Documenting Diagnosis: Now More Than Ever

By Teresa Duncan

The coming shift in dental coding and reimbursement will change the way we handle our patients’ information. Our industry is looking at a shifted focus to diagnosis versus reporting. Dental codes are currently used to report the work we have already completed. If our claim is denied then we proceed to appeal it with a narrative that explains the necessity of the treatment.

Imagine that we are required to submit the narrative at the time of the initial submission. Veteran insurance coordinators already know which procedures require documentation – we send them with the first claim. Need payment for a crown? Send a radiograph and your best intra-oral image. Need payment for scaling and root planning? Send a radiograph and periodontal charting. What we may see in the future is also submission of your patient’s risk factors and medical history. Does it sound like a pain? You’ve just peeked behind the curtain of how medical billing works. We’re not that far away from that and I would love to see more offices prepared for the transition. Our future claim forms will probably include spaces for history of smoking, diabetic, caries risk and other descriptors of our patient’s health. Just as in medical billing the descriptors and diagnosis codes are meant to portray a more complete view of our patient’s overall condition. However we will not be able to send in claim information if the existing documentation is not adequate, not legible or does not support treatment performed.

Administrative team members will need to be able to read your charts and be able to use corresponding codes to support a claim. This means your documentation has to be consistent. By consistent I mean that all of your team members are using the same terms. This sounds simple but anyone who has worked with a new associate can tell you – not every dental school teaches the same material. Some doctors will document too much (pages of notes) and some will document too little (got patient numb, took out old filling, put in new one- I’ve seen some this simple!) The trick is to make clear to the team what should be documented and by whom. Any doctor that regularly delegates this task needs to be comfortable with handing their license and livelihood over to another person.

Many offices will tell you that their documenting and charting routines are not up to speed. When I review documentation needs in my insurance courses I’m always asked “How can I get my team/doctor to start charting correctly?” The frustration is obvious in their faces – this is not something they are completely unaware of. They are aware of the need to use proper documentation but for some reason or another they have not reached a successful resolution. The team needs to first buy into consistent documentation and it must be an easy transition process.

Step 1 – Motivate: Give them a reason and if that fails, scare them!
Let’s appeal to common sense first. Discuss an ideal situation in that one person could open any chart at all and be able to describe the patient’s health, treatment needs and treatment provided. This is an exercise that you can include in your next team meeting. Grab a handful of charts and see if your team passes the test. If not, use it as a learning opportunity. No scolding – just collaboration! Ask yourselves what could have been clearer; were post-op instructions given; and did we miss billing any procedures because they never made it on the record? This exercise usually is convincing enough for most team members. It becomes very clear how adequate your records are when you have a third and fourth person reviewing the information.

Still have a holdout? Use a scare tactic – go ahead, it’s okay! This is a scary topic. The financial cost of a records audit is nothing compared to the emotional toll it will take on you, doctor. Imagine having to shut your office down, hire lawyers and that’s not including any action or fines that can be assessed if your records don’t support the treatment provided. Documentation is such an important part of a well-run office and yet it is one of the last systems to be addressed. Don’t wait until the insurance company or the state board comes knocking. Hygienists – your license is on the line too. And for team members that just breathed a sigh of relief, your paycheck is directly related to the outcome of any investigation. Offices have had to close or lay off employees in the wake of an extensive investigation. It’s a team effort because it affects the whole team!

Step 2 – Lay out a simple path
With any change comes pain. Roll up your sleeves and embrace the change. Your team meeting in which you reviewed the charts was a great first step. I would also reach out to your malpractice carrier and ask if they have printed guidance material. Most insurance companies have forms to use and may offer to come to your office and perform a risk assessment. This is information that would be valuable to bring to your local dental society, by the way. If one office needs it then you can bet ten more could put the information to good use.

Next on your agenda should be a discussion of your most commonly used notations. If you’re not paperless consider adding this to your plan of moving to electronic charting. By setting up templates it can make your chart entries less painful and more comprehensive. Discuss which abbreviations are most used in the office and make sure everyone knows what they mean! Administrators that are working in a paper environment – create a master list of your employee’s initials. I’ve managed an office for over 18 years – do you know how many employees have written in the charts over that period of time? I don’t! But I do have their initials on their employment forms so that I can recognize who made the entry in case it is ever called into question. For paperless offices ensure that your team knows when entries are to be made and how to change them. Some software closes out each entry at the end of the day – some at the end of the month.

Also discuss who documents. Is it the clinical team or the administrative team? And what are their methods? I recently talked with one manager who uses voice recognition and has it posted to a Word document so that she can check it for accuracy. Then she posts it to the dental software. Wouldn’t you want to know who in your office is doing it this way? What if he or she is not available on a daily basis or misses some time at work? What is your back up plan for documentation duties?

Step 3 – Revisit the process
This system is one that should be assessed on a yearly basis. It doesn’t mean that you have to hold a huge meeting on this every year. Doctors and managers – think about how many new employees you’ve had. Have they all been trained? This should be part of the new employee training. Also discuss if you’ve brought on any new technologies. Are you documenting your procedures differently as a result? The hard part is moving everyone to the same system – after that the maintenance is easy.
When a new claim form comes into play with diagnosis fields and medical history descriptors, you’ll be ready. I firmly believe that this is the direction in which our industry is headed and my hope is that we are all prepared for it. The shift will be huge for offices that don’t have an effective system for documentation. It will be a painful shift as well. My recommendation to all progressive dentists out there is to address this issue now and sleep well at night. Use the steps outlined above to protect your office, your employees and your patients.

Teresa Duncan is President of Odyssey Management, Inc. She is an international speaker that focuses on recapturing and maximizing revenue opportunities for dental offices. Insurance and accounts receivable systems are her specialty. She can be reached at

5 Steps to a Superstar Hygiene Team

By Heidi Arndt, RDH, BSDH

The healthiest, most profitable dental practices have a strong and high performing dental hygiene team. Their hygiene team is productive, team focused, they practice to the top of their license and they are highly respected. They are the cornerstones of the practice.

Registered Dental Hygienists do not come by their license easily. Dental Hygiene school is a demanding and rigorous program.,.In just a few short years, dental hygiene students need to reach competency in over 40 skills. When they graduate from hygiene school they take written and practical board examinations to confirm their competency in their dental hygiene skill. These competencies are all skill based, however their path for development is not over.In fact, most of their development needs to happen in the real world, in your practice.

Development of the dental hygiene team is key to the success and health of the practice. Without further development, your dental hygiene team will struggle to understand their role in the success of the business.

  1. Educate your team on the Business of Dental Hygiene. Like dentists, dental hygienists do not received business training of any sort during their dental hygiene education. Many dental hygienists do not understand how the care they provide to their patients is directly correlated to the success of the practice.As a result, when a dental hygienist is involved in a discussion regarding financial information they often times react negatively and may make irrational comments like, “why is it all about the money”.
    The office manager or dentist should educate the dental hygienists on the business of dentistry and how the dental hygiene portion of the business adds to the success and health of the practice. Create clarity as to how the dental hygiene team fits into the overall picture of practice success.
    When having the business discussion with the dental hygiene team, keep it simple and practical. For example, break down hygiene revenue by showing them the impact of hours worked and the fees of each procedure, and how each hour and each day impact revenue of the practice.
    Once the dental hygiene team completely understands the revenue side of the business, layer in the expenditures of the practice, insurance adjustments, etc. so they understand the real margin of the practice. This piece will be difficult for them to process, as well as an eye opener for them.
  2. Lay out clear expectations for the dental hygiene team. Does your dental hygiene team know what is expected of them? How do you track and analyze their performance?
    Most dental hygienists enter the practice understanding that they need to provide dental hygiene care to their patients, follow infection control protocols, be a team player, etc. However, are these the things you monitor in order to measure their success?
    A successful hygiene team needs to connect with clear expectations and goals. Key Success Indicators are the best way to define expectations and goals for your dental hygiene team. There are 8 KSI’s for the dental hygiene team:
    a. Hygiene Productivity – Production per Hour, Production per Patient, Production Per Day
    The best measure of hygiene productivity is to track by hygienist, by practice and by the group total. Putting these measures in place will allow you to see exactly where changes need to be made.
    b. Mix of Services – Periodontal and Preventive
    The hygiene department is not just a cleaning service. This is the first stop in assessing the needs of your patients and providing meaningful care that goes beyond the cleaning.
    c. Scheduling – Schedule Efficiency/Utilization and Supply & Demand Balancing your dental hygiene supply and demand can be tricky. You want to have enough play in the day to accommodate emergencies or appointment over-runs without leaving your hygienists with unproductive time. So how do you achieve that balance?
    d. Profitability – The Ratio of Hygiene Revenue to Total Compensation
    How are you currently measuring your hygiene department’s profitability? The truest measure is hygiene revenue as a % of total compensation.
    e. Hygiene Revenue – Hygiene Revenue as a % of Total Practice/Group Revenue Ideally, 30% of your practice revenue should be coming from the dental hygiene team.
    f. Patient Retention Would it surprise you to know that most dental practices have a mere 30% of their total patients in active care? Do you know what your number is? Do you have the strategies in place to improve these numbers? This is one of the most misunderstood benchmarks in the dental industry.
    g. Treatment Acceptance
    h. Doctor revenue treatment planned from the Hygiene chair. Over 75% of the doctor revenue should be treatment planned in the hygiene operatory.How well is your hygiene team teeing up and presenting restorative and cosmetic treatment for the doctor?
  3. Partner with your dental hygiene team. Aside from the doctor, the dental hygiene team is the care provider in the practice.They make up over 30% of practice revenue and support more than 75% of the doctor revenue in the practice.Do you see why being a PARTNER with your hygiene team is so important?
    What does partnership look like?The doctor and dental hygiene team must speak a common language and have a consistent philosophy of care.The doctor should trust the guidance and recommendation of their hygienists and vice versa. Strong collaboration on each patient and the success of each day is what a true partnership is all about.
    The doctors that take the initiative to openly partner with their dental hygiene teams see a strong commitment to the practice, retention and true ambassadors for a successful business. The dentist cannot afford NOT to partner with these powerful professionals in the office.
  4. Empower your hygiene team. Your dental hygiene team is well educated and has a scope of care that they have been licensed to provide. Successful dental hygiene teams practice to the fullest extent of their license. This means if they are licensed to provide laser treatment, they should do it. If they are licensed to provide non-surgical periodontal therapy, they need to be providing it in the office.
    When you empower and trust them to partner with you, by taking the lead in periodontal and preventive health of your patients, you will inevitably see results. Empowerment = trust = respect. This is a MUST for your team.
  5. Reward and Recognize. It is as simple as this – Reward the behaviors you want repeated.
    Rewarding your team beyond their compensation seems obvious to most; however, some dentists avoid the practice all together.
    The most successful dentists and dental practices are those who recognize and reward their team for their efforts. Recognition and reward will build trust and loyalty. It has been proven that employee retention is higher in teams that have a strong connection and bond with their boss and understand how their performance impacts the practice’s bottom line.
    One of the best ways to keep your team happy and loyal to you is to make sure that their hard work is appreciated. Find a few minutes each day/week/month to recognize people. You, in turn, will reap the rewards of their loyalty and ongoing performance.

Taking the time to develop and partner with your dental hygiene team will help you meet your goals and create ultimate success in your practice.
Dental hygienists want to be successful, but they need the support and guidance from their doctors and managers. Don’t assume your dental hygiene team understands your expectations and goals. Communicate with them and do so regularly. Partner with and empower your hygiene team to master the patient care that falls under their umbrella of their expertise. Create a strong co-diagnosis and your patients will feel the synergy and commitment to total oral health.
These 5 steps have been used over and over in successful dental practices and groups across the country, and they can be used in your practice as well. There is no better time than today to partner with the powerful Dental Hygiene professionals in your practice.

Heidi Arndt has worked in the dental field for 18+ years. Her experience ranges from working as a treatment coordinator, dental assistant, and practice manager before graduating from the University of Minnesota with a bachelor’s degree in Dental Hygiene.

Heidi spent the early part of her dental hygiene career working in private dental practices and at the Mayo Clinic (Department of Dental Specialties). Heidi worked with American Dental Partners, as a dental hygiene mentor/coach later promoted to Director, Dental Hygiene Development. Heidi developed a mentoring and coaching program and led all dental hygiene development activities for American Dental Partners affiliated dental groups (over 200 practices and1,000 hygienists) across the United States, and increased hygiene profits exponentially year after year.

In 2011, Heidi founded Enhanced Hygiene. She is dedicated to helping dental practices realize their total hygiene profit potential through the development of their hygiene team, quality patient care, patient-centric service and by empowering the entire team.

Tips From The Trenches

Expanding Into Remote Locations

By Ben Burris, DDS, MDS

The advantage of being in small towns or remote locations is obvious. The lack of competition makes it easy to attract all the potential new patients to your office. The negatives are not always as easy to recognize but can include things like:

  • A town that is too small to support a full time practice, especially a specialty practice
  • Finding providers to go to the remote location can be difficult
  • If the practice is not open full time, staffing can be an issue because of travel and the need to hire for part time positions.The lack of a full time team can result in less consistency and can cause patient management issues or potentially, patient dissatisfaction.
  • There is the potential for the team to abuse unsupervised time.

Staffing multiple locations can be a pain – especially if you don’t have a dedicated team for each location and you all have to travel between the offices. Having had a great deal of experience in traveling with the team in private cars and corporate vans and planes to distant offices, I can tell you that traveling teams always present a challenge.

There are a few obvious and easy ways to deal with these issues.

  1. Don’t open a practice in an area that will not support a full time practice and thus a full time team.
  2. Be sure you have a practitioner lined up before opening another office location and do what you can to keep them invested (possibly through buy in or profit sharing)
  3. Don’t expand at all until you maximize the facilities you already have (extended hours, more days, weekends, nights, more technology, more marketing, increased capacity, increased speed, etc.)

If you do decide to have multiple locations without a dedicated full time team at each, then there are some ways to avoid team and patient upsets.

  1. Be very clear about duties and travel when hiring.
  2. Be very clear about office hours and availability with patients.
  3. Have at least one team member who lives in the remote community available for emergencies.
  4. Pay team members for time if they commute in the company vehicle.
  5. Realize that if you want to grow a remote office it often takes being open more than just the time that’s necessary to see the scheduled patients.

Most of us who have multiple offices have developed, inherited or bought them over the years and learn by trial and error. It is often difficult to have an objective assessment of our ROI and opportunity cost, and even more difficult to admit that having an office in such a location was a mistake and close it. Having closed an office in an ill-advised location, I will tell you that I am much more particular about when and where I expand. Efficiency in Group Practice is all about bigger, better and more. We want you to take it to the next level, but also want you to avoid the mistakes that others have made when going from a solo shop to dominant corporate force. As always, the best advice we can give is to find someone who is already doing it bigger and better than you are and ask their advice. I’m constantly amazed by how generous successful doctors are with their time and advice when I humbly ask for help.

Dr. Burris graduated from The Citadel, in Charleston, SC, with a BS in biology prior to receiving his DDS from the University of Tennessee-Health Science Center’s College of Dentistry in 2001 where he then completed his orthodontic residency and received his MDS in 2004.

After purchasing his first, small practice right out of residency, Dr. Burris expanded his business to include more than a dozen locations across Arkansas and Missouri in less than seven years. He has since sold all but five of his practices, which allows him to pursue his other interests and initiatives in the industry.

Ben created the model for and founded the first chapter of Smile for a Lifetime Foundation (, which provides orthodontic scholarships to deserving children. S4L now has more than 118 chapters across the US and Canada and since its inception in November 2008, the foundation has provided in excess of $16 million in free care for children in desperate need and otherwise without access to care. All of Ben’s offices participate in the Foundation and in December 2011 his NE Arkansas

Chapter of S4L awarded their 100th scholarship in the three short years since its inception!
Ben lectures routinely to dental students and orthodontic residents across the country and enjoys his role as Clinical Professor of Dental Medicine at Roseman University in Las Vegas where he helps teach the business and practice of orthodontics to the next generation. Ben is the Director from Arkansas for the Southwest Society of Orthodontists, is an alternate delegate to the AAO House of Delegates, serves on the AAO Committee to Study Members’ Practice Environment and Marketplace and is an owner and active member in the exclusive Pro Ortho Business Study Group.

Ben is also co-owner and a frequent contributor to The Progressive Dentist ( and The Progressive Orthodontist ( magazines, which focus solely on teaching the business of running a practice and provide real-world tips on managing a successful dental business.

From the Publishers: Welcome to Efficiency In Group Practice

From Bill,

Efficiency In Group Practice is a collaborative effort by two experienced publishers in the dental arena. MDSI and Hixson-Burris Media are working together to bring large group practices, regional multi-location practices, effectively the entire spectrum of corporate dentistry, timely and useful information that is pertinent for the entire team. From the clinician to the procurement manager, we’re focused on helping you grow and thrive in your group practice.

It’s a known fact that group practices are among the fastest growing business models in dentistry. However, good, focused educational, motivational and clinical content for dental group practices is limited and fragmented. Our goal with Efficiency In Group Practice is to give our readers specific information that will enable the group practice to perform at its very best. We will include columns and articles which will keep the entire team engaged, up to date, motivated and of course, efficient. In upcoming issues you will enjoy our practice profiles, “The Efficient Clinician,” human resource, real estate, finance, marketing and many other group related topics.

Let’s begin our journey together!

Bill Neumann

From Bonnie,

One of the most rewarding things about working in the field of dentistry is the strong network of colleagues many of us enjoy. At Hixson-Burris Media, we’ve enjoyed bringing you new insights and solutions for the challenges you face as not only a dental professional, but a small business. It is with great excitement that we now introduce our collaborative venture with MDSI to bring you Efficiency in Group Practice. Bill and I come from two different segments of the dental industry, and together, we’ll keep you informed on the newest trends, technologies, educational opportunities and concepts to build your most efficient, profitable group practice.

We understand the unique challenges you face as a group practice and in each edition we’ll bring you the most current and progressive ideas from today’s most respected experts in business and dentistry. We’ll show you how to get the highest ROI from your technology and product investments and help you to stand out in a sea of “one size fits all” dental practices. Your business is unique and goes well beyond the confines of the traditional dental practice. We look forward to showing you new ways to capitalize on your distinct strengths and differences to reach new heights of efficiency and create a balanced life that allows you to enjoy the fruits of your labor.

To your success,

Bonnie Hixson