Dental Billing and Coding Documentation: Small Changes, Big Impact

When entered properly, dental billing and coding, as well as documentation, insurance representatives will understand the terminology. Director of Medical Billing Education for Devdent, Laurie Owens shares ways to make small changes that yield a big impact.‍

From the time they are born, children are measured by height, weight, and even head circumference. Ezekiel, my preemie grandson, was born at 35 weeks and 5 days … and through this experience has shown me how small things make a big impact. Right now, we rejoice over the .08 ounces of weight gain and the .20ml of sucking on a bottle. This has led me to a realization of how the small changes in our dental billing and coding, as well as documentation, can make a big impact on your claim.

Now, most practice management software does its best to provide access and necessity for dental documentation. However, medically, they are lacking. And rightly so. This is not in any way meant to degrade their capabilities. As we move closer to requiring dental providers to diagnosis even on our dental claim forms, this will change.

As providers, clinical team members, and administrative support, we need to work on our medical necessity for all patients. When documentation is done for medical necessity, dental insurance representatives understand the terminology. Let’s talk about the small things in our documentation that will yield big results.

Documentation for Medical Billing in Dentistry

Blood Pressure

It might seem like a tedious job, but it can gain you documentation points for SOAP notes. How will your doctor know that this patient can be safely treated at your office without a history of blood pressure levels? What can you base an increase of pressure if you do not continually check it?

PH Alkaline Level

According to the Mayo Clinic, “Saliva helps prevent tooth decay by neutralizing acids produced by bacteria, limiting bacterial growth and washing away food particles. Saliva also enhances your ability to taste and makes it easier to chew and swallow. In addition, enzymes in saliva aid in digestion.”

When you have patients that suffer from Xerostomia (dry mouth) due to long term medication use, how can you determine Xerostomia? A PH test is one of the first tools that can point a provider in the right direction! With this inexpensive tool, you open the door to medical billing because of documented diagnostics.

Impacted verses Embedded

When you remove wisdom teeth: complete bony sites, you would document embedded. For partial bony or surgical extraction, you would document they are impacted. This very small distinction can impact your claim to the possibility of full reimbursement.

The Word Teeth

Some people would say, Laurie, you are crazy! We are dentists and in the dental field. Why would taking out the word teeth matter for medical billing? Documentation stating you are treating teeth means this is not truly a medical procedure. The teeth should not be the reason, you are preserving the maxillary and/or mandibular arches. Tell me which sounds more medical:

1. The best treatment recommendation is to extract tooth #14, bone graft, membrane, and implant.
2. In order to reconstruct the maxillary arch, we will need to remove due to periodontally diseased #14, correct the moderate atrophy, place a resorbable membrane to promote healing, and insert an endosteal implant due to the severe Xerostomia caused by Sicca Syndrome.

Anytime we want services to be covered by medical insurance there must be a medical necessity.

Medication/Medical Condition Induced

Documenting medications and oral systemic conditions that affect the oral cavity makes another big impact. Remember Tetracycline? The use of this medication is discoloration and non-caries lesions. There is a direct link of oral systemic cause that makes treatment a medical necessity.

Every day we see little victories for my grandson. Our family chooses to celebrate only the victories and to work on correcting the defeats. Your practice needs to do the same. Celebrate and correct: These are the two C’s for effective medical billing documentation for dentistry. The end victory is that your chart documentation will match your medical diagnosis coding.

‍Learn more about how RevenueWell improves case acceptance and creates more close-knit relationships between dentists and their patients.