As Artificial Intelligence becomes more and more commonplace in the world of dental insurance claims, you need to know what you need to do. That’s now combined with increased scrutiny from government agencies, too, and UPIC contractors are now targeting dental practices to identify fraud, waste, and abuse in Medicaid claims. Payers are looking for precise clinical notes, so if you’re having a tough time trying to figure out what you need to document periodontal examination, talk to a trusted team about your office’s direction.
Here at Dental Auditing Solutions, we help offices be better prepared for potential audits through quality compliance services. It’s important to know best practices for documenting periodontal examinations, as these can demonstrate medical necessity when done well. If your team is sloppy with your charting or clinical notes, you could face financial penalties like recoupment or even trigger a payer’s Predictive Risk Scoring algorithm. We’re here to make sure you’ve got what you need to prevent that.
Your paperwork is a big part of your day. Talk to Angela Miller-Leathers at Dental Auditing Solutions about ways to stay compliant, even in an AI-dominated world.
Payer Documentation Needs Are Becoming More Complex
When you send in your claims, there’s probably a computer looking over it all first. Both private and government payers are starting to use AI technology to become more efficient, and that can mean changes for your office. If your team has been a little lax when documenting care, it’s time to find a more compliant way forward.
Periodontal examinations are a great example of this. No longer are payers looking for static record-keeping, they are searching for dynamic clinical justification. Your team has more to document now than they did just a few years ago.
Your Periodontal Examination Checklist
When your team performs a periodontal examination, keep these steps in mind:
- 6-Point Probing: Spot checking is no longer enough. AI tools want to know about the entire mouth, so it’s important to check each side of each tooth.
- Recession and Clinical Attachment Loss: Probing depth can only prove so much. CAL documentation helps to show the true extent of periodontal disease.
- Bleeding on Probing: Bleeding on probing is a primary indicator of periodontal disease activity, so make sure it’s in your clinical notes.
- Furcation and Mobility: Use a Naber’s probe to grade furcation and tooth mobility. These stability markers can justify more advanced periodontal treatment.
- Bone Loss Radiography: Note what you see. Radiography images provide clear documentation.
- Comorbidities: Does your patient have diabetes? Cancer? It’s important to note them.
Learn More With Dental Auditing Solutions
Having a tough time trying to understand what payers want? We can help your office to understand what you need to do. To find out more about periodontal examination documentation, call Dental Auditing Solutions at (972) 459-1508 today.