical description of the treatment for this chronic disease—unlike the cut-and-dried descriptions of other more readily quantifiable dental treatments—and the alternative numbers were not attracting adequate rebates from the health funds.

“One of the problems we found with the old formulation of item 281 as a complete course of treatment was that some specialists would do a complete course of treatment in one appointment; some in three, four or five, but the rebate was always the same,” says Dr Bonanno.

Following submissions from ANZAP. the ASP and a number of individuals, the Schedule Committee was tasked with reviewing and considering the feedback.

“There was a good dialogue with members on the board of ANZAP, including Dr Garraway,” says Dr Bonanno. “In addition, committee members went to visit periodontic practices to gain a better insight into what was happening. They viewed the procedures within these practices to try and develop an understanding of the content of the submissions from the practitioners’ perspective.”

As a result of these considerations and field trips, the committee accepted the recommendation in the ANZAP and ASP joint submission that some existing numbers such as 222 needed to be updated to reflect modern practice. Following consideration of their submission, the committee also resolved to recommend the introduction of two new numbers: 250 and 251. These would replace 281 and 282 respectively.

The two new item numbers are worded completely differently to the replaced item numbers. “What this did, it’s fair enough to say, was to fix up the issues we had with the wording of 281 and 282, so that we now have a modern descriptor which clearly delineates between simple and complex periodontal treatment,” Dr Bonanno says.

“And by really drawing a line in the sand, really defining what you’re doing, what the level and progression of the disease is, it basically tells you when the number is applicable.”

Instead of periodontal treatment being described as a full-mouth treatment, the new items divide it up into quadrants—that is, each quarter of the mouth, which is more reflective of modern periodontal practice.

“So basically we have items that are clearer—there’s no ambiguity about when they should be used, and they are probably more user-friendly because they allow flexibility in terms of describing what has been done in each appointment,” says Dr Bonanno.

“Everyone’s happy because the rebates should be more accurately applied.”—Dr Carmelo Bonanno, interim chair, Schedule Committee, ADA

“The descriptions are up-to-date and everyone’s happy because the rebates should be more accurately applied. Health funds can probably better formulate their rebate to reflect what has actually happened. The process is less arbitrary.”

So, given the importance of these new, accurate descriptors to the level of rebate specialists can expect to receive, when will the new changes come into effect?

The health funds have had several months’ notice about the changes to the Schedule but Private Health Australia has indicated that the new numbers will not be implemented until 1 April 2017, which coincides with the new administrative year.

Dr Bonanno says, “It’s not unreasonable for the members of ANZAP to expect rapid implementation, but that’s something that is still under negotiation.”

This saga demonstrates that the ADA welcomes feedback on the Schedule—indeed, it is vital to keep the lines of communication open to all stakeholders to ensure their considerations are not overlooked.

“When you’ve been looking at something so closely, sometimes you miss something that’s glaringly confusing,” says Dr Bonanno.

“We know and understand the Schedule intimately, but there are clearly times when fresh eyes can help us to see the forest for the trees. Certainly this is a reason we welcome the variety of experience on the committee.”

As for the Schedule, there is a view in some quarters that it should go electronic, to ensure that the latest version is always available and there is no confusion as to the most recent edition. This makes sense in the modern world and there is growing support for it as younger dentists fill the ranks. Perhaps this will be a future consideration for the Schedule Committee.

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