Narratives Must Match the Code

Narratives Must Match the Code

As an experienced insurance claims processor, I am appalled when I hear someone ask “anyone got a good narrative for a crown?”

The rules of billable coding are fairly simple, use narratives correctly and wisely.  The clinical notes that the dentist provides are what we use to create the narrative that is unique to this person only.  You cannot use a narrative for one patient on all patients with the same procedure without drawing attention to the lack of supporting documentation.

 The clinical notes would say something like this:”patient presents tooth #3 fractured ML cusp, decay undermining existing old amalgam restoration MOD, the patient complains of cold and bite sensitive #3, sharp edge cutting tongue and #4 area, #4 MOD decay visual and x-ray, This visit, single PA, limited eval, smooth sharp edge to eliminate tongue abrasion.  

Patient to be appointed ASAP for #3 PFM(high noble) and #4 MOD composite.

From these clinical notes, the claims processor can create a short narrative to support the doctor’s diagnosis such as:

#3 fx ML cusp, decay, tooth structure at 50% loss,#4 MOD decay, visual and at an x-ray.

A narrative can establish proof of loss.  Clerks and non-dental administrators do not deny claims in regards to treatment, dental consultants do.

 The plan administrator is looking for whether the code is covered under the contract liability not whether it is justified treatment.

If it is a covered code it is them looked to have supporting documentation to verify whether the treatment rendered is standard of care in its delivery.

Even though the code is the same for a crown, every patient will have a different or customized reason for the crown and that is what needs to be documented.

Insurance companies look for evidence of loss in a narrative that not only matches the policy benefits but is justified by the clinical evidence.

 

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