In today’s insurance economy, insurance companies require solid justification, or reasons, for treatment: submission of x-rays, intra oral photos, periodontal charting, missing teeth, past history, prognosis, chart notes, peer reviews, second opinions, and the list continues. The insurance company may request just about every piece of documentation you could possibly imagine to aid in their consultants review of your procedure.

One of the key components to your insurance claim submission is your clinical narrative. It goes without saying that clinical documentation is incredibly important when it comes to timely payment from insurance. Delays caused by insurance company requests for additional details cost you time and money, so it is important to try and submit all details with the first attempt.

Keeping track of clinical justification in the chartless environment can be cumbersome until you establish a set workflow of where you place notes. If you are part of the many offices who have taken steps toward going chartless, you may have found that there could be several places to document clinical justification for a procedure. The transition to electronic charts always presents an interesting environment for offices, and it takes time to become accustomed to the new location of notes and documentation.

Your paper version of clinical justification was great. You had a special place within the chart where those notes could be found. Your billing team could expeditiously review the chart and find the narrative. It is the quick (and accurate) action of your billing team that ensures the claim is submitted and reviewed in a timely fashion.

Blasting into an efficient chartless environment using Procedure Notes

In order to create this same level of efficiency in a chartless environment, you must create guidelines of where your clinical justification will be stored in the electronic record. The documentation of a clinical narrative in Easy Dental is best handled in procedure notes. Procedure Notes is a text field located within the Edit Procedure window.

You can quickly access the Edit Procedure window from the progress notes panel in the Chart module. Double click the procedure line to open the Edit Procedure window. Simply type in your procedure note and click OK to save.

Once the procedure is set complete, the procedure is transferred to your patient’s account for your billing team to create the claim. During the claim creation, the procedure notes are accessible through the Edit Procedure window within the account. Your billing team can easily copy and paste the notes into the claim remarks box. Keep in mind that only 274 characters will print on a paper claim form DX2007 and the number of characters that will transmit on an electronic claim is carrier specific (some allow 150 characters).

Today, I have shared with you a simple documentation process that will affect the entire team. I encourage that you share this tool with your team. The application of the procedure note field for clinical justification will expedite your insurance claim filing and eliminate unnecessary delays in insurance claim payment. It’s a win-win combination!

David Broom is Senior Director of Product and Business Development. David has a master’s degree in Information Technology (IT) from the University of Texas in Dallas and has more than 35 years of experience from many global companies such as Hitachi Vantara, Methode Electronics, and Keane, Inc. In his current role, he is responsible for all aspects of the product management and field service teams at Henry Schein TechCentral, which identifies the ideal advanced technologies to meet the unique needs of the dental market and ensure that dental offices are using the right IT to be more efficient and effective.