Documentation
What must be documented for all encounters and cannot be inferred from a prior date of service?
Hint: Why are they sitting in front of you?
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
Who is able to alter the dental record after the notes have been approved?
No One!!
Altering medical records, for any reason has the potential to create doubt regarding the basis of diagnosis, treatment plan, and communication with the patient. It can also have serious implications for the quality of care being given by the provider.
Medical Records should never be altered after approval.
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.
Name one administrative duty that a dental assistant can be asked to provide
Schedule appointments
Make reminder calls
Answer Insurance questions
Updating and maintaining patient records
Checking patients in or out
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 type of evaluation is provided for a specific oral health problem or complaint?
D0140 limited oral evaluation – problem focused
Typically, patient’s receiving this type of evaluation present with a specific problem and/or dental emergencies, trauma, acute infections, or when the patient has been referred for a specific problem. Any radiographs, prophylaxis, fluoride, restorative, or extraction service is reported separately.
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
A scribe is instructed to document and enter information into the EHR by the physician.
A scribe can make independent decisions or translations while capturing the physician's dictated information.
False!
The Scribe cannot make independent decisions or translations while capturing the information.
The Scribe cannot appear to be providing services that they are not licensed for.
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
Weak or missing documentation can be used to support allegations of fraud, abuse, or malpractice?
TRUE
Failure to keep adequate dental records is an act defined as Professional Incompetence under 828 IND. ADMIN. CODE 1-1-15(a)(12) by the Indiana State Board of Dentistry.
Who is responsible for keeping current with coding additions, deletions, and revisions?
The Dental Team!
What are 6 questions that one should attempt to answer for each patient encounter?
(HINT: Think back to High School English Class)
WHO: Legible identity of the provider
WHAT: Relevant: History, physical findings, and test results
WHEN: Date of service (DOS)
WHERE: location of treatment (Tooth#, Quadrant, specific tooth surface)
WHY: Reason for encounter
HOW: Plan of care / treatment provided
What type of evaluation is provided to a new or established patient that has had a significant change in health conditions and/or has been absent from active treatment for 3 or more years?
D0150 - Comprehensive Oral Evaluation - new or established patient
It is a thorough evaluation and recording of the extraoral and intraoral hard and soft tissues. This does include an evaluation for oral cancer, the evaluation and recording of the patient’s dental and medical history and a general health assessment. Any radiographs, prophylaxis, fluoride, restorative, or extraction service is reported separately.
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)
Your chosen CDT code set(s) provide supplemental support to the encounter note on the date of service
FALSE!!
the CDT code sets chosen are only supported by the chart documentation. The documentation is not supplemented or supported by the chosen code sets.
IF IT ISN'T DOCUMENTED - IT DID NOT HAPPEN, IT WAS NOT PROVIDED, IT WAS NOT DISCUSSED
This animated dentist is known as Nemo's captor in "Finding Nemo"
Dr. P. Sherman