12.1 Telehealth Ethics: When It Fits, How to Deliver It, and Honest Dates on Claims

The ethical frame

The ADA Policy on Teledentistry, first adopted in 2015 and updated since, sets the ethical baseline:

• The dentist is responsible for, and keeps authority over, the safety and quality of services delivered through teledentistry.
• Services should be consistent with in-person services, and exams must be based on the same level of information that would be available in person. The dentist must make sure the records collected are sufficient for a diagnosis and treatment plan.
• Patients have the right to know who the provider is and what they will pay before care.
• Privacy and security laws apply in full (Section 8.3).

These are the familiar principles applied to a new tool: nonmaleficence (don't diagnose what you cannot see), autonomy (the patient chooses telehealth with informed consent), and veracity (describe and bill the service honestly).

When is telehealth clinically appropriate? (K2061)

Criteria to ask each time:

1. Can I gather enough information to meet the in-person standard?
2. Is the patient able to take part and consent? Do they have the technology and a private place?
3. Is there a plan for in-person follow-up if I find something I cannot evaluate remotely?
4. Am I licensed where the patient is, and is this service within my scope?

If any answer is no, convert to an in-person visit. The patient always keeps that right (B&P § 2290.5(c)).

Delivery methods (K2062)

The ADA policy identifies four modalities:

• Synchronous: live, two-way video between patient and provider.
• Asynchronous (store and forward): images, radiographs, and records sent securely for the dentist's later review.
• Remote patient monitoring: health data collected from the patient in one place and sent to the dentist in another.
• Mobile health (mHealth): education and monitoring through phones, tablets, and apps.

Good practice for any modality:

• Collect a full history and identifying, insurance, and contact information first.
• Verify identity and location, and document telehealth consent (Section 8.3).
• Keep the same documentation standard as an in-person visit, and give records to the patient on request.
• Coordinate with on-site auxiliaries under the Dental Practice Act's supervision rules, and give patients the written notice required when care is delivered away from the dentist's office (B&P § 1684.5(c)).

Telehealth and justice

Used well, teledentistry serves the ADA principle of justice: it brings preventive care and early diagnosis to schoolchildren, homebound elders, nursing home residents, and rural patients who rarely see a dentist. California's virtual dental home provisions (Section 8.3) exist for that reason. The ethical risk is the opposite: using remote models to sell high-margin services, such as aligners or whitening, without the examination the patient needs. Ask whether a telehealth offering expands access to appropriate care or only expands sales.

Honest dates and codes on claims (K2063)

The date of service on a claim is a factual statement to the insurer. ADA Advisory Opinion 5.B.4 says that reporting incorrect treatment dates to help a patient get benefits that would otherwise be denied is an unethical, false, or misleading representation. For teledentistry:

• Report the date the service was actually performed. For an asynchronous review, that is when the dentist actually reviewed the records, not an earlier or later date chosen to fit a benefit period or frequency limit.
• Use the teledentistry codes, D9995 for synchronous and D9996 for asynchronous encounters, along with the codes for the services actually provided, so the claim shows how care was delivered.
• Never bill a remote review as an in-person comprehensive exam if the in-person elements did not happen (ADA 5.B.5).
• Knowingly presenting a false claim is also unprofessional conduct under B&P § 810 and a crime under Penal Code § 550 (Section 12.2).

Worked scenario

A dentist reviews photos and radiographs a hygienist took at a nursing home on March 30. The patient's benefits reset on April 1. The dentist reviews the records on April 2, diagnoses caries, and plans restorations.

• The asynchronous review's date of service is April 2, the day the dentist performed it. Reporting it as March 30 to use last year's benefit would violate ADA 5.B.4.
• The claim lists D9996 with the services performed.
• Restorations are scheduled in person or, where permitted, as interim therapeutic restorations by the hygienist under the dentist's direction (B&P § 1910.5).