Rayan FaroukMaintaining accurate health records and ensuring smooth billing processes are critical for every dental practice, especially under the Dubai government. As a dentist, understanding the nuances of clinical oral evaluations and the corresponding billing requirements can greatly streamline your administrative tasks.
With the excessive rush of patients and interactions, documentation is not just a formality, it’s a necessity. From the initial interaction, initial evaluation, and treatment progress notes to follow-up treatments, these need to be carefully recorded. Clinical oral evaluations, in particular, require comprehensive documentation to justify claims and ensure compliance with the Dubai Health Authority (DHA) standards. Proper records provide a clear account of the patient’s condition, treatment plan and follow-up needs, serving as a basis for correct billing.
Each treatment group has a certain way of billing and documenting. In this blog, we will focus on the proper billing and documentation of clinical oral evaluation codes.
What to document?
- Patient Health History
A complete and up-to-date health history is the foundation of any evaluation. The medical conditions, medications and any previous dental treatments should be written.
- Chief Complaint
Always document the patient’s primary reason for visiting. Ranging from a routine checkup to pain or cosmetic concerns, the C/O supports the necessity of the evaluation.
- Diagnosis
Note the diagnosis that aligns with the findings of the evaluation and provide a clear rationale for any future treatments.
- Treatment Plan
Your plan should be specific, actionable and documented with a clear timeline. Whether the patient requires immediate treatment, follow-ups or monitoring, the plan should reflect the clinical judgment.
- Treatment Performed
If any treatments are conducted during the evaluation, like dental cleanings or basic restorative work, these must be accurately recorded with the date and type of treatment provided.
Clinical Oral Evaluations Treatment Codes:
- D0120 – D0160
- D0170: re-evaluation – limited, problem-focused (established patient; not post-operative visit)
- D0180: comprehensive periodontal evaluation – new or established patient
What are the billing requirements?
After the documentation, the next step is ensuring that the billing process aligns with DHA guidelines. Here’s how to properly bill:
- For D0120 – D1060 codes, it’s important to note that dental consultations or evaluations by the same dentist within a 3-month period are considered follow-up visits. Follow-up visits cannot be billed to Dubai government health insurance programs. This rule applies unless the patient develops new symptoms that require a separate, problem-focused evaluation.
- It’s important to note that dental consultations or evaluations by the same dentist within a 3-month period are considered follow-up visits. Follow-up visits cannot be billed to Dubai government health insurance programs. This rule applies unless the patient develops new symptoms that require a separate, problem-focused evaluation.
- You cannot bill for both separately if a dental procedure is conducted on the same day as the evaluation. In such cases, the evaluation fee is considered part of the treatment cost. For example, if a filling or extraction is performed during the initial consultation, only the treatment can be billed—not the consultation.
Inaccurate CDT code selection can lead to claim denials. Always double-check the CDT code to match the nature of the evaluation. Followup visits should not be billed as new consultations. Always keep the 3-month rule in mind, no billing for follow-up visits unless there is a new problem requiring separate evaluation. Ensure that all documentation requirements are met before submitting a claim. This includes attaching any necessary radiographs or periodontal charts for comprehensive evaluations.
The submission requirements for treatment code D0170 are PA x-rays and for treatment code D0180 is a periodontal chart, bitewing x-ray or OPG.
Best ways to record-keep for smoother billing:
Efficient record-keeping not only helps with accurate billing but also improves patient care. Consider the following strategies:
- Digital health records: Transitioning to a digital system like Balsam Medico can streamline documentation and reduce errors. Digital records allow for easy tracking of patient visits, treatments, and billing submissions.
- Regular Audits: Organize regular audits of your patient records and billing processes to ensure that everything is accurate and up-to-date.
- Training for Staff: Ensure that your staff are well-versed in dental billing codes and DHA guidelines. Regular training can help minimize billing errors and ensure timely payments.
- Stay Updated on DHA Policies: Billing rules may change over time. Stay informed of any updates from the DHA to ensure compliance with the latest standards.
We at Balsam Medico will make sure you are informed about the most recent rules and policies. Stay tuned for our blogs to find out more.
Do you want to learn how to manage your billing through Balsam Medico? Check our previous blogs or contact us today. Our team is here to help you get started with everything you need.
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