Part 2: Autonotes and Appeals

My last blog discussed the denial of dental insurance coverage based on the company's standard for indicating periodontal disease. Did you read it? Unfortunately, many dental insurance companies are sighting radiographic bone loss (RBL) instead of calculated attachment loss (CAL) as the hallmark of periodontal disease.  

We already covered that indicating RBL as the hallmark of periodontal diseases is not supported in the literature. We were all taught better, so how do we assist our patients in getting the care they need to be covered?   

As I continue to urge dentists and hygienists to deliver local anesthesia, I feel compelled to address pushback from insurance companies from periodontal treatments that often require some form of sedation. My office has a current FMX and full mouth probe depths submitted to insurance for all patients needing scaling and root planing. Recently my dental practice updated our autonote to be more thorough and to set us up for better reimbursement should a denial occur. I strongly encourage you to do the same.    

An Autonote Example

Here is an example of my office autonote. We use Eaglesoft, but Dentrix and Open Dental allow template notes to be attached to a dental code.

S: UR & LR quad SCRP  OR  UL & LL quad SCRP 

CC: 

O: Reviewed medical history: no significant changes 

Blood pressure is 

Smoker - None, less than 10 per day, more than 10 per day, other tobacco usage: 

Diabetic - Normoglycemic, Controlled diabetic HbA1C <7, Poorly controlled diabetic HbA1C >7, unknown blood sugar levels 

Pregnancy Status - N/A, Not pregnant, Recent Pregnancy, Currently or trying to get pregnant 

Cardiac Health - no dx, hx of heart disease, stroke, MI, high blood pressure 

CAL at site of greatest loss: (per quad being treated) 

A:  Patient has active stage II Grade B periodontal disease with bone loss limited to the coronal third of the tooth  

Patient has active stage III Grade B periodontal disease with bone loss past middle third of root &/or more than one tooth lost to periodontal disease 

P: Patient understands treatment risks and gave consent to continue.  

Dried tissues and 20% benzocaine topical placed for two minutes. Hygienist administered LA (34 mg of 2% lidocaine 1:100K epi IANB w/ LB and 68mg 4% articaine 1:100K epi: PSA, MSA, ASA.) 

Cavitron, hand scaled and root planed. Verbal POI given. 

Patient was in dental chair for treatment for 45 min/ 60 min/ 90 min 

Reason for return: 

Recommended next visit:  

Important aspects of the chart note:

When taking chart notes, I recommend indicating the following:

1. Chart what treatment the patient is scheduled to receive. 
2. Medical history should be reviewed at every appointment. Update when changes occur. 
3. Please, please, please take the patient's blood pressure. As previously discussed, high blood pressure is rampant in the United States. 
4. History of smoking, diabetes, pregnancy, and cardiac health has been recently added to the chart notes in my office. There is excellent literature linking periodontal disease with low birth weight, cardiac disease and diabetes. Patients who smoke more than 10 cigarettes daily and/or have HbA1c greater than 7 will be GRADE C. I cite any of these medical conditions in appeal letters to insurance companies.  

 Statements such as:

• "Given the link between low birth weight and untreated periodontal disease, immediate treatment is recommended. 
• "Given the link between heart disease and untreated periodontal disease, immediate treatment is recommended."
• "Untreated gum disease has been shown to negatively affect blood sugar levels in diabetics. Immediate treatment is recommended."

 All get the insurance carriers' attention.   

New Autonote Updates

1. CAL

Calculated attachment loss (CAL) listed by tooth is new to my autonote.  

In years past, a printout of the most recent full mouth probe depths was adequate to submit to insurance for reimbursement. Five mm pocket tells me at least 1 mm of CAL, assuming the absence of gingival hyperplasia.   

Most of my patients receiving treatment for their periodontal disease are Stage II Grade B. However, patients come in wide varieties. You never know when a new patient will be Stage I or Stage IV. Procedure notes have not changed much in my office over the last decade. A quick mention of informed consent, amount of anesthesia administered, and documentation of the procedure performed are quickly noted. 

2. Time In The Chair

Another new addition to my auto note is charting time in the chair. I have had requests from insurance companies for a copy of my daily schedule. This annoys me. In lieu of a HIPPA-compliant copy of our schedule, I now print a copy of the patient's notes on the day of scaling and root planing.   

Bottom Line

Do not feel overwhelmed. I find it easier to delete the information that may not be relevant to the patient in the chair rather than trying to remember to put pertinent information into the note.   Including medical history seems to be the most helpful in getting insurances to cover periodontal disease treatment. This is an important note, especially as hygienists are certified to deliver local anesthesia after completing my local anesthesia certification for dental hygienist.

Please come back soon. My final blog of this three-part series will complete this topic and include a template for periodontal appeal letters that I have used successfully.