What Documentation Does a Physician Want from a Dentist?

by Rose Nierman, CEO Nierman Practice Management
Are you looking for a way to increase both the number of Dental Sleep Medicine (DSM) patients your practice sees and also improve patient care? Oral appliance therapy (OAT) for obstructive sleep apnea (OSA) involves colleagues from different healthcare professions with specialized skills and expertise working together. Being part of a multidisciplinary team of talented doctors saving lives can be an exciting and fulfilling way to grow your practice.
How do you join a multidisciplinary team in your community? There isn’t a signup form online or a meetup group to try out. The key to obtaining and retaining relationships with other medical professionals is through consistent communication regarding actual patients these physicians have an interest in and have seen. Why would a physician’s office refer more patients for oral appliance therapy if they don’t know whether OAT was successful for the first patient they referred, or whether they ever even started treatment? When you are part of a multidisciplinary treatment team, documentation and progress reports shared between referring and treating colleagues are essential to patient care. The great news is: there is already a well-established “medical-model” documentation and report writing standard. The same records used to communicate with physicians also verify the medical necessity of treatment. Using common language and report writing formats within your physician network helps to ensure smooth sailing. With the right tools, you’ll secure yourself as the go-to DSM professional for physicians to continually refer patients.
There are two standards for medical documentation and communications:

  1. S.O.A.P. Notes and Reports
  2. Documentation Guidelines for Evaluation and Management Services created by the Centers for Medicare and Medicaid Services (CMS).

S.O.A.P. reports

Dental S.O.A.P. notes and reports greatly improve communication among all providers and insurance carriers. The S.O.A.P. note was first created in the early 1970’s, under the acronym P.O.M.R. (Problem Oriented Medical Record). S.O.A.P. is by far the most common format used today. S.O.A.P. stands for Subjective (complaints & history), Objective (testing & exam findings), Assessment (diagnosis) and Plan (treatment plan). Many dentists have found that this way of organizing data and the critical
thinking this format elicits has truly revolutionized their practices. S.O.A.P. is the preferred format to communicate with your network of physicians, especially when reporting the outcome of OAT for your
mutual patients.
The American Dental Association’s documentation guidelines recommend that dentists take good medical histories, record the reason for the visit, chart findings and have detailed written plans of care. What’s missing? The assessment! It’s time to put the “A” in S.O.A.P. in dental practices, especially for practices providing OAT for OSA and for those billing medical insurance for other services such as TMJ appliances, CT scans and oral surgeries.

Documentation Guidelines for Evaluation and Management (E&M) Services

Evaluation and Management Documentation Guidelines support Current Procedural Terminology (CPT) codes as well. It’s reasonable and common to bill CPT 99204 (level 4) for a new patient office visit: medical decision-making is moderate, the presenting problems are moderate and the provider typically spends 45 minutes face-to-face with the patient.  For this level be sure to document:

  • A comprehensive history
  • A comprehensive exam
  • Medical decision-making of moderate complexity

You can find the AMA documentation guidelines and information on the CMS.gov website or from the link below (see references).
Dentists collaborating with ENT’s, maxillofacial surgeons, sleep physicians, pain management specialists and others find that a well organized letter format sets you apart and can be prepared with software.  It’s important that patients complete a questionnaire designed for DSM, TMD and when surgeries are billed as medically necessary. The patient signature should be obtained for verification of chief complaints, history of present illness, past history and the location, duration and frequency further describing their condition (these are some of the elements in the Guidelines). Your exam should be specific to the medical necessity of a service or procedure and include the ICD diagnosis codes as part of your assessment. It’s imperative that the provider sign the notes. Although your documentation is sent in advance to commercial medical carriers, some insurers perform post payment reviews checking for “insufficient documentation”. An insurance auditor’s “red flag” may be raised by a “cut and paste” template approach. This is referred to as a type of “cloning” by insurers and may involve using an online program or word processor with no questionnaire completed to validate medical necessity and level of care. Be sure to get direct input from your patients and make custom notes for each patient. These suggestions will help decrease the possibility of a compliance audit, as well as assist in a successful outcome to avoid refunds or penalties if you do undergo an audit.

International Classification of Diseases – ICD-10

With the transition from ICD-9 to ICD-10 diagnostic codes on October 1, 2015, (ICD-10 for OSA is G47.33), commercial insurance companies will process claims in a speedier manner when your documentation of medical necessity is sent with the claim or the preauthorization. Making it a habit to be on top of these changes and knowing what information is wanted and needed is your recipe for success.
Also, since TMD (Temporomandibular Disorder) issues and sleep issues coexist in so many patients, dentists who provide TMD treatment services will be pleased to know that over 34 states mandate that TMJ treatment be considered medically necessary. To find out if your state is listed, please contact me at contactus@DentalWriter.com or call 1-800-879-6468. Also, feel free to contact me with questions on coding options for TMD since the code, S8262 for Mandibular Orthopedic Repositioning Device, was retired in July.
Ensuring your practice has accurate and detailed documentation and narrative reports will not only help you to provide better care to patients and support the medical codes you bill, but will also safeguard your practice. Just as importantly, remember that the medical community (your current and future multidisciplinary treatment team) expects it and will do the same for you.

Rose Nierman with DentalWriter users and seminar attendees in Atlanta.
Rose Nierman with DentalWriter users and seminar attendees in Atlanta.

Team Nierman

Nierman Practice Management (NPM) has become synonymous with cross-coding
in the dental industry. With the largest team of medical billing, OSA, TMD, dental CT and oral surgery implementation experts on the quest to accomplish Rose’s lifelong mission of helping millions of people, thousands of dentists rely on the Nierman Team for their years of dedication, experience, and proven results.

About the Cover:

Rose Nierman:

On a Mission to Make Medical Billing in Dentistry Commonplace
Having dedicated the past 30 years to her lifelong mission of helping millions of people gain access to the medically necessary dental treatments they need, Rose Nierman is on a quest to make medical reimbursement in dentistry commonplace.
As a hygienist and insurance coordinator in a busy general practice treating temporomandibular joint dysfunction (TMD), Rose was helping dentists get paid by medical insurers for TMD sufferers as early as 1980.

Rose’s Story

Many of Rose’s patients asked why medical insurance wouldn’t reimburse for their treatment when their previous treatment attempts for facial pain, headaches and referred ear pain stemming from the TMJ were covered with other healthcare providers.
Researching medical insurance protocols, Rose started making a case for coverage using the standard documentation insurance carriers are familiar with. “We felt these chief complaints were not related to the teeth but were muscular or orthopedic, in nature.” The medical insurance carriers concurred when given a full S.O.A.P. report of the chief complaints of the patient, exam findings, the assessment with ICD codes, and the dentist’s plan for treatment. “We were elated,” says Rose.
Patients started coming in the door seeking treatment, referred by healthcare providers who had received Rose’s S.O.A.P. narratives and progress reports on mutual patients. And most patients were accepting treatment due to both the financial relief and greater confidence in the therapy.

The Insurance Oracle

Once other dental practices began to find out that Rose was getting medical insurance coverage, she was receiving calls from dentists all over the United States, asking if she could help get reimbursement for TMD, oral surgery and other medically compromised patients. She could, and she did.
By 1988, Rose had built a reputation as the “Medical Insurance Oracle” and was spending every weekend either at her kitchen table in Jupiter, FL with dentists and their insurance cases, or speaking at dental meetings with her The Complete TMJ Manager™ and Successful Medical Insurance in Dentistry™ manuals in tow.

An Easier Way

Seeing the impact of being able to profitably provide affordable care to patients was having on the dental practices she helped, Rose was inspired to help thousands of dental practices to help millions of patients. With a backlog of kitchen table and phone appointments, Rose knew reliance on her time was the limiting factor in helping millions. There had to be an easier and more efficient way to help more practices implement treatment and billing and create the S.O.A.P. narratives and medical claims on their own, she thought.
By the early 90’s, Rose had hit the road with 20 CE accredited Successful Medical Insurance in Dentistry™ courses, and Dental-Writer™ Software had become the first and leading software solution for implementing medical necessity reimbursement. Leading dentists, treating sleep apnea & TMD throughout the US and Canada, credit much of their success to using DentalWriter to build their practice, develop referral relationships and establish efficient protocols. “It changed the entire landscape,” says Steve Lamberg, DDS.

Sleep Apnea

By 2002, with increased Obstructive Sleep Apnea (OSA) diagnoses and oral
appliance innovations, dental practices all over the US were getting reimbursement for OSA with the DentalWriter “Sleep” module and support from Rose and her team. “We had to fight tooth and nail to get reimbursement before there was an official CPT code or reference to OAT in insurance policies and guidelines,” says Rose. “Now with specific codes and policies, it’s much easier”.

Stay Relevant With Dental Sleep Practice

Join our email list for CE courses and webinars, articles and more..

Shopping Cart
Scroll to Top