CurrentSelectHealthPolicy DO2O

Dental Record Documentation

Defines SelectHealth's documentation standards for dental records that support billed services for Commercial and SelectHealth Advantage plans, and explains consequences (denial/overpayment) if documentation is insufficient. Affects dentists and clinical staff who bill SelectHealth.

Policy Summary

PayerSelectHealth

PolicyDental Record Documentation

Policy CodePolicy DO2O

Change TypeNo material changes

Effective DateSep 1, 2023

Next Review DateN/A

Key ActionProvide complete, legible dental records that support billed CDT codes and make records available to SelectHealth upon request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90max days to amend

All CDTapplicable codes

1stand‑alone encounter req

Multiplereasons codes disallowed

Documentation-Linked Coverage Criteria

Documentation-linked coverage criteria

Policy Summary

PayerSelectHealth

PolicyDental Record Documentation

Policy CodePolicy DO2O

Change TypeNo material changes

Effective DateSep 1, 2023

Next Review DateN/A

Key ActionProvide complete, legible dental records that support billed CDT codes and make records available to SelectHealth upon request.

SourceLink

On This Page

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Documentation must verify the service was performed and the appropriate level of care delivered; reimbursement will not be made for services not clearly documented in the patient record.

All pertinent documentation must be maintained in the patient's dental record and made available to Select Health upon request.

Documentation must demonstrate dental necessity; if a service is not reasonable and necessary, Select Health will not reimburse.

Electronic records and electronic documents must be authenticated and signed appropriately in the manner defined by the system used; time should be documented when time is a factor in reporting care rendered.

Each billable encounter (procedure or service) should be documented as a stand-alone record organized in a consistent manner, with each page containing the patient's legal name, the licensed health care provider's name, and the date of service.

Telephone or verbal clinical conversations should be documented with date and time, and telephone orders must be authenticated by the ordering provider.

Addendums or amendments are acceptable when made by the original clinician within 90 days, signed and dated with the correction date; deliberate falsification is prohibited and may be subject to recovery or other actions.

Use of electronic documentation must be patient- and date-specific and must reflect that the dentist or clinical staff personally performed the work described during that encounter.

CDT code disallowance may occur if any of the following are present

Indiscriminate use of copy/paste resulting in inaccurate coding.
Contradictions within the progress note.
Unnecessarily lengthy or redundant progress notes (chart bloat).
Propagation of false information that may lead to dental errors.
Inability to identify the provider's thought process or to follow the care of the patient.

Incomplete or illegible records can result in denial of payment or classification of previously paid claims as overpayments subject to recovery.

Applicable Procedure Codes and Documentation Quality

Applicable procedure codesmixed

ADA CDT codes

All ADA CDT compliant procedure codes are applicable to this policy.

Documentation quality thresholds

Patient- and date-specific documentationDocumentation must be patient-specific and date-of-service specific to support the services billed.

Clear identification of services performedThe CDT code reported should reflect the documentation in the dental record; 'not otherwise classified' services require a detailed description of the procedure performed.

Support dental necessitySubmitted documentation must display dental necessity and demonstrate that the dentist or clinical staff personally performed the work described.

Avoid indiscriminate copy/paste and chart bloatIndiscriminate copy/paste, contradictions, unnecessarily lengthy or redundant notes (chart bloat), or propagation of false information may lead to code disallowance.

Maintain legible, authenticated entriesAll entries must be complete, legibly written, and signed/initialed; electronic documents must be authenticated and signed appropriately.

Provider Submission Requirements and Billing Risks

Documentation Required

Documentation submission and availability

Documentation must be complete, legible, and maintained in the member's dental record to support billed CDT codes. All pertinent documentation (including patient history, telephone calls, prescription refill calls, signed notes, start/end or total times when time is a factor, and descriptions for 'not otherwise classified' procedures) must be available to SelectHealth upon request. Incomplete or illegible records can result in denial of payment or classification of previously paid claims as overpayments subject to recoupment.

All pertinent documentation must be maintained and made available upon request
Each billable encounter should be a stand-alone, consistently organized document
Each page should contain patient legal name, provider name, and date of service
Telephone/verbal conversations, orders, and authorizations must be documented, dated, timed, and authenticated
Electronic documents must be authenticated and signed per system standards
If reporting a 'not otherwise classified' CDT code, include a detailed description and highlight it in submitted records

Denial Risk

Denial and overpayment risk

If documentation is insufficient or illegible, SelectHealth may deny payment for the billed service. Additionally, claims previously adjudicated may be reclassified as overpayments and partially or fully recouped if documentation does not support the paid services.

Insufficient or illegible records can lead to denial of payment
Previously paid claims lacking adequate documentation may be recovered as overpayments

Billing Rule

Coding requirement

Use ADA CDT-compliant codes on all claims and ensure the CDT code reported on billing forms accurately reflects the clinical documentation. When a 'not otherwise classified' procedure code is used, provide a clear, detailed description of the procedure in the submitted records.

All ADA CDT-compliant codes are applicable
CDT codes must match the documentation in the dental record
Provide detailed descriptions for 'not otherwise classified' codes

Key Definitions

Dental record

DefinitionA confidential document that describes the dental care given and documents subjective and objective observations, diagnostic tests, procedures, treatments, follow-up, diagnosis, and outcomes.

PurposeRecords serve as formal documentation and communication between providers, patients, and insurers.

ContentsShould record history, examinations, diagnostic tests and procedures, treatment plans, outcomes, and responses to care.

Stand-alone billable encounter

Stand-alone encounter requirementEach billable encounter (procedure or service) should be a stand-alone document organized in a consistent manner.

Required identifiersEach page of the patient's dental record should contain the patient's legal name, the licensed health care provider's name, and the date of service.

Documentation of communicationsTelephone or verbal conversations concerning clinical care should be documented with date and time and filed in the dental record.

Copy/paste and template use

Permitted use with review and authenticationCopy/paste and templates are permitted if they produce concise, dentally relevant notes; copied content must be reviewed, updated, and authenticated by the dentist or clinical staff.

No identical notes across visitsHPI, exam, and dental decision-making portions cannot be identical notes from previous visits and must pertain to the presenting problem with enough changes to show the service was performed on that date.

Focus on changes when appropriateWhen relevant information already exists in the record, staff may review and verify rather than reentering unchanged information; documentation should emphasize what has changed since the last visit.

Risk of misuseIndiscriminate copy/paste that results in inaccuracies, contradictions, chart bloat, or propagation of false information can lead to CDT code disallowance.