Please help me with this problem; I have been filing insurance for a large practice for a number of years. When I am asked to bill for a crown or bridge there is seldom enough evidence written in the chart to warrant the procedure. I have to go back and ask the doctor why the crown is recommended and what is wrong with the tooth. If there is an existing crown, the clinical staff never writes the age or approximate age of the existing restoration. Sometimes I just wing it by putting a reason for the crown from what I can see in the x-ray or by saying the amalgam is fractured, decay is under restoration, etc. just to get it through for payment. Now I am hearing that insurance companies may ask for audits and if the evidence is not clearly demonstrated in the record they may want their money back. How can I get my clinical team on track and make them accountable for this important information?
I often receive questions from clients attending our ADVANCED DENTAL BUSINESS COURSE about formulating the “perfect narrative” to support a claim and get it paid. There is no “canned” single narrative that guarantees payment every time. However there is a system that you can use that will insure payment most of the time. In order to get your clinical team compliant, these questions need to be added to the chart (if paper) or you need to check your software system as many have the screens available to text information. The clinical team may need to be trained so that they understand the importance of detailed charting and that everyone is documenting in the same fashion. A training module offered during a Team Meeting is appropriate and adding this system to your office policy manual will make it official. The information necessary is as follows:
- EXISTING RESTORATION
- SURFACE/SURFACES-modb, mif, etc.
- CONDITION—fractured DB cusp, leaking M margin, hole in occlusal of crown, prior endo and when endo was final
- AGE OF RESTORATION OR DATE OF INITIAL PLACEMENT
- AMOUNT OF REMAINING TOOTH STRUCTURE—1/3 natural tooth etc
- AMOUNT OF LOST TOOTH STRUCTURE—2/3 natural tooth lost etc.
- DECAY-NEW OR RECURRENT—location of decay—MD, GF etc.
- OBSERVATIONS NOT VISIBLE IN THE X-RAY
- TAKE INTRAORAL PHOTOS-if possible-or draw a picture
- CHART LOCATIONS OF FRACTURES, CRACKS AND HOW EXTENSIVE THEY ARE
- NOTE CRACKED TOOTH SYNDROME
- SEVERE CRAZE LINES ON ANTERIOR TEETH
- WASHED OUT EXISTING COMPOSITE RESTORATIONS
- CHART PERIODONTAL FINDINGS
- ADEQUATE BONE SUPPORT FOR CROWN / BRIDGE
- ABSENCE OF PERIAPICAL or PERIODONTAL PATHOLOGY IN X-RAY
- BRUXISM CAUSING BREAKDOWN OF PERIODONTAL SYSTEM
This information needs to be attached or written on a claim when submitting or as an attachment when e-mailing claims. Make sure that the patient’s information and the billing doctor’s information is on this sheet. It is not necessary to write a long detailed narrative when you give the information in a concise, accurate and brief format.
Never give up on informing your staff of the importance of careful clinical charting. It is important not only for insurance processing but for the risk management of the entire team. We live in a litigious society where patients are more informed than ever of their rights. The courts will not favor sloppy inaccurate records should you have to defend your treatment in a judicial setting.
For more information about improving your practice, contact McKenzie Management AND The Center For Dental Career Development today.
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