News — Recordkeeping

How often do you and your staff obtain a new written informed consent for treatment? State laws vary some, but let me throw this out there.... I frequently see dentists disciplined for not having signed consent when they should have had it. Conversely, I have never seen a dentist disciplined for having consent forms signed for every clinical procedure (or too many consents). When in doubt as to whether or not you need consent, err on the side of caution and get it!Some principles to remember about consent: Always get consent in writing Consent forms should give patients enough information to...

Many states require that Dentists (and even staff members) maintain current BLS, ACLS and/or PALS. Additionally, there are requirements that Dentists have and maintain suitable emergency oxygen and have emergency drugs "as a reasonable Dentist with your training and experience."As a State Board Investigator, I investigated patient deaths and hospitalizations. I saw the real life consequences for Dentists who were not prepared for Medical Emergencies in their practice. Not only do you have the legal and administrative hassles, the worst consequence is that you have to live with yourself. Medical Emergencies are real and being prepared is vital. It starts...

I work with Private Equity firms as a partner in their due diligence processes. For my parts, office review and records audits, it is about identifying proficiencies and deficiencies (or what I call ‘opportunities’).

 Is the office compliant with OSHA, infection control, DEA regulations, radiation regulations, sedation safety/medical emergency preparedness, HIPAA, advertising/marketing, dental board rules/Dental Practice Act? What safety mechanisms are in place to ensure patient and employee safety? Does the practice code/bill properly? Using correct codes? Have adequate supporting clinical notes to support what is billed? Any overbilling or fraud issues? If so, are they isolated or systemic?

Daily perspective (pre-bill) audits help identify and minimizes billing errors by ensuring the accuracy of claims before they are submitted. This step alone can help compliance programs pay for themselves. Periodic retrospective audits involve the detailed review of clinical and billing records for compliance with state and federal recordkeeping and billing requirements. Some items to check include verifying the quality and quantity of radiographs, consent for treatment, proper coding, clinical notes to support each claim that was billed, and medical necessity.

My mantra is: “If It Is Not Written, It Did Not Happen!” Record audits must be documented. In the face of a fraud allegation this documentation can help your defense attorney make their case.

After many years of Compliance Consulting in Dentistry, I have come up with a set of Recordkeeping Guidelines, which I affectionately call: "Tooth Cop's Rules of Record Keeping" 1. If it is not written down, it did not happen and it was not discussed 2. When in doubt, write it out 3. You can never write too much 4. Be objective with documentation 5. Be timely with documentation 6. Be clear, concise and accurate   Click here to get a Downloadable Tooth Cop's Rules of Record Keeping Poster!Make today your greatest ever! And if you want some face time with yours truly... Click HERE and we can schedule...