A New Day For Oral Health In Virginia

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A New Day For Oral Health In Virginia
Fall 2008 Provider Training Seminars October 21
24, 2008

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Agenda

• Welcome and Introductions
• Review the Training Objectives for the Session
• Discuss Program Coverage Guidelines for Scaling
  and Root Planing
• Discuss Dental Records Guidelines for Adequate
  Chart Documentation
• Review Helpful Tips Regarding Claims Submission
  and Payment
• Present News and Updates Regarding
• Conversion from WPS to PWP
• Web-based Broken Appointment Tracking
• Q A

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Training Objectives

• Explain the guidelines for Scaling and Root
  Planing Coverage and how the treatment protocols
  can improve the outcomes of children with
  periodontal disease.
• Provide helpful information about the dental
  record, including components of a dental record,
  appropriate treatment documentation and retention
  of patient records.
• Increase understanding of steps to be taken to
  ensure accurate and timely claim payment.
• Present updates regarding the latest changes to
  the program.

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Program Coverage Guidelines for Scaling and Root
Planing
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Scaling and Root Planing Defined

• CDT definition This procedure involves
  instrumentation of the crown and root surfaces of
  the teeth to remove plaque and calculus from
  these surfaces. It is indicated for patients
  with periodontal disease and is therapeutic, not
  prophylactic, in nature. Root planing is the
  definitive procedure designed for the removal of
  cementum and dentin that is rough, and or
  permeated by calculus or contaminated with toxins
  or microorganisms. Some soft tissue removal
  occurs

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Scaling and Root Planing Questions to Ask

• Is the bone loss significant enough to access the
  root for scaling?
• Is there radiographic evidence of subgingival
  calculus on the root surfaces?
• Does the patient have a past history of
  documented periodontal disease?
• How many teeth in the quadrant are affected?
• D4341 or D4342?

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Dental Records Guidelines for Adequate Chart
Documentation
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Sources of Information

• The information used in this training was
  compiled using material from
• American Dental Association (2007). Dental
  Records.
• Virginia Department of Health Professions,
  Virginia Board of Dentistry (2007). Recordkeeping
  Beyond the Regulatory Requirement.
• Virginia Board of Dentistry (Revised July 24,
  2008). Regulations Governing The Practice of
  Dentistry and Dental Hygiene.

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The Dental Record

• The dental record, also referred to as the
  patient chart, is the official office document
  that records all diagnostic information, clinical
  notes, treatment performed and patient-related
  communications that occur in the dental office,
  including instructions for home care and consent
  to treatment.

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Importance of Complete Record Keeping

• Diligent and complete record keeping is extremely
  important for many reasons
• Care for the Patient Patient records document
  the course of treatment and may provide data that
  can be used in evaluating the quality of care
  that is provided to the patient.
• Means of Communication Complete and accurate
  records contain enough information to allow
  another provider who has no prior knowledge of
  the patient to know the patients dental
  experience in your office.
• Defense of Allegations of Malpractice The dental
  record may be used in a court of law to establish
  the diagnostic information that was obtained and
  the treatment that was rendered to the patient.
  Information found in the record may be used in
  determining whether the diagnosis and treatment
  conformed to the standards of care in the
  community.
• Aid in the Identification of a Dead or Missing
  Person Dental records may help to provide
  information to appropriate legal authorities.
  The most common element of forensic dentistry
  that a general practitioner is likely to
  encounter is to supply antemortem (before death)
  records for a forensic odontologist.

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Are Most Chart Notes Adequate?

• Most Dental records are seriously inadequate and
  often fail to support patients insurance claims,
  withstand insurance audits, and worse yet,
  survive malpractice lawsuits.

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Insurers Views as to the Frequency of Various
Record Keeping Errors
Top 15 Types of Dental Record Keeping Errors (In
order of Frequency 1 Highest to 15 least)
Based on a 2005 survey conducted by the ADA
Council on Members Insurance to determine the
frequency, severity and cause of dental
malpractice claims reported between 1999 and 2003.
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The Results

• In the opinion of professional liability
  insurance companies, it is fairly common to find
  that dentists with malpractice claims are not
  adequately documenting
• Treatment Plans
• Patients Medical History
• Informed Consent/Refusal Process
• Errors and inadequacies in the patient record
  prevent professional liability insurance
  companies from successfully defending some
  dentists against unfounded allegations of
  malpractice.

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Types of Treatment Record Documentation Errors
Most Common Among SFC Providers

• D9920 (behavior modification) No documentation
  supporting the patient behavior issues requiring
  behavior modification No documentation of what
  the provider did to modify the members behavior
  i.e. additional time, additional staff,
  immobilization.
• D9230 (nitrous oxide) No documentation of
  start/stop time No indication of level of
  nitrogen and oxygen administered No
  documentation of time when member was receiving
  only oxygen at the end of the appointment.
• No treatment plans
• No documentation of next visit needs
• No existing conditions charting on initial visit

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Complete Dental Record

• A complete record will address every aspect of
  the practice of dentistry
• Evaluation
• Diagnosis
• Prevention
• Treatment
• Or explain why it does not

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Content of the Dental Record

• The following are examples of what is typically
  included in the dental record
• Identification data Name, birth date, address,
  contact information
• Medical and dental histories, notes and updates
• Progress and treatment notes
• Conversations about the nature of any proposed
  treatment, the potential benefits and risks
  associated with that treatment, any alternatives
  to the treatment proposed, and the potential
  risks and benefits of alternative treatment,
  including no treatment
• Diagnostic records, including charts and study
  models
• Medication prescriptions, including types, dose,
  amount, directions for use and number of refills
• Radiographs
• Treatment plan notes
• Patient complaints and resolutions
• Laboratory work order forms
• Mold and shade of teeth used in bridgework and
  dentures and shade of synthetics and plastics
• Referral letters and consultations with referring
  or referral dentists and/or physicians
• Patient noncompliance and missed appointment
  notes
• Follow-up and periodic visit records
• Postoperative or home instructions (or reference
  to pamphlets given)
• Consent forms
• Waivers and authorizations
• Conversations with patients dated and initialed
  (both in-office and on telephone, even calls
  received outside of the office)

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Content of the Dental Record (cont.)

• No financial information should be kept in the
  dental record.
• Ledger cards, insurance benefit breakdowns,
  insurance claims, and payment vouchers are not
  part of the patients clinical record and should
  be kept separate from the dental record.
• Note The Virginia Board of Dentistry identifies
  patient financial records as a required item for
  compliance with Virginia recordkeeping standards.
• The outside cover of the chart should only
  display the patients name and/or account number.

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Virginia Minimum Recordkeeping Standards

• The Virginia Department of Health Professions
  identifies the minimum recordkeeping standards
  as
• Patients name and date of treatment
• Updated health history
• Diagnosis and treatment rendered
• List of drugs prescribed, administered, dispensed
  and the quantity
• Radiographs
• x-rays should be of diagnostic quality and you
  are required to keep them
• Patient financial records
• Name of dentist and dental hygienist providing
  service
• Laboratory work orders
• Name and address of the lab
• Patients name or initials or ID
• Date the order was written
• Description of work, including diagrams if needed
  
• The type and quality of the materials to be used
• Signature and address of the dentist

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Health/Dental History

• Health history can address
• Health conditions or illnesses that may affect or
  be affected by dental treatment
• Medications that a patient is currently taking
  that will have a potential drug interaction with
  the local anesthetic or other drugs the dentist
  may prescribe that may affect dental treatment or
  a patients other heath condition(s)
• Reason a patient is seeking care
• All dentists should take health histories
  initially and update the same periodically as
  necessary.
• The Virginia Board of Dentistry requires
• The health history of a patient, who is receiving
  dental care at least once a year, should be
  updated at least annually or more often if
  medically indicated. If a patient seeks dental
  care less often than annually, the health history
  should be updated at the time of each visit. The
  taking of an updated health history shall be
  documented in the patient record.
• A patient should be questioned at each visit to
  determine if the health status or medication has
  changed.
• The record should have a dated notation that the
  patient was asked about recent health and
  medication changes and any changes should be
  updated in the patients record.
• With the increasing diversity in patient
  populations, dentists may find it necessary to
  provide a health history form in multiple
  languages.

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Who Makes Entries in the Record?

• Some entries may be delegated to office staff if
  allowed by state law.
• The Dentist is ultimately responsible for the
  patients chart.

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How to Write in the Records

• It is best to document while the patient is still
  in the office, or as soon as possible after the
  patient leaves.
• All entries should be dated, initialed and
  handwritten in ink and/or computer printed.
• Handwritten entries should be legible.
• The information in the dental record should
  primarily be clinical in nature.
• All entries should be objective in nature.
  Confine comments to necessary information about
  the patients treatment.
• Be sure that any attachments are included in the
  patients record, especially radiographs.
• Do document a patients informed consent for
  treatment.
• Should a patient refuse to accept the recommended
  treatment plan, notate the patients reasons for
  refusing care in the record.

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Use of Abbreviations and Acronyms

• If you must use abbreviations or acronyms, make
  sure they are in common use (or can be easily
  explained).
• Avoid the overuse of abbreviations and acronyms
  in record keeping.
• Avoid the use of arcane symbols in record
  keeping.
• Have a universal key readily available to all
  staff, or included in the chart, providing
  definitions for all abbreviations and acronyms.
• Acronyms, abbreviations and symbols selected for
  your office should have a single meaning in your
  office.
• Abbreviations and acronyms should not be used on
  patient informed consent forms.
• Dentists are also advised to refrain from using
  abbreviations when writing prescriptions for
  patients.

6MR
abc
BBTD
CA
DB


MFL
NKDA
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Corrections or Alterations

• You must be able to read the wrong entry
• Never obliterate an entry.
• Do not use markers or white-out.
• A single line should be drawn through the
  incorrect information and the new corrected
  information added.
• Date and initial each change or addition.
• Do not insert words or phrases in an entry. If
  you remember something you wish to record at a
  later date, just make the entry chronologically
  and refer to the date of the visit in question.
• Do not leave blank lines between entries with the
  intent of adding something at a later date. It
  could be construed as an alteration.

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Retention and Storage

• State law and participating provider contracts
  generally specify the time following the last
  patient visit that records must be maintained
• Virginia Board of Dentistry requires
• For purposes of review by the board, records must
  be kept for not less than 3 years following the
  most recent date of service
• SFC Provider Agreement requires
• Any and all Member records will be maintained the
  greater of a period not less than five (5) years
  or the minimum required by the State, from the
  termination of this Agreement, and retained
  further if such records are under review or audit
  until such review or audit is complete.
• HIPAA also affects recordkeeping requirements for
  offices that are covered by generally requiring
  that offices maintain patient records for
• Six (6) years and
• Two (2) years after a patients death
• As HIPAA contains the longest mandated time
  period, it is recommended that providers maintain
  records in accordance with HIPAA requirements.

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ADULT BENEFITS
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Benefits For Enrollees Age 21 and Older

• Coverage for adults, age 21 or older, is limited
  to medically necessary oral surgery and
  associated diagnostic services.
• Diagnostic services include the oral examination
  and selected radiographs needed to assess the
  oral health, diagnose oral pathology, and develop
  an adequate treatment plan.
• Extractions for adults must be medically
  necessary and be complicating the patients
  general health as documented by the dentist or
  medical provider
• Severe periodontal infection which causes acute
  pain, loss of appetite or weight due to pain or
  infection
• Exacerbates a medical condition/medical
  management such as diabetes, heart valve condition

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Help Wanted We Need You!

• Adults covered under the SFC program generally
  have difficulty locating a participating provider
  willing to treat them.
• Providers willing to treat adults can assist by
  ensuring the office profile on record with Doral
  is up-to-date and accurate.
• Doral is also soliciting providers that may not
  desire to treat adults on a regular basis, but
  are willing to accept emergent and urgent cases
• Coordination of these cases will be handled by VA
  Doral Staff
• No changes to the providers office profile or
  directory will occur
• Please see Kristen Gilliam immediately following
  the training to confirm your acceptance of these
  referrals.

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CLAIMS
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Helpful Claims Tips

• Submit claims electronically.
• Submit legible and correctly completed ADA claim
  forms.
• Alert Doral of any changes (i.e TIN, NPI,
  location, etc.)
• Staple multiple claim forms and supporting
  information together.
• All initial claims for payment must be received
  by Doral within 180 Days from the date of service
  or the provider will face timely filing denials.
• Providers should follow-up with Doral regarding
  any claims outstanding greater than 45 days
• Any dispute regarding payment will be deemed
  waived unless the Provider submits written
  notification of the reasons for the dispute
  within thirty (30) days of receipt of the
  payment, statement of denial or adjustment.
• Claim status can be checked by
• Reviewing your printed remittance statements, or
• Visiting Dorals website
• www.doralusa.com
• Or
• by calling Doral at 1-888-912-3456

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NEWS AND UPDATES
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Conversion from WPS to PWP

• Effective December 31, 2008, Web Provider
  Services (WPS) will no longer be available.
• After December 31, 2008, Providers will need to
  utilize our updated Provider Web Portal (PWP)
  site at
• www.doralusa.com/ProviderServices
• There is no need to register if you are a current
  user
• Use your current User Name and Password

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Web-based Broken Appointment Tracking

• Enhancements to the PWP are currently underway to
  allow automated, user-friendly functionality for
  reporting Broken Appointments
• System populated member information
• Drop down menus
• View of member broken appointment history
• Providers will receive more information regarding
  this new enhancement prior to implementation.

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Contact Information

• Doral Smiles For Children Staff
• Cheryl Harris, MSHA
• Project Director
• Toll-Free 866-853-0657
• Direct Line [phone]
• Fax [phone]
• Email cpharris_at_doralusa.com
• Bridget Hengle
• Provider Relations Representative
• Toll-Free 866-853-0657
• Direct Line [phone]
• Fax [phone]
• Email bhengle_at_doralusa.com
• Kristen Gilliam
• Outreach Coordinator
• Toll-Free 866-853-0657
• Direct Line [phone]

• DMAS Smiles For Children Staff
• Sandra Brown, MSW
• Dental Program Manager
• Direct Line [phone]
• Fax [phone]
• Email sandra.brown_at_dmas.virginia.gov
• Lisa Bilik
• Dental Contract Monitor
• Direct Line [phone]
• Fax [phone]
• Email lisa.bilik_at_dmas.virginia.gov
• Dr. Marjorie Chema
• Dental Consultant

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Thank You!