Clinical Charting Using Your Computer Software Critical for Accuracy and Claim Reimbursement

The advantages for good dental charting has been around for decades but many dental practitioners have abbreviated what they do down to a minimal few words because there wasn’t any demand that they not.  It is becoming more and more apparent that this abbreviated type of charting is being questioned because of the influence of evidence based care, changes to ADA codes and influence of insurance companies with combination medical/dental policies, changes in the ADA 2012 dental insurance claim, ICD-10 diagnostic codes and many other contributing factors.

Introduced in 2014, caries risk assessment codes that some insurance companies want performed before “routine” x-rays are reimbursed.  These changes are supported by the contracts with the insurance companies.  The days of billing  4 bitewings yearly because the plan will pay for them is becoming obsolete as more and more insurance companies are sending denials back for lack of evidence based data.

Each insurance company and every state has differing views on what is acceptable for dental charting.  The rules are stricter if you are sending claims for any Medicare recipient or Medicaid or other state or federal paid program.  There is a trickle down to other insurance companies that are requiring detailed narrative in the form of SOAP notes that have been standard on medical claims.

Dental Clinical Charting:

As procedures are completed, each step should be detailed point by point as much as possible during documentation using the Soap format. When a tooth is restored, charting “#15 MOD composite” is insufficient.  Include details on whether anesthetic was used (include the type, quantity in number of carpules and applicable epinephrine ratio).  Even if you don’t charge for a procedure it should still be charted that is was performed and the details of how and what was delivered. Note the type and brand of restorative material used, including the type of base, liner or varnish if used and the shade if a tooth colored material was used.  The reason for the procedure (decay, fracture) must be noted for filing insurance correctly.  When seemingly sound amalgam fillings are removed because the patient wants white fillings, careful documentation after the removal of the amalgam would be necessary if you want the insurance company to participate in the payment.  If the insurance company inquires as to the reason these restorations were performed, having charted any defect in the existing amalgams and evidence at removal of existing decay underneath or fracture would help the claim other than saying “for cosmetic reasons” or “patient requests.”

Document how the patient tolerated the procedure and describe any other incidents that were pertinent to the procedure.  Often noted but rarely accepted as complete is “Tooth #16 Ext.” Was there infection of the pulp beyond restoration?  Was the tooth fractured?  How was it fractured? Is it endo or perio involved beyond restoration? Was it fully erupted or partially? Notations should include applicable information such as ease of extraction (regular, dento-dissection, surgical), gingival tissue flap required, and bone recontouring on buccal or lingual, kind and number of sutures placed and reason for removal. Always include notation on bleeding and coagulation.

The deadline for EHR or electronic health records (unless you see the requiring number of Medicare patients) keeps getting pushed forward but this doesn’t mean that dental practices should abandon the legal, ethical and responsible habit of documenting treatment on patient paper or digital charts.

Sure, clinical charting the correct way can consume large amounts of time in an already time challenged environment.  Manual input onto paper clinical charts is fraught with inconsistencies and errors due to haste and illegible handwriting.  A failure to standardize abbreviations with the people who are making the entries: doctors, hygienists, assistants and business staff can open the practice up to litigation issues. By subscribing to computer-driven, digital formats, these problems can be circumvented and conserve time too.  A series of standardized templates can be stored and edited to make modifications based on the individual patients soap notes.  Dental software companies are in competition with each other to provide a better product that meets the needs of the ever changing landscape of dentistry.  Trying to hold back changes because “this is the way it has always been done” is foolhardy and in time will put your practice in the “stone age” category.

Consult with your software support for help in implementing the clinical charting format available to you and start using it.  Dentrix has new medical alert documenting in the G6 version.

You will find that it will simplify, organize and bring much needed efficiency into the very important system of clinical charting.


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