Documentation
What must be documented for all encounters and cannot be inferred from a prior date of service?
Chief Complaint
It is a brief, concise statement describing the symptom, problem, condition, diagnosis, or the physician’s recommended return.
It is required to identify why the provider evaluated the patient on the given DOS - It must stand on its own
How often are the CDT codes updated, deleted, and revised?
Annually - once per year
What type(s) of documentation is used to support allegations of fraud, abuse, or malpractice?
Weak or missing documentation
If you need translation services, you can use Google translate or ask the patient's family member
False - Only Language Line or Certified Interpreters can be used
What type of document is a dental record?
Legal Document
Can be requested in legal and insurance proceedings and inquiries.
It is the only witness with an accurate memory.
What is considered "timely and reasonable" for documenting and approving your chart entries?
24-48 hours
What date are the CDT code updates, revisions, and deletions implemented?
January 1st
__________ is one example of Fraud?
Financial information is documented in the contact notes within axiUm
True.
Never document financials in the treatment notes unless that information directly impacts the treatment being provided on the date of service.
Which animal has the same number of teeth (32) as an adult human?
A giraffe
What is the most common audit finding when charts are reviewed?
Inadequate supporting documentation
What CDT code would you select for a completed Periodontal Maintenance encounter?
D4910
Periodontal Maintenace follows SRP treatment & continues at the dentist's discretion.
Document specific teeth that are root planed
Once a provider has been made aware of “Abuse” but doesn’t correct the error while ignoring the potential consequences, he or she then crosses the line into _______________ and the violation of abuse can then elevate to Fraud.
Reckless Disregard
D4910 Periodontal Maintenance routinely follows a Comprehensive Oral Evaluation
False!
D4910 routinely follows Scaling and Root Planing (SRP)
D4341 SRP - 4 or more teeth, per quadrant
D4342 SRP - 1-3 teeth, per quadrant
Who is the elf in Rudolph the Red Nosed Reindeer that wants to be a dentist?
Hermy the Elf
What can happen if you use unrecognized abbreviations, symbols, acronyms, or misspelled words in your charting?
Harm or unfavorable outcomes to the patient
What type of evaluation is done to determine an established patient's oral health status since their last check-up?
D0120 periodic oral evaluation - established patient
_________ states that over-coding and under-coding are equal and clear violations.
False Claims Act
Scaling is the definitive procedure during a scaling and root planing (SRP)
False! Root planing is the definitive procedure.
Document the specific teeth that were root planed to support SRP code set nomenclature in order to appropriately bill this service
Who is responsible for keeping current with coding additions, deletions, and revisions?
The Dental Team!
What must be proven in your documentation and drives the need for services rendered for each encounter?
Medical Necessity
What CDT codes would you choose:
Periodic oral evaluation - est. Pt.
Prophylaxis - adult
topical application of FL varnish
bitewings - four radiographic images
D0120 Periodic oral evaluation - est. Pt.
D1110 Prophylaxis - adult
D1206 topical application of FL varnish
D0274 bitewings - four radiographic images
Which Fraud and Abuse Law prohibits the exchange, or offer to exchange, anything of value in an effort to induce or reward the referral of business that involves any item or service payable by the federal healthcare programs.
Anti-Kickback Statute (AKS)
2 periapical (PA) radiographs taken of #21 and #22 would be coded as:
D0220 intraoral - PA first radiographic image #21
D0220 intraoral - PA first radiographic image #22
False! Correct coding is:
D0220 intraoral - PA first radiographic image #21
D0230 intraoral - PA each additional radiographic image #22
This animated dentist is known as Nemo's captor in "Finding Nemo"
Dr. P. Sherman