5.11.12 Issue #531 info@mckenziemgmt.com 1-877-777-6151 Forward This Newsletter

Belle DuCharme, CDPMA
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Building Narratives for Dental Claims
Belle DuCharme, CDPMA

Heed good advice in never claiming to be an insurance expert. The products for consumer purchase in the realm of “dental insurance” are ever changing, so verify eligibility and coverage on each patient. One thing is for certain - to be paid in a timely manner one must give the claims examiner the correct information or you will be resubmitting, or worse, having to go through the time consuming review process.

The most common mistakes seen on claims are the absence of information and attachments. Billing out an anterior tooth as a posterior tooth is careless posting and will result in a denied claim. Giving incorrect information can cause headaches, but not providing enough information can cause the same delay. Below is a formula that may help to get claims paid in a timely fashion.  Remember to check the doctor's clinical notes for information on each service and use that verbiage in the narrative. A cookie cutter narrative for every similar claim may end up being a red flag to an examiner.

. Tooth number
. Existing restoration is: Filling, Onlay or Crown
. Age of existing
. Clinical reason to replace restoration: Decay, Fracture or Pain/cracked tooth
. Missing restoration
. Is this the initial placement of this crown?
. Date of initial placement

Build-up is a separate procedure completed the day of the crown preparation (or other date prior to seat) to restore missing or destroyed tooth structure in order to retain new crown? “The large, old, failing restoration had decayed with destruction of supporting tooth structure making the build-up necessary to restore function by supporting new crown.”  Send a current periapical x-ray showing apex and a bitewing x-ray.

Multiple 3-4 Surface Composite Restorations
. Existing restoration
. Age of existing restoration
. Clinical reason to replace restoration: Decay, Fracture or Pain

In the case of multiple composite restorations, the evidence of decay and fracture may be required. Replacing amalgam because it is metal or the patient wants white fillings is usually not reason enough to replace restorations. Send periapical with apex and bitewings of teeth treated.

Same as for crown narrative, but you must include the words “cusp fracture” and include a periapical, and if available, an intra-oral photo demonstrating the missing or fractured cusp. This restoration is an inlay with an onlay component, meaning it must completely cover a cusp to be considered an onlay. List the cusp that is fractured in the narrative.

. Tooth number
. Existing restoration?
. Age of existing restoration
. Clinical reason to replace existing

Narrative should include verbiage such as: “Tooth number(s)____ have existing facial or 3-4 surface composite that is cracked, fractured, washed out, leaking or decayed. Remaining tooth structure will not sustain another composite restoration, a veneer is necessary to restore to function.”

Scaling and Root Planing
Narrative should contain the condition that the patient presented at the time of clinical examination. Such as: “Patient presents with periodontal disease including BOP, exudate, (if present) mobility, and generalized 4-6 mm periodontal probing depths.”

Include a current FMX and periodontal charting showing comparisons if available.  Any other detail from the clinical notes of the dental hygienist or dentist may be added to the narrative.

Implant Crown
. Tooth number
. Date of extraction
. Clinical reason for extraction
. Surgical notes
. Why implant is recommended
. Long term prognosis

“Tooth # ___ was extracted because_______________________. Surgical implant placed by _______________to replace missing tooth. Implant crown # ___ and custom abutment # ___ placed to restore chewing function in the arch and to retain integrity of the bone and facial structures”

Panorex or FMX, periodontal charting and narrative should be sent with claims for implants and implant crowns.

Keep narratives short, but include the information necessary to give the claim examiner the documentation needed to pay the claim. Supporting information required will vary slightly from one insurance company to another.  The above system will help you understand the importance of good clinical notes and excellent radiographs.

If you would like more information on McKenzie Management'sTraining Programs  to improve the performance of your team, email training@mckenziemgmt.com

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