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 Teresa@OdysseyMgmt.com.

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