Record-keeping and insurance

Record-keeping is an essential function of a dental office. Patient care and treatment continuity are supported by adequate charting and recording.

Carol Tekavec, RDH

Record-keeping is an essential function of a dental office. Patient care and treatment continuity are supported by adequate charting and recording. Without detailed records of a patient's diagnosis, treatment plan, progress notes, and maintenance strategy, treatment can turn into chaos. Without detailed record-keeping, no one in the office knows what treatment is to be done for a patient that day or what treatment was completed during the last visit.

Records also are essential for documentation and support with third-party payers. Insurance carriers are increasingly using aggressive utilization review of procedures when dealing with dentists.In its February 2 issue, the ADA News reported that West Virginia's Medicaid program requested itemized documentation or "repayment" for "multiple restoration codes" from 340 West Virginia dentists for claims sent during the previous several years!

How can dentists prove the procedures submitted for reimbursement were completed? They can do it with detailed records.

Malpractice carriers have always advised their dentist-subscribers to use detailed records to avoid malpractice lawsuits. When detailed records are presented at the outset of a case, plaintiff's attorneys may decide that their case is "unwinnable." Therefore, the dentist is never forced into court. Patient records can be on either paper or computer, but they must contain (but may not be limited to) certain key elements:

* Comprehensive, updatable medical history, including the patient's chief complaint
* Initial data base and recommendations, to include existing conditions and restorations, pathology, and perio conditions
* Treatment plan consistent with the patient's diagnosis
* Adequate number of radiographs, based on FDA guidelines
* Progress notes written in ink, signed and dated by the dentist
* Signed informed consent outlining risks, benefits, fees, and alternatives

An excellent guide is the "Process of Care Evaluation Measures," approved by the California Association of Dental Plans, the California Dental Association, and Delta Dental Plan of California, format by Dr. D. E. FitzGerald. For a free sample of an adequate dental record, call (800) 548-2164.

Where insurance is concerned, the more detailed the patient record, the better the claim form can be completed, and the quicker the claim can be paid. When a treatment plan is clear, the office person submitting the patient's claim has an easier time of providing the details that carriers are looking for to approve the claim. For example, Code D2950-Core Buildup, including any pins, refers to building up the anatomical crown with any type of material, including pins. A crown is typically placed and coded separately, either at the same time or at a later date. Many insurance carriers do not reimburse for core build-ups under any circumstance, except previous endodontic treatment. Insurers who do provide a benefit typically require that the remaining anatomical crown be described in a narrative as less than 50 percent and inadequate to provide proper crown retention. The insurance requirement does not mean that teeth with less than a 50 percent anatomy may not receive a core buildup, only that it is a guideline for payment. When previous endo or the 50-percent condition exists, the dentist notes this fact on the initial data-base form and indicates a build-up is needed on the treatment plan. The person filing the claim consults the chart for the correct wording to be used on the claim. This reduces requests for "more information" and decreases payment delays.

Dentists who wish to provide treatment and receive direct payment for patients covered by dental plans are obliged to furnish documentation that pathology has been diagnosed and treated. Network dentists, such as those who are Delta providers, sign contracts agreeing to this. Dentists who do not want direct payment may furnish patients with statements and require them to apply for their benefits themselves. However, even in this case, documentation may be requested at a later date.

Carol Tekavec, RDH, is the author of the Dental Insurance Coding Handbook Update CDT-4, co-designer of a dental chart and an informed consent booklet, and a national lecturer. Contact her at (800) 548-2164 or visit her Web site at www.steppingstonestosuccess.com.

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