To ensure that your claims are paid, the documentation needs to be as supportive as possible. Here's my challenge to you:
- Can a screenshot of your clinical record show me what was done and why?
- Is the periodontal charting as complete as possible (including recession, gingival margins, and clinical attachment levels)?
- Are your radiographs clear, dated, and taken within 24 months?
- Is the patient's "stage" listed in the diagnostic information? What about his or her "grading" during healing?
Was the last bullet point a surprise? Staging is part of the periodontal guidelines to be used in your patient's clinical diagnosis. This should be present in your notes. But what if you're unclear on how to record it, much less discuss it with patients? That's why I asked Rachel Wall, RDH, of Inspired Hygiene to come on my podcast to explain it all to me.
She not only explained it but also broke it down so administrative team members can talk about "staging" and "grading" with patients. Team members should know this terminology to educate our patients and obtain coverage for their claims. A clinical record that shows a full picture of the patient's periodontal and overall health is your strongest documentation for this category of claims.
Click below to listen to our discussion on this hot topic and how it can help your practice.
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