Improving Patient Documentation through Nonclinical CDT Codes

Dental Professionals are revolutionizing Dental Record-Keeping with Innovative CDT Code Application

Jan 18, 2024 – In a groundbreaking approach to dental record-keeping, dental professionals are now leveraging nonclinical Current Dental Terminology (CDT) codes to enhance the comprehensiveness and legal robustness of patient records. This innovative strategy, detailed in an article by Dr. Charles Blair and Dr. James DiMarino in Dental Economics, underscores the critical role of meticulous record-keeping in ensuring patient care continuity and providing legal protection for both patients and dental practitioners.

In-Depth Insights:

Oral Cancer Screening Documentation: The article emphasizes the importance of documenting oral cancer screenings, which are included in CDT codes D0120, D0150, and D0180. Despite the lack of a separate CDT code for oral cancer screening, its inclusion in these evaluation codes necessitates thorough documentation.

This is especially pertinent given the increasing incidence of oral cancer. The article advises that findings from these screenings be meticulously recorded in the patient’s chart at the time of evaluation to ensure that there is evidence of screening, particularly if a cancerous lesion is discovered during treatment.

Recording Non-Billable Services: The authors highlight the significance of documenting procedures that do not have an associated fee. For instance, duplicating patient records (CDT code D9961) is a critical task when a patient requests a transfer of records to another dentist or specialist.

Similarly, documenting missed (D9986) and canceled appointments (D9987) is crucial, as these instances can impact the success of treatment and indicate patient noncompliance.

Addressing Compliance Barriers: CDT code D9991 is used for documenting dental case management, specifically addressing barriers to appointment compliance. This could involve assisting patients with transportation, managing fluctuating work schedules, or overcoming childcare challenges.

Documenting these efforts is vital in demonstrating that the patient was informed of the importance of maintaining scheduled treatments.

Care Coordination and Motivational Interviewing: The article also discusses the use of CDT codes D9992 and D9993 for care coordination across multiple providers and motivational interviewing, respectively. D9992 is employed when coordinating oral health care among various specialties, requiring additional time and resources.

D9993 is used for reporting patient-centered counseling methods, like motivational interviewing, to identify and modify behaviors that hinder positive health outcomes.

The Importance of Accurate Records:
The article stresses that in today’s litigious environment, having accurate and well-documented dental records is non-negotiable. Utilizing these nonclinical CDT codes not only aids in creating a detailed dental history but also plays a crucial role in legal protection and patient care.

For more comprehensive information, the full article is available on Dental Economics’ website: How to create better patient records with nonclinical CDT codes.

 

 


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