The “Tunnel Vision” In Dental Notes
We see it daily in our clients’ offices and the dental claims that providers seek to file to medical insurance. The “tunnel vision” that echoes through every clinical note we read. Periodontal disease, decay, fractured teeth, gingival recession, etc. We open the provided health history ready to dig in and find those diagnosis codes that are going to make or break our chance for well-documented claim. Codes that will paint a picture for the reviewing medical consultant of what this patient’s health has done to create the need for the listed procedures. We are sure they will be there because the notes mentioned nothing, so it must be mentioned already somewhere else. And we find the health history…blank. Not a diagnosed comorbidity in sight.
For years it has been a familiar topic in dental offices. Medical practitioners don’t see how oral health impacts overall health. They don’t see how diseases and illnesses can impact a patient’s oral health. However many, many dentists suffer the same problem.
Recently a fellow eAssister reached out to me to help her with a claim for a client of ours that needed to go to medical. This doctor never files to medical however the patient had failing implants and could not afford the needed treatment with only his dental insurance. The dentist asked if we could give the medical a chance to cover some of the treatment. My colleague and I are chatting and she’s explaining to me that previous implants placed by another dentist were being removed by our client as the bone had become unstable and the implants were failing. We walked through our crosscoding of CDT codes to CPT codes and finally arrived at our diagnosis coding. We reviewed the clinical notes, assembled some codes from that and then I asked the most basic question we have in our department. What caused the symptoms/treatment? She immediately saw the conundrum, there was nothing in the notes documenting the WHY of the situation.
Here is where medical and dental part ways. In dental it is simply enough that the restoration failed. We replace it and we move on. We look for decay or a fracture and that is enough. Visible to the eye and easy to comprehend. For medical it isn’t enough when you’re asking them to cover a dental procedure as a medical necessity. We needed to know why this bone was resorping and the implants were becoming unstable. An x-ray would tell us that the bone was gone but not why. Periodontal probing wasn’t going to help. We navigated our way over to the health history just knowing we would find something we could use to provide a clear pathway of cause and effect to the carrier. And you probably have guessed right by now…the health history was empty. This patient had marked that they had not a single health issue. After a few minutes of pondering it out we both decided that this was impossible. Bone doesn’t just dissolve into nothingness with no reason. My colleague reached out to her client who reached out to the patient to have him revisit his health history.
Osteoporosis. Several unlisted medications known for negative impacts on bone density and implants. He had been asked if his history had changed and he had been adamant all was correct without even glancing at his old medical history. We were able to provide a much more comprehensive picture for the insurance company and meet the threshold of medical necessity with that added information. A claim that would have otherwise been denied changed by one simple check mark on the patient’s medical history.
Tunnel vision in your dental notes can be fatal to your medical claims. Some things that can help you avoid missing vital secondary diagnosis are:
- Have your patient fill out a medical history update if there have been any changes or it has been greater than 12 months since their last update. Many patients will wave away that there have been any changes until they actually have to sit down and check off each box.
- Communicate and review the health history with your patient. Let them know that this is important to the coding and payment of their medical claim as well as their treatment.
- Document medical conditions and symptoms in your chart notes. If there isn’t a place for it on your health history write it in your notes. If your patient elaborates on a condition or symptom during your treatment include it in your notes.
- If you suspect something give the patient a referral. If the patient does have a clean or mostly clean health history but something about their dental symptoms isn’t adding up don’t be afraid to refer them back to their primary care for some diagnostic testing. Many dentists have helped diagnose autoimmune disorders, diabetes and even cognitive deficiencies by being observant of their patient and picking up on something that showed through in their oral health treatment before their overall wellness.
Be cognizant of your notes and your documentation as it will play a central role in supporting your claims for payment. Poorly written and vague notes lead to ill-supported and thin claims that are easy for carriers to deny. Make sure you are providing as comprehensive an outline as possible to the people who have not seen the patient and must rely solely on your knowledge to adjudicate the claims filed.
Dental Billing Tips and News for Pros; Edition #133