Editor’s note: This is part two of a three-part series. Read part one here.

In part one of this series on preventive dental billing, we discussed the importance of obtaining, verifying, and understanding your patient’s insurance details before they present to your office. This proactive approach protects the entire revenue cycle and helps to ensure the practice will be paid for the care it provides. 

Once the patient is in your dental chair, the second pillar of preventive dental billing begins: clinical documentation.

Claim denials are a sign that your license may be at risk and that your treatment notes will likely not hold up in court. One of the most common reasons claims are delayed or denied is due to incomplete or ambiguous clinical notes. 

Take a few minutes this week and audit the clinical documentation for 10 random patients in your practice. Look at multiple providers. Look at busy days, slow days, and everything in between. As you read through the clinical notes, ask yourself:

• Do the notes accurately and completely capture every detail of the encounter?
• Is there a documented diagnosis?
• If you utilize templates, are there any lines left blank, and what does this signify?
• Are notes signed by the hygienist and by the doctor performing the exam?

Insurance carriers have to justify why they are approving a claim for payment. If your documentation lacks the “why” behind the treatment, it will likely be questioned or rejected. 

When claims repeatedly come back denied or requesting more information because the clinical team didn’t document completely, your administrative team then becomes frustrated and burned out. They start blaming insurance companies and resenting the clinical providers. This toxic cycle impacts both your office culture and your bottom line.

Fortunately, just as thorough pre-appointment data gathering prevents administrative billing errors, there is a proven way to prevent clinical documentation insurance delays.

Step 1: Return to SOAP notes

There is a reason providers are taught to write SOAP notes in their training, yet it remains a mystery why so many abandon them in private practice. 

Implementing and enforcing a strict SOAP note protocol for every patient visit takes the guesswork out of the practice’s revenue. 

Quick SOAP notes review:

• Subjective: What is the patient saying? What is the chief complaint?
• Objective: What are the exam findings? Why were x-rays prescribed, and what were the results? What are the vital signs? Were intraoral photos taken, and what do they show? What tests were performed?
• Assessment (diagnosis and prognosis): What does the provider recommend based on the subjective and objective findings? What is the likely outcome of the recommendation?
• Plan: What treatment was performed today, or what needs to be scheduled for a later date? Were any prescriptions (include all Rx details) or home-care instructions given?

By holding team members accountable to complete SOAP notes accurately, you are taking the necessary steps to ensure that you are paid for the services you provide. 

Related reading: Are you writing SOAP notes for every dental patient? Here’s why you should be

Step 2: Establish clinical note etiquette—who, what, when

For days to operate smoothly, you must clearly define who is recording the information for each section of the clinical note. 

Many successful providers use a staggered protocol. The dental assistant starts the note by recording vital signs and quoting the patient’s chief complaint. The dentist then performs their initial exam and prescribes any radiographs. While the assistant is taking x-rays, the dentist uses that downtime to start their objective note and document why the x-ray was ordered. 

As the appointment progresses, use natural breaks to continue documenting. For example, after administering local anesthesia, use the waiting period to either type out the note yourself or dictate to your assistant what has been accomplished up to that point.

It is vital to document exactly what materials, topical/local anesthetics, and other products were used. If a patient returns with an unexpected or unfavorable result and there is no record of what was utilized, it becomes incredibly difficult to rectify the situation defensively or clinically. 

No blank spaces when completing clinical notes. If anyone in the practice is utilizing a templated note and leaving any field blank, your practice is at risk. This is a red flag for payers and auditors as well as leaving you legally vulnerable. Rectify this by initiating a “no blank spaces standard.” Add it to your ongoing training and enforce it through periodic monthly audits of chart notes.

Step 3: No note, no money

For your administrative team to accurately collect payments for today’s visit or estimate for future treatment, they must have the completed clinical note. 

They cannot work with: 

• A sticky note saying “next visit” 
• A route slip with “MOD” scribbled on it but no tooth number
• A promise that the note will be written “at the end of the day”

If a treatment is so complex that the provider requires more time to capture all the details, then collecting from the patient and preparing future treatment plans must also wait. If the idea of delaying collections doesn’t sit right with you as a practice owner, then you must provide the clinical documentation that enables those administrative functions to happen in real time. 

Your administrative team is not in the treatment room with you. An accurate, thorough clinical note is the essential communication they need to ensure the practice is paid for your hard work. 

The end of the appeal letter

Do you dread walking into your office and seeing a list of patients your billing team needs you to dictate a narrative for?

If you never want to see another one of those requests on your desk, provide your team with a complete SOAP note from day one. Today, most insurance companies are no longer accepting posttreatment appeal letters. They simply want a copy of the original clinical note. If that note is incomplete, the claim stays denied. 

If you are in-network, your contract may require you to write off the work that was denied due to lack of clinical support. If you are an out-of-network provider, your patient will be upset with you for a denied claim that leaves them with an unexpected out-of-pocket expense because their provider neglected to completely and accurately document their findings. 

Conclusion

It is the responsibility of the practice owner and any licensed professional to not only provide patients with quality dental care but to meticulously capture the details of that care. 

Consistent, quality clinical documentation avoids requests for more information, prevents delayed reimbursements, and stops clinical denials in their tracks. It protects you legally and provides your team and patients with superior communication. By having a system in place that requires thorough documentation, you fast-track the revenue cycle and conquer the second pillar of preventive dental billing.