There is an increased focus on the dental community from the New York State Office of Medicaid Inspector General (OMIG). At an increasing rate, OMIG is conducting audits of dentists and dental specialists, putting additional burden on providers already taxed with other statutory, regulatory and malpractice concerns.
At a recent presentation aimed at dental providers, OMIG stressed the importance of record keeping. Specifically, the agency reminded providers that:
- Dental records are a legal document that provide a main source of information about what happened and why;
- Dental documentation must support the dental necessity of the service, to what extent the service was rendered, and why it was medically justified;
- Accurate and complete documentation can ensure better care and increase the chances of full and fair reimbursement;.
- Pay attention to the Dental Manual–it identifies important record-keeping requirements
What documents and information does OMIG want to see in a dentist’s medical chart?
- each patient encounter should include the date, the reason for the encounter, appropriate history and dental exam, review of lab and x-ray data and other ancillary services (where appropriate), an assessment, and a treatment plan; entries to the dental record should be dated and authenticated;
- Testing or diagnostic service
- Type of treatment
- Service on other intra-oral structures
- Treatment plan
- Extension notes
- Failed appointment notes
- Communication notes
Providers were also reminded that dental records should be complete and legible.