Diagnostic codes are a key to EHR interoperability. Diagnostic codes are used to group and identify diseases, disorders, symptoms and medical signs. The ADA Dental Claim Form [2012 © American Dental Association](5) already reflects this direction by adding a field for diagnostic codes. Selecting the correct codes should be based on medical necessity. Medical necessity is not commonly documented in dentistry and won’t be a choice with EHR.
Medical necessity is the reason why a test, a procedure or an instruction is performed.(6) Medical necessity is different from person to person and changes as the individual changes. The team, including hygienists, must provide consistent methodical documentation of medical necessity for coding. Coding is not limited to codes for insurance. Codes are the language of EHR.
Transitioning to EHR won’t be worth the effort if there is no improvement, enhancement or value gained by all stakeholders particularly the patients. EHR will not make inadequate recordkeeping magically become useful. Waiting until your state mandates EHR makes little sense; now is the time to get started in this brave new world. Embracing concepts like medical necessity prepares the way to break down the silos.
1. DiGangi, P. (2012) Breaking Down the Silos with Electronic Health Records. The Richmond Institute. Last accessed 7/31/13: http://www.richmondinstitute.com/article/infection-control/breaking-down-the-dental-silos-with-electronic-health-records.
2. Minnesota Department of Health (MDH) (2013) Guidance for Understanding the Minnesota 2015 Interoperable EHR Mandate. Last Accessed 6/11/2013: http://www.health.state.mn.us/e-health/hitimp/2015mandateguidance.pdf.
3. Uretz, M. (2013) Minnesota’s EHR Mandate for Dentists – A Trend? DentalSoftwareAdvisor. Last Accessed 7/30/13: http://www.dentalsoftwareadvisor.com/minnesotas-ehr-mandate-for-dentists-a-trend/.
4. EHR Intelligence. (7/25/13) Minnesota mandates certified EHRs for all dentists by 2015. Last Accessed 7/30/13. http://ehrintelligence.com/2013/07/25/minnesota-mandates-certified-ehrs-for-all-dentists-by-2015/.
5. American Dental Assocation (2012). ADA Dental Claim Form. Last Accessed 7/4/13. http://www.ada.org/sections/professionalResources/pdfs/ada_dental_claim_form_completion_instructions_2012.pdf.
6. DiGangi, P. (2013) DentalCodeology: More than Pocket Change. P. 10. Last accessed: 7/31/13. http://dentalcodeology.com/.