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- Can I always claim for an emergency appointment?
- How much treatment is required?
- Can I claim for prescribing Antibiotics?
- Is an examination required?
- 'Permanent filling' and 'Extraction' are both list in the regulations as Urgent items and also Band 2 items. When these items are provided, what Band is appropriate to claim?
- Can I provide urgent care and submit an urgent claim before opening a Band 1, 2 or 2 course of treatment?
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When can I make a claim when a patient attends with dry / infected socket?
- Key points
- Appendix
Can I always claim for an emergency appointment?
If the patient is already undergoing an NHS Band 1, 2 or 3 course of treatment and presents with a problem that requires Urgent treatment, the additional treatment should be provided as part of the existing course of treatment, as a variation of the treatment plan.
If a patient attends for an unscheduled appointment outside of an existing course of treatment and treatment is provided to either relieve pain or prevent deterioration of the patient?s dental health, an Urgent claim is likely to be appropriate. The National Health Service GDS/PDS Contract Regulations defines urgent treatment as:
"A course of treatment that consists of one or more treatments listed in Schedule 4 of the NHS Charges Regulations (urgent treatment under Band 1 charge) that are provided to a person in circumstances where:
(a) A prompt course of treatment is provided because, in the opinion of the contractor, that person?s oral health is likely to deteriorate significantly, or the person is in severe pain by reason of his oral health condition;
and
(b) treatment is provided only to the extent that is necessary to prevent that significant deterioration or address that severe pain."
Treatment detailed in Schedule 4 are listed in the appendix, however further explanation is required.
How much treatment is required?
The regulations quoted above state that treatment is provided only to the extent that is necessary to prevent that significant deterioration or address the severe pain. A single urgent claim may extend across more than one patient visit, such as a patient in pain requiring incision and drainage at the first appointment and extraction at the second appointment - A single urgent claim would be appropriate for this.
A claim should not be submitted for an emergency appointment until the problem has been addressed. For example, if a patient attended with pain, had an assessment and a radiograph provided, and it was decided that extraction or extirpation was required (which the patient accepted), it would not be appropriate to submit an urgent claim until the treatment to resolve the pain (for example extraction or extirpation) had been provided.
Can I claim for prescribing Antibiotics?
There are few situations where only the prescription of antibiotics by a dental practitioner is justifiable. Faculty of General Dental Practice (FGDP) guidelines relating to prescription of antibiotics describe situations where antibiotics may be used as an adjunct to therapy and therefore it would be unusual to have a situation where an appropriate Urgent claim would be submitted that indicated only prescription of antibiotics.
An 'Examination' is listed as an item that could be provided as part of urgent treatment, however it is not a prerequisite for an urgent claim. Assessment of the patients presenting complaint is adequate to diagnose and plan a patients Urgent care (without other elements of an examination such as Basic Periodontal Examination (BPE) score, recall interval, risk assessment etc). However, a medical history update and soft tissue examination is usually expected as part of the patient assessment and a radiograph may or may not be appropriate.
An example would be when a patient attends with a broken tooth. A single permanent filling could be completed without providing an examination, and an urgent claim submitted appropriately. Alternatively, a temporary filling could be provided at the first appointment and the patient returns for a permanent filling on the second appointment. Again, no examination has been provided and a single urgent claim would be appropriate to cover the first and second appointment.
'Permanent filling' and 'Extraction' are both list in the regulations as Urgent items and also Band 2 items. When these items are provided, what Band is appropriate to claim?
Where a permanent filling or extraction is provided as part of urgent care and no examination is provided, an urgent claim is likely to be appropriate.
An examination is a prerequisite for a Band 2 claim and would normally include (but not be limited to) the recording of a dental chart, soft tissue examination, periodontal examination, other diagnostic tests as appropriate, treatment plan, risk assessment and a recall interval. Furthermore the provision of any planned treatment (each and every component, unless the patient withdraws from treatment) would be necessary to satisfy a Band 2 course of treatment and would include provision of necessary Band 2 item(s).
Consideration should be given to NICE Guidelines regarding recall, discussed with the patient and the agreed recall should over-ride any previous recall interval, and where necessary future appointments adjusted to reflect this.
Can I provide urgent care and submit an urgent claim before opening a Band 1, 2 or 2 course of treatment?
There may be circumstances where an urgent course of treatment is followed by other (non-urgent) treatment, which would be a separate Band 1, 2 or 3 course of treatment attracting a further patient charge where appropriate. In other circumstances, it may be more appropriate to regard any initial care and treatment provided to address a patient's immediate presenting complaint or symptoms as the first visit of a banded course of treatment to provide all proper and necessary treatment. It is essential that any patient attending for any course of treatment understands the basis of that course of treatment and gives appropriate consent, which should be recorded accordingly in the clinical records.
Due to the plethora of presenting symptoms and conditions, it is not possible to stipulate categorically which clinical scenarios should be classified as ?Urgent? and which should not. However, the classification of treatment provided and the resulting claiming approach should be based on the patient needs and expectations following discussion with them and a clinical decision made by the practitioner informed by these. There is also an expectation that all patients are treated equally irrespective of their payment status.
While it may be expected that a number of patients initially provided with an urgent course of treatment may return to a contractor for a further Band 1, 2 or 3 course of treatment, it would not normally be expected that the majority of patients treated under a contract to provide mandatory services would initially be provided with an urgent course of treatment before progressing to further care with the same contractor.
Where such a pattern of activity exists, a contractor may be required to justify this on an individual case basis if required to do so by the Local Dental Commissioners.
Can I provide urgent care and submit an urgent claim after submitting a Band 1, 2 or 3 course of treatment?
This depends on why the patient has returned after submitting the Band 1, 2 or 3 claim, an urgent claim may be appropriate. For example, a patient presenting with pericoronitis and requiring associated urgent care shortly after submitting the Band 1, 2 or 3 claim.
However, it would be inappropriate to submit a claim for aftercare.
What is aftercare?
Aftercare is care that is provided as a consequence of treatment recently provided; the care is recognised as an expected complication. A clinician may have submitted a claim for the course of treatment and it would be considered inappropriate for the same contract to submit another claim for the aftercare element of the treatment, even if it was a different performer working under the same contract that provided the aftercare element of treatment. Examples of this include (but are not limited to) the following:
a) A denture was recently provided, and a claim submitted. The patient returns for an ease of the denture. This ease would be considered as aftercare and part of the course of treatment already submitted. Submission of another claim would be inappropriate.
b) A filling was provided and a claim submitted. The patient returns because of a sharp edge/premature contact and the same filling was smoothed. This would be considered as aftercare and part of the course of treatment already submitted. Submission of another claim would be inappropriate.
c) An extraction was provided and a claim submitted. The patient returns for an infected socket. Treatment related to the socket would be considered as aftercare, and part of the course of treatment already submitted. Submission of another claim would be inappropriate.
When can I make a claim when a patient attends with dry / infected socket?
As discussed above, if the extraction was provided under the same contract, (which could include a different performer under the same contract), any treatment for dry/infected socket would be aftercare and no claim should be made.
If the initial extraction was carried out at a different practice under a different provider contract, then the second practice could claim urgent treatment for treating the infected socket as they wouldn't have carried out the original treatment.
The same principle applies for ease of a denture.
Key points
1. An Examination is not a pre-requisite for an Urgent course of treatment.
2. An Urgent course of treatment may extend across more than one appointment.
3. Treatment is provided to the extent that is necessary to prevent significant deterioration or address the severe pain.
Appendix
The National Health Service (Dental Charges) Regulations
SCHEDULE 4. Urgent Treatment under Band 1 Charge.
(a) examination, assessment and advice
(b) radiographic examination and radiological report
(c) dressing of teeth and palliative treatment
(d) pulpectomy or vital pulpotomy
(e) re-implantation of a luxated or subluxated permanent tooth following trauma including any necessary endodontic treatment
(f) repair and refixing of inlays and crowns
(g) refixing a bridge
(h) temporary bridges
(i) extraction of not more than 2 teeth
(j) provision of post-operative care including treatment of infected sockets
(k) adjustment and alteration of dentures or orthodontic appliances
(l) Urgent treatment for acute conditions of the gingivae or oral mucosa, including treatment for pericoronitis or for ulcers and herpetic lesions, and any necessary oral hygiene instruction in connection with such treatment
(m) treatment of sensitive cementum or dentine
(n) incising an abscess
(o) other treatment immediately necessary as a result of trauma
(p) not more than 1 permanent filling in amalgam, composite resin, synthetic resin, glass ionomer, compomers, silicate or silico-phosphate including acid etch retention
Reference:
1. FGDP standards: Antimicrobial Prescribing for Practitioners, 2nd edition, May 2012, FGDP (UK) Updated 2016.