Guidance on the new GP17

Transcription

1 Practitioner Ser ices Enabling Primary Care Guidance on the new GP17 New tooth specific claim system and reporting issues in your schedule. Also includes best practice when form filling.

2 Using the guide Use this page to find the specific areas of the form, or schedule reports. The relevant page number is given for each guidance area. How we will report tooth specific issues on your schedule Page Three examples of why we would reject a claim, and how this would be reported in your schedule. Major areas of change on the GP17 form The front of the GP17 Claiming tooth specific treatment Page 4 Entering the teeth present. Claiming for tooth-specific treatment. Claiming for deciduous teeth. Best practice - specific parts of the form Part 3 Page 4-6 Part 3 Page 7-9 Page 5 What if I make a mistake? What to avoid. Page 6 Shading the tooth-specific boxes. Part 1 Page 19 The front of the GP17 Part 2 Page 20 Completing: Part 1 PATIENT S INFORMATION Part 4 Page 10 Common non-tooth specific treatment & when to use the other treatment form area Page 7 Claiming non-tooth specific treatment. Tooth specific items when dedicated area is full. Free repair/replacement Discretionary Supernumerary teeth. Part 2 DATE OF REGISTRATION / ACCEPTANCE DATE OF COMPLETION OF TREATMENT Page 8 FDI two-digit notation guidance Part 4c Page 15 The back of the GP17 Part 6 Page Page 9 BPE scoring guidance. Free repair/replacement claiming Dentist s declaration Patient refusing treatment and failing to return. Observations Page 10 Relevant observations. Page 11 Other relevant observations. Page 12 Entering observations. Page 13 Submission of observations for prior approval. Part 4a Page 20 Part 4b Page 21 The back of the GP17 Part 5 Page 21 Part 7 Page 22 Completing: Part 4a PATIENT S DECLARATION ON ACCEPTANCE Part 4b I HAVE TO PAY NHS CHARGES Part 5 DENTIST S REQUEST FOR PRIOR APPROVAL Part 7 PATIENT S DECLARATION ON COMPLETION Patient category Avoiding selection box. 2 3

3 Front Claiming tooth specific treatment What if I make a mistake? If you make a mistake when completing the tooth specific area, you must shade in the void box. Re-enter the correct treatment in the next area on the form as shown below: Indicating the teeth present When completing treatment on the new GP17 form, please score out all teeth that are not present before you start treatment, as shown below: Our payment system will ignore this area as the void box is shaded We will use the re-entered treatment claims here. Claiming for tooth specific treatment To claim tooth-specific treatment, enter the 4 digit code under Item. You would use the 4 digit code stated in the Statement of Dental Remuneration. Indicate each tooth treated under this code in the area to the right of the Item box. Carefully shade the white box to indicate each tooth treated under the code: What to avoid when correcting a mistake Please do not try to correct the entry by scoring out as this will be detected by our scanning systems and lead to errors in your claims. Only use the void box when correcting mistakes. Claiming for deciduous teeth We have removed the reference to deciduous teeth from the patient charting area. When entering treatment for deciduous teeth, please enter in the same area as permanent teeth. Shade each tooth treated in the relevant quadrant as shown in the example below: Example The upper right, first deciduous, incisor (a) should be marked in position 1 as shown. e d c b a a b c d e e d c b a a b c d e 4 5

4 Front Claiming tooth specific treatment Front Claiming non-tooth specific items Shading the tooth specific boxes You will find some of the most common non-tooth specific items listed on the right side of the front of the form. When you are shading in the boxes for tooth specific information, you must make sure you shade within the box, and that it is completely shaded. Other treatments - how and when to use this area: For other items, begin by using the first four boxes in this area to enter the treatment codes as shown in the Statement of Dental Remuneration. Important If you make faint marks, or shade out of the box, this may result in: your claim being misread; payments being delayed; or your claim being rejected. Non-tooth specific treatment To claim non-tooth specific treatment, enter codes in this area of the form. For non-tooth specific treatment, the boxes highlighted here represent the quantity of the items being claimed for. For instance, 02 would represent two treatment items. Tooth specific treatment You can also use this area if you run out of space for tooth specific treatment in the main tooth specific claim area. Use the boxes highlighted here to claim the specific tooth being treated. Please note: for tooth specific treatment claimed here, the two digits refer to the specific tooth and not the number of teeth claimed for. You will need to use the Fédération Dentaire Internationale (FDI) World Dental Federation two-digit notation method to enter tooth specific treatment here. So, if you have treated the permanent upper right, second premolar, you would enter 15 here. Tooth 55 would represent the upper right second deciduous molar (see page 8 for more on the FDI two digit notation method). 6 Other reasons for using this area Free repair/replacement You must always use this area of the form for all free repair and replacement claims; both tooth specific and non-tooth specific claims (see page 9 for more). Discretionary 6 digit discretionary codes should also be entered in this area. Supernumerary teeth When you claim for supernumerary teeth, you will need to phone Practitioner Services. Our dental advisers will need to allocate a specific code for supernumerary teeth. Please contact our help desk on if you need to claim for supernumerary teeth. 7

5 Fédération Dentaire Internationale (FDI) World Dental Federation two-digit notation If you fill all areas of the tooth-specific area of the form, you can use the non-tooth specific area to enter tooth specific treatment. When claiming for tooth specific treatment in this area, you will need to use the FDI two-digit notation system illustrated below: Deciduous teeth upper right upper left Permanent teeth upper right upper left Front Basic Periodontal Examination (BPE)/ Community Periodontal Index for Treatment Needs (CPITN) A simple and rapid screening tool that is used to indicate the level of examination needed and to provide basic guidance on treatment need. Claiming non-tooth specific items Free repair/ replacement Place a cross in column A if you are claiming free repair/replacement. Remember: You can only claim for free repair/replacement in the event of trauma. This is unless it is for dentures, splints or bridges (see page 12 for more on the regulation 9 procedure). You must also enter details of the trauma in observations to claim free repair/replacement, or your claim will be rejected lower right lower left How to record a BPE score: The dentition is divided into 6 sextants Upper right Upper anterior Upper left lower right lower left Upper right Lower right Upper anterior Lower anterior Upper left Lower left Quadrant codes Quadrant codes Lower right Lower anterior Lower left 8 5 Upper right 6 Upper left 7 Lower left 8 Lower right Tooth codes 1 Central incisors 2 Lateral incisors 3 Canines 4 First molar 5 Second molar 1 Upper right 2 Upper left 3 Lower left 4 Lower right Tooth codes 1 Central incisors 2 Lateral incisors 3 Canines 4 First premolars 5 Second premolars 6 First molars 7 Second molars 8 Third molars All teeth in each sextant are examined with the exception of third molars. For a sextant to qualify for recording, it must contain at least 2 teeth. If a sextant has only 1 tooth present, the score for that tooth is included in the adjoining sextant. Scoring codes are 0, 1, 2, 3, and 4, depending on the clinical examination findings. Interpretation of the code indicates the clinical intervention that is required in each individual patient. The inclusion of an asterisk (*) indicates the presence of a furcation lesion, and/or a total attachment loss, at any site >7 mm, in that sextant. If there are no teeth in a particular sextant, this should be recorded by placing a dash (-) in the appropriate box on the GP17. Scoring codes 0 No pockets > 3.5 mm; no calculus/overhangs; no bleeding after probing. 1 No pockets > 3.5 mm; no calculus/overhangs, but bleeding after probing. 2 No pockets > 3.5 mm, but calculus (supra/sub gingival) present/overhangs. 3 Probing depth mm 4 Probing depth > 5.5 mm * Furcation involvement, and/or a total attachment loss, at any site >7 mm in that sextant. 9

6 Front Dentist s declaration The dentist s declaration area of the form has now changed. We will now need the dentist to indicate if the treatment has stopped before oral health can be secured and maintained. Treatment may stop because the patient may refuse treatment or they have failed to return for treatment. Relevant observations 1. Item 41b and 45c (Special Needs) An extra payment can be claimed when a dentist requires extra time to deal with a patient, for example a patient with learning difficulties, or a patient who has a disability. Enter observations with the relevant clinical information. If you do not enter observations your claim will be rejected. 2. Referral for specialist treatment If a patient has been referred to you for specialist treatment, you would claim an extra payment (code 4600). In the new form, you will need to enter the total number of referral claims in Referral (no. of claims) 4600 in part 3 on the right hand side of the form. And for the observations we need: Front 3. Trauma Please note: If this box is crossed indicating the patient has failed to complete treatment, and you have not indicated the incomplete treatment in the observations, the form will be rejected. You must cross the trauma box in Part 3 and indicate the nature of the trauma in the observations box. If you do not enter observations your claim will be rejected. 4. Free repair and replacements If you claim for free repair and replacement as a result of trauma external to the mouth you must enter observations. Trauma must be checked in Part 3. If you do not enter observations your claim will be rejected. the name of the referring dentist; referring practice address or list number; the details of the reason for referral. If you do not enter observations your claim will be rejected. When entering the number of referral claims, please enter a single digit number, in the right hand box. 5. Incomplete treatment after patient fails to return and balance adjustments You will need to note the incomplete treatment in the observations box. If the patient returns for treatment, you will need to add balance adjustment in the observations box, when you claim for the rest of the treatment. If you have checked the box for the patient failing to complete the treatment, and you have not entered observations, your claim will be rejected

7 Other relevant observations Back Entering observations 1. Request for further information If you request advice on fees, codes or treatments please keep questions as concise as possible within the observations box. 2. Continuation cases You should use the continuation case procedure if a course of treatment is started under one list number, and it is completed under another. Use the observations box as part of this procedure as shown here: On the first GP17, write CONTINUATION CASE PART 1 in this box. On the second GP17 form, write CONTINUATION CASE PART 2 with the details of the dentist s list number and acceptance date of Part 1. This helps us identify the claim more easily. For more information go to: 3. Regulation 9 Replacement of lost/broken dentures, splints, bridges and orthodontic appliances, due to an act or omission by the patient. In these cases you may take a deposit of up to the whole cost of replacement. You must obtain a decision from your NHS Board before submitting the GP17 form for processing. It must include the amount confirmed by the NHS Board to be claimed from public funds. Any deposit taken should be returned to the patient, as appropriate. You must also send the regulation 9 form, even if you are transmitting your claims electronically. You would usually enter Dentist s Observations in Part 6 to advise us of extra information that is needed to make a decision on particular aspects of a claim, or to seek advice. Examples of good practice You have entered the details of special needs and you have crossed the special needs box in Part 3. If you are treating a patient on referral you have entered the: dentist name or list number; address of the dentist referred to/from; reason for referral. You have entered the details of a trauma, or incident, and you have crossed the Trauma box in Part 3. Keep inside the box! In cases where prior approval is involved, as the total value is over 350, approval must still be obtained irrespective of the regulation 9 claim. However, if the appliance/prosthesis is the only item claimed on the form and is under 350, prior approval is not required. 4. Domiciliary visits If you are claiming for domiciliary visits to patients enter observations with the relevant clinical condition. If the cost of these visits takes your treatment plan over the prior approval limit you do need to request approval before proceeding with the treatment. Examples of when we will reject Writing radiographs available or models available when you have already crossed the relevant box in Part 3. Entering observations for a recement of a crown when you have already entered the code. There are marks, black dots or lines in the observations box when it should have been left blank

8 Submission of observations for prior approval Back Part 4c I do not have to pay NHS charges because Keep inside the box! When you make observations for prior approval, it is important that you keep inside the box. If you need more space, please use form DPD 285 for further supporting information. DPD 285 Important Please make sure you do not place a mark in this box in the list of categories in Part 4c of the GP17. This box is currently not in use. If you mark this box, your claim will be rejected, and your payments delayed. You can find the DPD 285 form on our web site at: Further observations for prior approval Item of service Supporting information required Crowns Indication for crowns. Periapical radiograph showing a clear apical view. We will not insist on radiographs for vital teeth requiring crowns, if a vitality report is submitted. Veneers Indication for veneers. Clinical photographs can be very helpful. Bridges Study casts, and appropriate radiographs showing a clear apical view of all proposed abutment teeth. A vitality report and details of the proposed bridge design. State whether the patient wears, or has previously worn, dentures (include type and material). Where relevant, state whether there is adequate posterior occlusal support. Endodontic treatment Pre-operative radiograph. Intravenous sedation Detail the treatment to be carried out on each visit in order that the number of visits can be justified. Periodontal splinting State the reason for splinting and provide radiographs where appropriate. The radiographs should demonstrate the presence of some supporting bone. Domiciliary visits State the reason for the number of visits, if there are more than 6. Extraction of special Provide a radiograph giving a clear view of root morphology and difficulty illustrating the nature of the difficulty. Staged treatment or Provide an outline of the proposed treatment plan demonstrating phased care appropriate staging and intervals between stages. No exam Discretionary Items 14 Given the requirement at each course of treatment to secure and maintain oral health please give an explanation if an exam fee is not being claimed. Give a clear indication why the item is proposed. Please note: an asterisk on the back of the form refers to printing the name of the person entitled to the benefit, and does not mean we require observations. Patient category If your patients need further information, you can guide them to the proof they need to have, if they are to claim free NHS dental treatment. The Scottish Government provide a handy table of guidance on the web about: categories eligible for free NHS dental treatment; the proof a patient needs to have; and where and how the patient can get the proof. For more on this guidance go to: Please note that web addresses are subject to change. 15

9 Reporting tooth specific issues on your schedule Example 1 A dentist treats a patient registered with her at the practice and claims three single surface amalgam fillings (1401) for teeth 13,14 and 15 and completes the form as shown in figure 1.1. Figure 1.1 Example 2 A dentist treats a patient registered with another dentist at another practice. The dentist claims three single surface amalgam fillings (1401) for teeth 13,14 and 15 and completes the form as shown in figure 2.1. Figure 2.1 Our dental payment system, MIDAS, determines the claim should be for occasional treatment, as it was carried out by a dentist at a practice different to that usually attended by the patient (figure 2.2). Figure 2.2 We then do the following: We then do the following: Delete the claim for the filling on tooth 14 as a previous claim had been paid for extracting this tooth with code Your schedule adjustment page would report this as follows: 1 This line shows that we only authorised two 1401 fillings (140102) for payment at Substitute the conservative treatment codes 1401 for occasional codes 5811; and 2. Delete the claim for the filling on tooth 14 as a previous claim had been paid for extracting this tooth with code Your schedule adjustment page would report this as follows: 1 This line shows that we authorised two 5811 fillings (581102) under occasional treatment for payment at This part shows that instead of the three 1401 fillings claimed (14(A)(1) ), we replaced with two (140102). 3 This part describes the reason we removed one of the fillings claimed for. It shows that a filling on tooth number 14 (140114) could not be claimed for because the tooth has already been extracted (21-Tooth 14). This extraction was claimed for on claim number This treatment was carried out on 1 April This part shows that instead of the three 1401 fillings claimed (14(A)(1) ), we first replaced with two (140102) before swapping the 1401 codes to occasional treatment as shown in 3 below. 3 4 This part describes the reason we removed one of the fillings claimed for. It shows that a filling on tooth number 14 (140114) could not be claimed for because the tooth has already been extracted (21-Tooth 14). This extraction was claimed for on claim number This treatment was carried out on 1 April This part shows that conservative treatment code for the two fillings was invalid for occasional treatment. Our system replaced with the occasional treatment

10 Example 3 A dentist sends in a claim to us for three full crowns cast in non-precious metal alloy (1712) on teeth 13, 14 and 15. There is also a claim for one extraction (2101). Figure 3.1 Further general guidance on the new GP17 form The form is completed as in figure 3.1. We then do the following: 1. Our dental payment system MIDAS detects that crowns on teeth 13 and 15 had been claimed previously. Only one crown is initially authorised. 2. A fee for providing a free repair or replacement of a crown within 12 months of provision is no longer payable under General Dental Services, unless as a result of trauma. The fees for teeth 13 and 15 are therefore deleted. 3. Tooth 11 has previously been extracted. The treatment claim for extraction on this claim is rejected. Your schedule adjustment page would report this as follows: 1 This line shows that we only authorised one 1712 crown (171201) for payment at Front Part 1 PATIENT S INFORMATION DO NOT USE HYPHENS If you enter a double-barrelled name with a hyphen this will only be partially read by our scanners. If forenames are hyphenated, the first part of the name is read only, and if the surname is hyphenated, the last part is read. So in this example, if you had hyphenated both parts of the name, we would read it as LILLY JONES. To avoid errors, please do not use hyphens. CHI NUMBER Make sure the Community Health Index (CHI) number is correct. S M I T H J O N E S L I L L Y M A Y U S E B L A C K I N K A N D B L O C K C A P I T A L S POSTCODE Enter the patient s full postcode as this is linked to the deprived area enhancement payments and Childsmile. A partial postcode, or missing postcode will mean these payments will not be paid correctly. 2 This part shows that we deleted the single extraction on tooth 11 (210101) you claimed for. Guidance is shown below this message and explained more in 3 below. 3 This part describes the reason we removed the claim for an extraction of tooth 11. It shows that an extraction on tooth 11 could not be claimed for as you had already claimed for one on this tooth on claim This treatment was carried out on 1 April This part shows that instead of the three crowns claimed for (171203) we replaced with one. Guidance is shown below this message and explained more in 5 below. These parts describe the reason we removed the two claims for crowns on teeth 13 and 15 ( and ). It shows that crowns on teeth 13 and 15 could not be claimed for because you had already claimed for this treatment on claim This treatment was carried out on 1 April Quick check D D M M Y Y All CHI numbers begin with the day, month and then the last two digits of the year of birth of the patient (DDMMYY). The ninth digit of the CHI number is always odd for males and even for females. 19

11 Front Part 2 DATE OF REGISTRATION / ACCEPTANCE The full date of registration or acceptance must be completed with every form submission. This date must be on or after 1 April Dates before 1 April 2013 must be on form version 10/08. If you use the wrong date on the form, it will be rejected. DATE OF COMPLETION OF TREATMENT Never complete when registration only. Back Part 4b I HAVE TO PAY NHS CHARGES To be completed by or on behalf of patients who are liable to pay for treatment. Back Part 4a Back Part 5 DENTIST S REQUEST FOR PRIOR APPROVAL To be signed and dated by the dentist if they need Prior Approval. PATIENT S DECLARATION ON ACCEPTANCE To be completed by or on behalf of the patient in conjunction with the practice staff. Patients should be advised they may be asked to attend the Scottish Dental Reference Service

12 Back Part 7 PATIENT S DECLARATION ON COMPLETION If circumstances have changed since the acceptance date the patient should enter the date of the change. They should also indicate which benefit they are receiving in Part 4c. Finally, make sure the patient has signed and dated Part Further information For more information please check our web site at: Or call our help desk at:

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