Proper Record Keeping and Documentation
April 19th, 2018 - Christine Taxin
Proper record keeping and documentation is not only essential for today’s dental practitioner, but is also required by law. Moreover, correct, current and accurate records directly enhance patient care by enabling the dentist to plan treatments, monitor progress, and provide essential notations. Clear and concise treatment plans, medical alerts, and patient preferences reduce mistakes and errors in the delivery of dental therapeutics.
Single line notation is rarely adequate, and pages of notes are impractical. When one adds a host of third party agencies reviewing dental records, and a more empowered dental consumer population, it is no wonder today’s dental professional is looking for “clearing house” to disseminate this vital information.
This critically important Proper Record Keeping and Documentation seminar will allow the attendee to:
· Understand the importance and need for complete records.
· Identify a comprehensive medical/dental history.
· Accurately chart an initial examination.
· Diagnose and sequence treatment plans.
· Determine what adequate radiographs are.
· Understand the role of informed consent
· Identify a “record” and who owns it.
· Become familiar with common coding errors
Proper documentation also supports efficient claim processing. Complete and accurate claims are processed faster than those that are not, reducing resubmissions that delay adjudication and increase staff frustration. Key sections of the ADA claim form, CDT codex and appropriate diagnostic narratives will be reviewed.
If you have questions or comments about this article please contact us. Comments that provide additional related information may be added here by our Editors.
Latest articles: (any category)Reporting Modifiers 76 and 77 with ConfidenceApril 18th, 2023 - Aimee Wilcox
Modifiers are used to indicate that a procedure has been altered by a specific circumstance, so you can imagine how often modifiers are reported when billing medical services. There are modifiers that should only be applied to Evaluation and Management (E/M) service codes and modifiers used only with procedure codes. Modifiers 76 and 77 are used to identify times when either the same provider or a different provider repeated the same service on the same day and misapplication of these modifiers can result in claim denials.Five Documentation Habits Providers Can Use Implement to Improve Evaluation & Management (E/M) ScoringApril 11th, 2023 - Aimee Wilcox
Provider education on E/M coding updates is vital to the success of any organization, but how do you whittle down the massive information into bite-sized pieces the providers can learn in just a few minutes? Check out the five steps we have identified to teach providers in just a few minutes that can significantly impact and improve coding outcomes.Second Quarter 2023 Updates are Different This YearApril 6th, 2023 - Wyn Staheli
The second quarter of 2023 is NOT business as usual so it is important to pay attention to ensure that organizational processes and training take place to avoid mistakes. Not only have ICD-10-CM coding updates been added to the usual code set updates (e.g., CPT, HCPCS, ICD-10-PCS), but the end of the COVID-19 Public Health Emergency will bring about changes that will also take place during the quarter (but not on April 1, 2023.7 Measures Developed by the HHS Office of Inspector General (OIG) to Identify Potential Telehealth FraudMarch 28th, 2023 - Aimee Wilcox
A recent review of telehealth services reported in Medicare claims data during the pandemic where these seven measures for identifying suspected fraud, waste, and abuse were applied, revealed more than a thousand Medicare providers potentially committed fraud during this period. What are the measures the OIG applied during their review, and how will that impact future telehealth guidelines moving forward?MUEs and Bilateral IndicatorsMarch 23rd, 2023 - Chris Woolstenhulme
MUEs are used by Medicare to help reduce improper payments for Part B claims. This article will address the use of the National Correct Coding Initiative (NCCI) and Medically Unlikely Edits (MUEs) and how they are used by CMS.It is True the COVID-19 PHE is ExpiringMarch 16th, 2023 - Raquel Shumway
The COVID-19 PHE is Expiring, according to HHS. What is changing and what is staying the same? Make sure you understand how it will affect your practice and your patients.Billing Process FlowchartMarch 2nd, 2023 -
The Billing Process Flowchart (see Figure 1.1) helps outline the decision process for maintaining an effective billing process. This is only a suggested work plan and is used for demonstration purposes to illustrate areas which may need more attention in your practice’s policies and...