You Must Believe Me

Paul Feuerstein, DMD
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When an office uses digital chart notes, there are usually templates that are far more thorough than the paper charts, which had entries like ‘#5 MO composite.’

With all the discussions on advanced dental treatment with new technology, there is an underlying issue that affects many of us. Some of us take insurance assignments, while others are fee-for-service and let the patients fend for themselves. I am in the former. Recently, it seems that the insurance companies are tightening things up with more requirements and restrictions. Technology can be quite helpful in dealing with them. I have often wondered about the math, though. When I started practice in the 1970s, most dental policies had a $1,000 or $1,500 maximum. The premiums were often paid by employers, or the patient had a minor contribution. In those years, a patient could get a lot of treatment and at least 2 to 3 crowns if the insurance paid 50% of these $500 to $700 fees. Premiums have gone up with inflation, so what about the maximums? Many are still $1,000, and a few get up to $2,000 (aside from some higher-end policies). In my simplistic analysis, the premiums have gone up, but the exposure of the insurance companies has not increased over these 40 years. Am I missing something? (End of soapbox.)

Preoperative image of a fractured molar. (Image courtesy of A.G. Khan, DMD, Billerica, Mass.) An image of a prep with a buildup.
(Image courtesy of Dr. Khan.)

One of the crackdowns reported by many dentists is that the insurance companies are often denying crown buildups. There is some blame on our end when a dentist puts a dab of Vitrebond (3M) on the prep and calls it a buildup. The insurance companies are asking for documentation. This starts in your charting, which is hopefully digital (so it is legible). When an office uses digital chart notes, there are usually templates that are far more thorough than the paper charts, which had entries like “#5 MO composite.” Everyone has his or her own version of the template, but one of the first entries must be the reason for the restoration—for example, an old, leaking amalgam with recurrent decay. The radiograph will, in most cases, verify this; thus, a preoperative radiograph is a must. When you are using a digital system, you can assure the patient that this radiograph is, in lay terms, being taken in at least one-tenth or less time of the old x-rays. In actual numbers, the film was usually exposed for about 0.2 seconds, while in digital it is closer to 0.02 seconds. The patient understands when you say “One of the old x-rays equals 10 of the new ones” or whatever numbers you feel are legitimate. The next pre-op image should be a photo using either an intraoral camera or an extraoral one with retraction and a mirror. If the camera is at your fingertips, there is plenty of time for you or your assistant to take this image at the beginning of the procedure, perhaps while the patient is getting numb. That image should be stored and dated in the practice management system and—this is very important—tagged with the tooth number. Many people take a lot of images, and most practice management systems allow you to search for an image by tooth number or pull up a tooth’s history the same way. When creating the tooth buildup in this new insurance world, there has to be verbal documentation of the process, and there should be visual documentation as well. It won’t take much time to get an intraoral camera image of the tooth after the old restoration is removed (to show what is left of the tooth) and another image after you do the actual buildup. The chart note should clearly state that there was not enough tooth structure for proper retention and that we used, for example, etch, bond, and core materials; a glass ionomer; a bioactive base; etc. Even with all of this, some companies don’t pay for buildups unless the tooth has had endo­dontic treatment, and others will not let you bill the buildup the same day as the crown (let’s hear from the one-visit-dentistry docs on this one). Still, the digital documentation is critical.

And just to belabor the story, there are also requests for post-insertion x-rays. (I feel a mistrust here, probably due to the low percentage of offices that are abusing the system.) Again, we must reassure the patients that this is a necessary verification of the fit of the restoration, although many of us already take an image before cementation to check the margins. This is all just one example of digital documentation we can and should do. One point is important here: I am not stating this information and saying the insurance companies are telling us to take these images. They are very important for a proper record and should be done anyway. Of course, it takes extra time, but if there is a camera in the treatment room, and it integrates with your imaging system, it really only takes seconds. The images are also good to have if a patient has an issue down the road: You can look over what was done, and, of course, if there are any accusations, you are well covered. Taking this whole discussion a step further, why not take before and after intraoral images for all restorative procedures? Some of the cameras, as we have noted, have caries-detection modes, which not only photograph the prep but could also surprise you. And most patients are totally impressed when you show them an “ugly, old silver filling” and then show them the beautiful, white tooth. It is a practice builder, and patients think you’re amazing; it’s far more impressive when patients see this transformation than when you show them that you’ve filled a root to the apex.

As a working GP, I am faced with this every day. The staff in my office is on top of things, and we have all of the bells and whistles for eligibility, coverage, etc, but they are the ones on the front lines listening to the patient complaints (or compliments) regarding billing a coverage. We workers “in the back” must do what we can to help that whole situation.

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