The most common mistakes when sending dental claims are incorrect coding and the absence of information and attachments. Billing out an anterior composite code on a posterior tooth will result in a denied claim, but is a 100% avoidable mistake. While sending incorrect information on a dental claim can cause headaches, not providing enough information can cause the same delay. In this article, we want to focus on the information necessary to build dental claim narratives that work and result in timely reimbursem*nt from the insurance carriers. Whether you are sending the narrative on the front or back end, be aware that a cookie-cutter narrative template may end up being a red flag to a claim examiner. Keep reading for helpful tips for building dental claim narratives that work, and the information you need to send clean claims and appeal insurance denials.
Clinical notes are crucial
The foundation for building dental claim narratives that work is using the doctor’s clinical notes. To ensure all of the necessary information is captured in a clinical note, the SOAP format is always suggested. SOAP is defined as:
- Subjective — the patient’s words
- Objective — the clinical observations from the dentist
- Assessment — the doctor’s diagnosis is
- Plan — the written treatment plan
It’s worth noting again that a cookie-cutter narrative for every similar claim may end up being a red flag to an examiner, and may contribute to an audit. Best practice is to avoid using template verbiage on a narrative. Check the doctor’s clinical note for information on each service and use that verbiage in the narrative instead.
Dental claim narrative for a crown
When building a claim, you can’t simply send off a template (as seen below). A specialist dental biller needs to look at the clinical notes against the films and create the correct narrative to add to the claim prior to submitting. Not sure where to find one? Click here.
Tooth #___
Existing restoration is__________ years old
Existing restoration is: Filling________ Onlay______ Crown________
Age of existing is: _______
Clinical reason to replace restoration is: Decay_____ Fracture____ Pain/cracked tooth_____
Missing restoration? ______
Is this the initial placement of this crown? Yes_____ No_____
Date of initial placement: _______
Crown build-up narrative:
Is a separate procedure completed the day of the crown preparation (or other date prior to seat) to restore missing or destroyed tooth structure in order to retain the new crown? “The large, old, failing restoration had decayed with destruction of supporting tooth structure making the build-up necessary to restore function by supporting new crown.”
- Send a current periapical x-ray showing apex, a bitewing x-ray, and an intra-oral photo after decay/existing restoration has been removed
Dental claim narrative for a multiple surface composite restoration
S.O.A.P. notes are essential in submitting a proper dental claim. The below example is exactly that, an example of what a narrative for a multiple surface composite restoration can look like. The utilization and organization of all clinical notes in one spot makes submitting a claim 10x easier. There really isn’t a “one size fits all” when it comes to submitting your claims. Want to know why? Click here.
Existing restoration? _____
Age of existing restorations: _______ years old
Clinical reason to replace restoration is: Decay_____ Fracture____ Pain____
Missing restoration? _____
In the case of multiple composite restorations, evidence of decay and fracture may be required. Replacing amalgam because just it is metal or the patient wants white fillings are usually not reason enough to replace restorations.
- Send periapical with apex and bitewings of teeth treated
Dental claim narrative for an onlay
Again, S.O.A.P. notes are very important here for your onlay dental claim narrative. You can use the below template as a guide. However, you must have the knowledge of each part of the clinical process to be able to properly fill out the narrative for this specific patient’s claim that corresponds with their specific insurance plan requirements. Every patient is different, therefore every claim will be different. Need help with putting your dental billing claims on autopilot? eAssist can do this for you.
You can use the same information above for the crown narrative, but be sure to include the cusp that is fractured in the narrative. Include a periapical and (if available) an intra-oral photo showing the missing or fractured cusp. The restoration must completely cover a cusp to be considered an onlay.
Dental claim narrative for veneers
The below template is just one example of what you can expect for veneers. Knowledge of each plan’s requirement is an absolute must. This template may work well for one patient but need complete reworking for the next. It is the duty of the biller to research and understand each patient’s plan requirements in order to submit a clean claim, which can be very overwhelming. Is your staff overwhelmed by the dental billing claims process? eAssist can help.
Tooth #____
Existing restoration? _____________
Age of existing restoration? ________________or initial placement date _______________
Clinical reason to replace existing? ___________________
A dental claim narrative that works for a veneer could include verbiage similar to:
“Tooth number(s)____ have existing facial or 3-4 surface composite that is
____ Cracked
____ Fractured (dentin exposed)
____ Washed out
____ Leaking or decayed
The remaining tooth structure will not sustain another composite restoration, a (restoration name-veneer)) is necessary to restore to function.”
Dental claim narrative for scaling and root planing
While using a template narrative, like the one below, is helpful, there will always be the possibility of including incorrect information from the previous patient you used this template narrative for. Errors such as this can cause delays in receiving payment from insurance. You need specialist dental billers to keep your claim submission process and cash flow running smoothly. Check out what eAssist can do for your practice by clicking here.
Building a dental claim narrative that works for scaling and root planing could contain the condition that the patient presented at the time of clinical examination. Consider using such verbiage as “Patient presents with periodontal disease including BOP, exudate, (if present) mobility, and generalized 4-6 mm periodontal probing depths.” If the dentist notes evidence of periodontal disease in the initial part of the evaluation use the code D0180 and follow the descriptor from the current CDT coding book. Include a current FMX and periodontal charting showing comparisons if available. Any other detail from the clinical notes of the dental hygienist or dentist may be added to the narrative.
Dental claim narrative for an implant crown
The below dental claim narrative for an implant crown, whereas helpful, is not a cookie-cutter narrative. There are many mistakes that can come about, such as possibly getting flagged by insurance for an audit due to the same narrative being received for all patients. You need the right person to set your claims up (and your practice up) for success. Find your dental billing specialist on the eAssist platform by clicking here.
Tooth #___
Date of extraction: ___________
Clinical reason for extraction: ____________________________________
Surgical notes: _________________________________________________
Implant recommended because: __________________________________
Long term prognosis: ____________________________________________
Written out, this dental claim narrative that works could look similar to this:
“Tooth #___was extracted because_______________________. Surgical implant placed by _______________to replace missing tooth. Implant crown #____and custom abutment #___placed to restore chewing function in the arch and to retain integrity of the bone and facial structures”
- Panorex or FMX, periodontal charting and narrative could be sent with claims for implants and implant crowns
Send it right the first time
The key to sending a clean claim for timely reimbursem*nt is giving the claims examiner the correct information the first time. This will decrease the time spent resubmitting the claim — or worse, having to go through the time-consuming review process. Supporting information required will vary slightly from one insurance company to another, and is changing regularly. We recommend staying in the know and ensuring you are sending the correct codes, attachments, narratives, etc, etc. with the industry’s leading dental coding resource.
Pro tip: Keep narratives short but with the information necessary to give the claim examiner the documentation necessary to pay the claim.
Outsourcing your dental billing can help narrative consistency
So, how do you build dental claim narratives that work? We build them so you don’t have to! Sending clean claims for timely reimbursem*nt is harder than it sounds. With insurance carrier requirements changing at least once a year, having extensive knowledge of insurance requirements is a necessary skill set for successful dental billing. Consider outsourcing your dental billing processes to a specialized team. This allows your in-house team to focus on what truly grows the practice, while your cash flow remains consistent. Learn more by emailing team@eassist.me, calling 1-844-327-7478, or clicking the link below.
