Building Narratives for Dental Claims
By: Belle DuCharme, CDPMA
Narratives are always built from the doctor’s clinical notes. A SOAP format is always suggested. SOAP is defined as Subjective (the patient’s words); Objective (the clinical observations from the dentist); Assessment (what the doctor’s diagnosis is) and Plan (the written treatment plan).
One thing for certain, to be paid in a timely manner one must give the claims examiner the correct information or you will be resubmitting or worse having to go through the time-consuming review process.
The most common mistakes seen on claims are the absence of information and attachments. Billing out an anterior tooth as a posterior tooth is careless posting and will result in a denied claim. Giving incorrect information can cause headaches but not providing enough information can cause the same delay. Below is a formula that may help to get claims paid in a timely fashion. Remember to check the doctor’s clinical note for information on each service and use that verbiage in the narrative. A cookie cutter narrative for every similar claim may end up being a red flag to an examiner and may contribute to an audit.
Crown: Tooth #___
- Existing restoration is____Filling? ________Onlay? ______Crown? ________
- Age of existing is? _______
- Clinical reason to replace restoration is? Decay_____Fracture____Pain/cracked tooth_____
Missing restoration? ______
- Is this the initial placement of this crown? Yes_____No_____Date of initial placement___
Build-up: Is a separate procedure completed the day of the crown preparation (or other date prior to seat) to restore missing or destroyed tooth structure in order to retain new crown. “The large, old, failing restoration had decayed with destruction of supporting tooth structure making the build-up necessary to restore function by supporting new crown.”
Send a current periapical x-ray showing apex and a bitewing x-ray.
Multiple 3-4 surface composite restorations:
- Existing restoration? _____
- Age of existing restorations? _______
- Clinical reason to replace restoration? Decay_____Fracture____Pain____Missing restoration___
In the case of multiple composite restorations, the evidence of decay and fracture may be required. Replacing amalgam because it is metal or the patient wants white fillings usually not reason enough to replace restorations.
Send periapical with apex and bitewings of teeth treated.
Same as for crown narrative but you must include the words “__cusp fracture” and include a periapical and, if available, an intra-oral photo demonstrating the missing or fractured cusp. This restoration is an inlay with an onlay component, meaning it must completely cover a cusp to be considered an onlay. List the cusp that is fractured in the narrative.
Veneers: Tooth #____
- Existing restoration? _____________
- Age of existing restoration? ________________or initial placement date
- Clinical reason to replace existing? ___________________
Narrative should include verbiage something like, “Tooth number(s)____ have existing facial or 3-4 surface composite that is 1. cracked,2. Fractured (dentin exposed), 3.washed out, 4. leaking or decayed. Remaining tooth structure will not sustain another composite restoration, a (restoration name-veneer)) is necessary to restore to function.”
Scaling and Root Planing
Narrative should contain the condition that the patient presented at the time of clinical examination. Such as “Patient presents with periodontal disease including BOP, exudate, (if present) mobility, and generalized 4-6 mm periodontal probing depths.” If the dentist notes evidence of periodontal disease in the initial part of the evaluation use the code D0180 and follow the descriptor from the current CDT coding book. Include a current FMX and periodontal charting showing comparisons if available. Any other detail from the clinical notes of the dental hygienist or dentist may be added to the narrative.
Implant Crown: Tooth #___
Date of extraction: ___________Clinical reason for extraction: ______________
Surgical notes: ____________Implant recommended because: _________
Long term prognosis____
“Tooth #___was extracted because_______________________. Surgical implant placed by _______________to replace missing tooth. Implant crown#____and custom abutment#___placed to restore chewing function in the arch and to retain integrity of the bone and facial structures”
Panorex or FMX, periodontal charting and narrative should be sent with claims for implants and implant crowns.
Keep narratives short but with the information necessary to give the claim examiner the documentation necessary to pay the claim.
Supporting information required will vary slightly from one insurance company to another. The above system will help you understand the importance of good clinical notes and excellent radiograph.
eAssist Helpful News and Billing Tips; Edition #119