Teresa Duncan – “Documentation Drives Revenue”

Teresa Duncan,
Teresa Duncan,

Teresa is passionate about teaching others and sharing her knowledge in the dental industry. She is the author of Moving Your Patients to Yes: Easy Insurance Conversations and a regular contributing author to the ADA’s CDT Companion Guide™.

Teresa has a motto she reinforces in all her courses “Documentation Drives Revenue”. In our conversation today she gives unique insight into how your clinical team can create better clinical notes to get claims paid faster, satisfy new coding rules and give your insurance coordinator the information she needs for claim attachments.

During our conversation Teresa offered up two of her famous tip sheets for your office. You can download them by CLICKING HERE Enjoy! If you are interested in Teresa’s insurance course you can find it HERE

Below is the full transcript from our podcast. It was transcribed by Otter AI so it is not perfect but you get the idea 🙂

Dayna Johnson  0:08 

We are super excited you have found Novonee on the Go, the premier Dentrix community’s free podcast. I’m Dayna Johnson, the founder of Novonee and my goal is to give you about 15 minutes of juicy content to take back to your practice and help your team have a more productive and less stressful day. Enjoy!

Dayna Johnson  0:28 

Hey, welcome everyone. I’m Dayna Johnson, your Dentrix expert. And my goal is to help dentists and dental teams understand their Dentrix software better, so you can create systems to improve the profitability of your practice, optimize your appointment book and have a more stress-free day. I started Novonee to be able to give all Dentrix users a platform to attend live one on one events with me and tap into best practices resources for optimizing your Dentrix software. If you want to become a member of our exclusive membership, go to novonee.com click on the green Join Today button in the upper right corner and join our community today.

Dayna Johnson  1:13 

So, I am super excited! I have one of my besties in the dental industry on with us today. Many of you know her, you’ve probably been to some of her courses. But, for anyone that is new to our industry. If you have come out of the woodwork, you used to be a waitress at Denny’s and now you are in the dental industry, then you may not know Teresa Duncan with Odyssey Management. She is our industry expert all things insurance. And you can find Teresa online with her online courses. She always gives her annual event with Vyne on coding on January 10. So, if you are now the insurance coordinator at your practice, and you want some additional knowledge and skills on managing insurance, go to Odyssey Management and Teresa has some online courses just for you. So welcome, Teresa, I’m super excited to have you today.

Teresa Duncan  2:26 

Oh, it’s always so much fun to talk to you. I always enjoy our talks because we geek out we totally geek out.

Dayna Johnson  2:34 

I know for sure. We’re always looking for those tips from each other. You know, the software expert and the insurance expert come together. It’s a very, very healthy relationship. It’s really nice in an industry like this where things change so fast to be able to have people that I can text or call and say, hey, what’s going on with this? What’s going on with this? And yeah, and it’s just so it’s we need it, and it changes so fast.

Dayna Johnson  3:02 

I know, I know it I know, I think we both have each other on speed dial right. I know when I get coding questions, I reach out to you. If you have Dentrix questions, you reach out to me, and we support each other and our clients that way for sure. Absolutely. Yeah. So, what we are talking about this quarter, we are now in fourth quarter. And it’s all about the clinical team. So, one thing that I remember hearing from you is some specifics that we really should have in our clinical documentation in our clinical note. And that really revolves around the X rays, images, any kind of diagnostics that you are taking on your patients. And you have given some really good tips about how we should document that in the clinical note. Sure. And so, what I’d like for you to kind of tell our audience is why is that important, first of all and then what tips do you have for the clinical team when they’re documenting those diagnostics?

Teresa Duncan  4:17 

So, it’s really important, and I’m so glad that you said you know why? Because when I talk about these changes in classes, all it sounds like to some people is oh gosh, this is more work. But there’s a reason behind it. Like I don’t like asking audience members to do more work unless I know it’s for sure something that is going to benefit them or to avoid costing a lot of money. And that’s what this part is the costing a lot of money. So, with radiographs if you read the code, you know it’s the taking of an image and the evaluation of an image and presumably we’re sharing the results with the patient. But radiographs are a prescribed procedure. So, you can’t just have a patient that comes in and the doctor, you know, is like, okay, just grab some X rays on them, and I’ll look at him when I come in. But that’s what happens all the time. What should happen according to the ADA, according to all sorts of health metrics, according to the FDA, actually, and I’ll get into that in a second. The radiograph should be prescribed based on the patient’s condition and their risk assessment. Okay, so there should be a reason for x-rays. And where a lot of offices get in trouble is they go insurance driven, not insurance friendly, meaning that they know that maybe bitewings are covered once a year. So, they’ll put actually in their standard operating manuals, bitewings once a year or as allowed by insurance. Well, that’s not right. It’s not right, because it should be based on the patient has to be specific to the patient. So, what I’d love for your audience to do is to Google FDA, ADA and radiographic guidelines, there’s a PDF that will pop up. And it’s what the legal system uses. It’s what the courts, the state boards use, its guidelines for when and where radiographs may be indicated. So, somebody like you and me, we’ve been in dentistry for a long time, we probably take care of our teeth, I’m sure really well, we may not need bitewings as often as somebody who is a recovering meth addict, perhaps, you know, so we shouldn’t be on the same bitewings once a year schedule, if our risk is not the same, okay? So same thing for FMX is, you know, just because it’ll, it’s allowed every three years, does that mean every patient needs it every three years? I don’t know, it depends on the patient. And so that’s the call that the FDA and ADA want the doctor to make. So, with that being said, if you don’t have anything in your clinical notes about why the radiographs are indicated why they’re prescribed, then if you ever were to go through an audit, then you’re pretty much you have no defense because you can’t just put in x ray take and it has to be the why. And then also we reviewed them and here are the findings, you know, or the findings, discuss with patients is what you need. So, it’s not as cut and dry as a lot of people think like x-ray seems to be like a pretty easy category to teach and it ends up becoming pretty problematic. So, what I want your team to do is include in the templates, in the beginning, radiographs required due to ______ and then fill in the blanks, I mean, new patient evaluation is a perfectly good reason to take films. So new patient evaluation, patient complains of ________ patient has tight contacts, patient has recently undergone chemotherapy, patient is on a lot of prescription drugs, you know, whatever it is, I mean, your doctor, honestly, comprehensive evaluation is that that’s enough right there for your FMX. And then the question I then get is, well, what about when patients come back for their cleanings? You mean, I have to grab the doctor and have them come in and diagnose or prescribe before I can take them? No, at the current appointment, the doctor would make the prescription in there, you know, so radiographs required at next cleaning appointment, and blah, blah, blah for whatever reason. So, the third prescriptions there.

Dayna Johnson  8:28 

Yeah, yeah. So great points. So, what I hear you saying then is . . .

insurance frequency is not a reason to take x-rays.

Teresa Duncan  8:38 

No, no and honestly like it, let’s take a step back. Like if we’re okay with insurance dictating the frequency of x-rays, then why aren’t you okay with insurance dictating everything else? Right? So it’s not that’s the way it’s a guideline it all clauses, all limitations for insurance are cost control measures. And, if you change your way of thinking from limitations frequency as cost containment measures.

Dayna Johnson  9:07 

Exactly, yeah. So I think what I also hear you saying is we could build templates in our clinical notes to make it super easy for an office to have a have the documentation in there and then have maybe have some kind of a checklist as to why, you know, you can have, you know, five to 10 reasons why you are diagnosing these x-rays and I loved what you said about let’s prepare the patient for their next visit. You know, so the doctor is in for the exam today. We know that the that the patient needs an FMX or you know, a seven series next time they come in, and why are we taking those x-rays for the next visit? So we’ve already diagnosed it for the next visit.

Teresa Duncan  9:56 

Absolutely! And you know, things happen what if your doctor you know wants to go on vacation. And you’re in a state where the hygienist can take films and see the patient without the evaluation, which they couldn’t take the x rays if they weren’t already in the chart. So, there’s, you know, there’s that. So yeah, you’re right. There are simple things we can put into the chart that make it easy on us. So, it’s not such a burden. So first, I said, the radiographs review rating is required due to and then the second half of that is radiographs reviewed findings, discuss with patients, and I’m but honestly, you have to discuss the findings with patients. So, make sure that’s true.

Dayna Johnson  10:35 

You know, that goes without saying really. But if it isn’t documented, it didn’t happen. Right. Right.

Teresa Duncan  10:41 

Right. Well, and that leads into something else. That’s interesting. And I don’t know if this was on the agenda to talk about, but it just popped up. So, I just better to share it. The description of the periodic oral evaluation actually got changed in 2022. There was an addition to it clarification that said, “findings discussed with patients”, oh, when patient and the reason being now the insurance carriers are the ones who push that change through because what they are getting is a lot of complaints from patients that say, I went in for this, and they never talked to me about this, this and this. So they wanted that put into the code. Well, whenever anything is changed with the code, I always ask what are the what’s the opportunity for that change? What’s the repercussions? And if you don’t have anything in your notes about findings discuss, then you technically have not met the criteria of the code. So that’s an audit point in my mind. So, to me, it was a very strategic change.

Dayna Johnson  11:39 

Well, and I think that that is really important that you brought that up, because a lot of our teams don’t know the changes that happened with the codes, you know, because we, we’ve just been using the same codes for so many years. And if there’s language changes inside the code, and we don’t take your course, or we don’t do the research to find out if there are any language changes with the codes, you know, we just don’t know. And if that changes the way we should, we should be documenting our clinical notes. I mean, that makes a huge difference in in how we document.

Teresa Duncan  12:18 

I mean, it’s the common sense part of it. Like when you’re on a stand, and you’re maybe being grilled by a lawyer, it makes sense to you. And to me that if we did an evaluation, not only did we evaluate, but we also discuss, so it makes sense to us. So, it seems like it’s overkill. But you’re right, though, if it’s not in the notes, then how can we know that we actually discussed it? And what was the patient’s reaction and patient agreed to move forward and patient Express disbelief and all of that stuff. So, it’s, it is really important to document the patient’s reaction to these findings as well. I recommend always having something that the patient said some quote that the patient said, and then you know, that way, it also it just looks like you’re doing a good job with documentation. You probably are if you’re doing that.

Dayna Johnson  13:05 

I think common sense has kind of gone out the window. And a lot of things I think we have to reel back in the common sense and, and really understand, you know, that we’re not documenting these things just to be frivolous. And over an overachiever, we’re documenting these things, because it’s important. And our number one goal is to protect our doctor’s license. And, and that is our number one goal. And because of our doctors don’t have a license, we don’t have a job. And so, we have to protect our doctor’s license, and also, you know, protect the interests of our patients.

Teresa Duncan  13:47 

Absolutely. Yeah. I mean, that’s, that’s so important. And I think a lot of times, we lose fact, we lose sight of that fact that everything we’re doing is really for the patient’s benefit. So, we’re not over prescribing, we’re trying not to under prescribe, I think under prescribing is actually what we do the most, because we’re so nervous about getting the know, or we hate delivering bad news or whatever it is. I mean, I see that more than I see over prescribing now. In the pediatric side, that may not be the case, but that’s a whole different makeup because of the Medicaid money and all of that. Yeah, and there’s a lot of bad apples over there. I mean, Kevin and I talk about that on the Chew on This podcast all the time about Medicaid fraud and how it’s so terrible on the pedo side. But yeah, we’re all just trying to do the best that we can

Dayna Johnson  14:34 

Agree. Yeah, I agree. I agree with you 100%. And, and I, you know, I like what you said we we don’t want insurance companies to dictate our care. But we also we don’t want insurance companies to you know, take away what we’ve know we’ve done a good job at and if, if we’re not documenting it correctly, or or thoroughly, then and they could come in and, you know, take money away from our practice. And we have to protect our practice from that.

Teresa Duncan  15:07 

So let me bring up one other thing that this might be a little bit of a sore point because it usually involves somebody in the office who is not doing their job. So, say you have, you know, Harriette the hygienist, that takes terrible x-rays, and I’m not going to pick on just hygienist it’s probably like Annette, the assistant that does the same thing, right? So, she takes terrible x-rays, it’s overlap cone cuts, whatever. I mean, you just name it, we’ve seen an open bite all that. So, in many of the provider manuals that the carriers push out their clinical guidelines, most of the time, you will see next radiograph diagnostic quality. Okay, so and then in one, I noticed, it’s specifically called out this the first time I’ve seen it line items. So, I expect it to be more it was in a Blue Cross Blue Shield policy, and it said, radiograph must be a diagnostic quality. So, it’s pretty much it’s been scattered throughout. But this was like one big line, like, hey, stop it, you know, in, in bold, right. And so, what that means, and in talking to the people who are doing audits and helping offices with audits, what’s happening is you’re sending in maybe a really bad x-ray to get your crowns paid, okay? And you’re like just crossing your fingers because you know, it’s a bad film. But you know, they just took one and like, the ship has sailed, you can’t get another x-ray, right. So, you’re just crossing your fingers. So, you do this over and over and over again. Well, what happens is the carriers now, especially with AI, and all of the data that they have, they’re going to see that your office films are not a diagnostic quality, on a regular basis. And if they can, if they suspect that they’re not, they can, if you’re a network, go ahead and raise that flag and do an audit on you maybe just in focused audit on the PAs and the bitewings. But if they find something in all the contracts, they are able to then expand, you know, to see what the extent is for sure. And so, if you’re sending in bad films, you really are upping your risk of getting audited. And there are stories out there that officers are paying back, you know, small amounts from what I’m hearing, like $10,000 – $20,000, for PAs that are not of diagnostic quality 10 – $20,000 a small change only because I’ve seen some like six figures fine. Yeah. Other cases, I have to for sure. Yeah, it’s terrible. So, but what you don’t want is for them to come in and look around, you know, that’s, that’s really what you want to avoid. So why don’t you talk to the team about, you know, hey, this x ray, you may be able to make a diagnosis off of it, but it’s not actually of diagnostic quality. And so, this is the argument. So, I was talking to a couple insurance consultants about this because I’m talking about the ones who review the claims. So, I stay in constant contact with those people. And what they were saying to me is, listen, the code says, you take the x-ray, you review the findings, the code has its diagnostic quality. So, if you did a filling, and the filling had one open margin, you did not really deliver a good filling, and you shouldn’t bill for it, right? So, the x-ray is a contract for the product, the product is the x-ray. And if you’re not delivering a good product, it’s like a faulty product, then you really should not be paid for that. And I kind of see that from a patient’s point of view. Yeah. You know, if I go to another office, and they’re like, oh, these x-rays suck , I’m like, wait a second, you know, like, my insurance paid for those. Right? That’s where I think we have to think as a consumer, it’s not fair to deliver a product that isn’t the best that we can deliver. And that’s where that school of thought comes from.

Dayna Johnson  18:50 

Agreed. Yeah, I agree. So, so one more question for you, and then we’ll kind of wrap it up. I have also heard in the industry, and I’ve probably heard this from you as well. Because you are the voice of everything new with insurance, that insurance companies are no longer wanting our teams to write in narratives in the remarks for unusual services on the claim, they’re actually requesting a copy of the entire clinical note. Yeah, so tell me a little bit more about that. And what tips are you giving offices just to build a better narrative inside the clinical note?

Teresa Duncan  19:34 

Well, I think we need to just dump the term narrative only because it it’s got so many connections to somebody like you and me, writing the narrative, the doctor review it and let’s be honest, in many cases, the doctor never even saw the narrative it just got sent in right. And that is that is why the carriers are like, you know, this is ridiculous.

Dayna Johnson  20:14 

I remember the that remarks for unusual services box. I mean, it cuts off at like 80 characters anyway. So yeah, you might write this beautiful description, but then it cuts off half way.

Teresa Duncan  20:26 

Exactly, exactly. So electronic attachments are the way to go with this. So, if, if you have somebody who has it was struggling with clinical documentation that you need to give me with the bond to using templates, really good explanatory templates, because all your job is now see, I’m really excited for insurance coordinators, because now all I have to do is screenshot the clinical notes. Now exactly, I’m also double checking the clinical notes to make sure things are in there like age of existing crown, and, you know, reason for replacement. I mean, that all has to be there. So as an insurance coordinator, it’s a lot easier for me to scan clinical notes than to recreate them. So, I’m super excited about this actually. So, it started just to give your readers or your listeners a heads up on this, it started back I think, in 2018 is when Delta Dental of Northeast published it in their provider portal in their manual. And I remember going oh, this is interesting. And then so I have four offices that I work with on a just a like almost like a beta testing. Like I’ll say to them, hey, try this, try this. Try this. So, we started doing that. And in my own office, which I still bill for we have not sent in a narrative. It’s got to be three years for sure. Definitely three years, maybe even four, but three years for sure. It’s all been screenshots of clinical notes. And it has been a just a time saver. We don’t have to worry about that anymore. Yeah. And if the notes aren’t complete, like, I would sit down to write a narrative and the notes aren’t complete. Well, now I don’t have to wait for that. Because I’m like, Oh, hey, clinical team.

Dayna Johnson  21:57 

Yeah, so easy. I mean, all you have to do on the attachment is say, attach a copy of the clinical note, and then it attaches it you don’t even it’s so easy. You know, you don’t, and they don’t want to recreate anything.

Teresa Duncan  22:11 

And they want that. And overwhelmingly when I talked to the consultants, they want that because sometimes the handwriting on paper charts is terrible. So, it really does push them to use electronics. They know that it’s not the doctor writing it. So, they by looking at the clinical record, they’re getting the actual like, Doctor terms, you know, like so you’re not just saying it my favorite of all time is my very first client and she would write for Crown buildup. Note or tooth missing need more tooth to put crown on. That was her narrative for building for a buildup. And it’s like, Oh, she’s so sweet.

Teresa Duncan  22:53 

She meant well, she was like, what it makes sense. I was like, I know it makes sense. But that’s not right. So yeah. So, if we can get our doctors to give us that good documentation working alongside the clinical team, because really, the clinical team is what drives this piece. And if we don’t get if we don’t nail this, and it definitely affects your revenue. And so, you know,

I’ve got this motto, documentation drives revenue that I’ve been say that in all my classes, documentation drives revenue.

And if I don’t have good documentation, I can beg pretty please send cakes, cookies, whatever, I’m not going to get your claims paid it just it’s impossible. So, they got to help me be better with that.

Dayna Johnson  23:34 

Yeah, yeah, it’s a team effort, for sure. Now, I think I remember when we were when we were chatting before we got started this morning that you had, like a tip sheet or something that that we could put up in the show notes or something that people could reach out to you and get?

Teresa Duncan  23:54 

Yeah, absolutely. So, I have I’ll do two, I have two handouts. And my one of my most popular handouts is a full page. And it’s a graphic. And it’s basically saying procedures that require documentation, you’ve probably seen that. And I have a lot of offices that will tell me that they put that on the inside of every cabinet door and put it in the sterilization area and one off, which was like it’s right across from the toilet in the employee lab. So, there’s no reason for no one to know, like they needed that x-ray and all of that. So, I’ll send that along. And then the next thing I’ll send is basically this way to amend your clinical notes so that it’s insurance friendly, because we don’t want to be insurance driven. We want to be insurance friendly. So, in this section, for example, when your doctor is doing their evaluation and they see a tooth that needs to be re crowned, what an insurance friendly note looks like is patient states crown is over and then whatever it is, Crown will be replaced due to and so it’s kind of just written in there. is very easy. And I’m also training the doctors that if the patient has no idea how old the crown is to say, do you think it’s over 10 years old? 12 years old? What do you think? Because if I can get the patient to say, oh, yeah, for sure we’re 12 years old, then my notes now say, patient states crown is way over 12 years old. And then that pushes me past that frequency limitation that we can’t read into, because we don’t need an exact date. We don’t need an exact date. They just need to know the year when it was done.

Dayna Johnson  25:29 

Okay, that’s good to know. That’s good to know. All right, perfect. Well, I will definitely have that. Have your contact info in our show notes. So, if anyone out there is interested in reaching out to Teresa for maybe some one on one coaching or they want to take one of your online classes, then I’ll definitely have your contact info in the show notes for sure.

Teresa Duncan  25:55 

Very cool. Thank you very much. I appreciate that.

Dayna Johnson  25:58 

Yeah. So, if this topic resonated with you and you know, other doctors or other dental teams that would benefit from our podcast, please share it, rate it, review it. Wherever you listen to podcasts. This really helps get the word out about our Novonee family of resources. I look forward to watching your journey of becoming a Dentrix superuser. And make sure to follow us on Facebook, Twitter, Instagram, we’re on all the social media networks. And Teresa, I hope you have a great rest of your weekend. Thank you for joining us today.

Teresa Duncan  26:33 

Thanks Dayna.

Transcribed by https://otter.ai