Documentation
What is your only witness with an accurate memory when complaints are levied against you?
Your documentation
If the supporting documentation is not there for the services and procedures delivered, instructions given, or patient non-compliance then it simply didn’t happen.
Radiograph documentation of films taken on the date of service or are referred to from a separate date of service supports:
Medical Necessity and/or Continuity of Care
How often are the CDT codes updated, deleted, revised and undergo editorial actions?
Annually
Implemented on January 1st
Who is responsible for any claims and recorded information that is submitted from the office regardless if there is direct knowledge of the submissions?
The Dentist
it is possible that the ancillary staff can also be held accountable for fraud and abuse as well by False Claims Act provision 31 USC 3729.
It is OK to cut and paste information from a previous date of service?
False
Cloning = Inaccurate Information = Misrepresentation of Medical Necessity = Compromised Record = Doubt of treatment provided = High risk of errors and investigations
828 IAC 1-1-15(a)(12) - Failure to keep adequate dental records
What are the 6 questions of documentation that you should attempt to answer for each patient encounter?
Who - Legible identity of the provider
What - History, physical findings/updates, test results
When - Date of service
Where - location of treatment = tooth #, quadrant, surface(s)
Why - Reason for encounter = Medical Necessity, Chief Complaint, Diagnosis
How - Treatment Plan, Method
Do radiographs belong in the Treatment Notes or the Contact Notes?
Treatment Notes
Your chart note states that 4 PA's were taken at todays visit. PA's were taken of #26 - #29.
What are the appropriate CDT code(s) for these services?
D0220 intraoral – periapical first radiographic image #26
D0230 intraoral – periapical each additional radiographic image #27
D0230 intraoral – periapical each additional radiographic image #28
D0230 intraoral – periapical each additional radiographic image #29
What accounts for nearly half of all fraud cases and provides opportunities for fraud and abuse to exist in the dental office setting?
Internal Weaknesses
"The dental record is a legal document as well as the primary tool for the documentation, organization and delivery of professional care"
True
Fill in the blank:
"________ what you do and _______ what you documented"
"Document what you do and code what you documented".
What do bitewing radiographs show?
The upper and lower teeth's biting surfaces on the same film for the portion of teeth above the gum line
Patient presented to the Emergancy Clinic with the complaint of #14 pain when eating and drinking anything hot or cold.
Which CDT evaluation code do you select?
D0140 limited oral evaluation - problem focused
An evaluation limited to a specific oral health problem or complaint.
What is it called when the violation of abuse elevates to fraud?
Reckless Disregard
The Chief Complaint can be noted from the patient's previous visit if they are being seen for the same diagnosis?
False
The patient’s chief complaint cannot be inferred from a prior date of service. The chief complaint must stand on its own for each specific date of service. It is required to identify WHY the provider evaluated the patient on the given date of service.
What must be proven in every patient encounter and drives the need for services rendered on the DOS?
Medical Necessity
This principal states that radiation exposure should be kept "as low as reasonably achievable"
ALARA
A radiation protection principle that says radiation exposure should be minimized while still obtaining diagnostic-quality images.
What CDT codes would you select for:
A. Periodic Oral Evaluation
B. Bitewing - 4radiographic images
C. Prophylaxis - Adult
D. Topical application of fluoride varnish
D0120 – periodic oral evaluation – established patient
D0274 bitewing – four radiographic images
D1110 prophylaxis – adult
D1206 topical application of fluoride varnish
Fill in the blank:
Overcoding and undercoding are violations of the ___________ and are misrepresentations of the facts.
False Claims Act
Both scenarios provide deliberate false statements as they relate to provided services and are misrepresentations of the facts. They hold the same level as a violation under the FCA and are fined the same.
When documenting an impacted tooth extraction, you need to document the type of impacted tooth to support the appropriate code set
True
D7220 removal of impacted tooth – soft tissue
D7230 removal of impacted tooth – partially bony (PBI)
D7240 removal of impacted tooth – completely bony (CBI)
D7241 removal of impacted tooth – completely bony (CBI), with unusual surgical complications
D7250 removal of residual tooth roots (cutting procedure)
What is the most common finding against a dental professional when charting is reviewed?
Inadequate supporting Documentation
Poorly maintained dental records are considered Professional Incompetence under 828 IAC 1-1-15(a)(12)
Name one procedure or service that typically does not include radiographs. When assigning CDT codes, radiographs, when taken with these procedures, are reported separately.
Evaluations
Prophylaxis
Fluoride
Restorations
Extractions
Patient presents for extraction of #12. During the procedure the tooth breaks and must be sectioned for removal. You would still select D7140 extraction, erupted tooth or exposed root for the claim set
No, the procedure elevates to a surgical extraction
If you are performing a simple extraction, D7140, and the tooth breaks and must be sectioned for removal then simple extraction elevates to a surgical extraction and you would select D7210 extraction, erupted tooth requiring removal of bone and/or sectioning of tooth to report the service.
True or False?
Under the False Claims Act (FCA), a person merely has to have specific intent to defraud the government to be held liable.
False
Fraud = False statements or misrepresentations and can be intentional or non-intentional.
Documenting specific teeth receiving the root planing during an SRP is required to support the specific code nomenclature of the number of teeth per quadrant.
True
Chart documentation must indicate that root planing was performed, not just scaling, to support the specific code nomenclature of D4341-D4342 because root planing is the definitive procedure of the SRP.