Why First-Time Accuracy Matters
Revenue leaks don’t just happen when insurance denies a claim—they often start at the first keystroke in the patient chart. Incomplete documentation, incorrect E/M coding, or failure to classify tooth loss properly can set off a domino effect: denials, delayed payments, compliance risks, and frustrated patients.
Documentation: The Foundation of Every Claim
If it’s not documented, it didn’t happen—and if it’s not documented thoroughly, it won’t get paid. Too often, dentists begin documentation with the treatment they recommend or provide, skipping over the patient’s condition and the rationale for care.
The SOAP format—Subjective, Objective, Assessment, Plan—ensures the whole story is told in a way that supports medical necessity.
Example of SOAP documentation that pays off:
Subjective:
Patient presents with difficulty chewing food and reports routine use of antacids. Chief complaint is ill-fitting dentures. Past medical history is significant for type 2 diabetes, history of cholecystectomy, and nonalcoholic fatty liver disease (NAFLD). Current medications include Metformin, Pioglitazone, a GLP-1 receptor agonist, and an SGLT2 inhibitor.
Objective:
Panoramic radiograph demonstrates alveolar bone resorption. Clinical exam confirms poor retention and stability of current prostheses.
Assessment:
Moderate to severe maxillary and mandibular atrophy with complete edentulism. Functional impairment noted (inability to chew properly), with systemic risk factors present (diabetes).
Plan:
Recommend placement of four endosseous implants in the mandible and six in the maxilla to support a fixed hybrid prosthesis following adequate healing and osseointegration. Patient is scheduled for a pre-operative visit, including CBCT imaging for surgical stent fabrication. Patient understands and agrees with the treatment plan. All risks and associated complications have been discussed.
That’s the kind of documentation that connects the dots for insurers: patient condition → evidence → clinical reasoning → treatment plan. Without it, claims sound like “because I said so”—and that’s rarely enough to win approval.
Evaluation & Management (E/M) Codes: Getting Paid for Your Time
E/M codes aren’t just for physicians; dentists are often eligible when the visit involves complex histories, detailed exams, or significant medical decision-making. Think trauma, sleep apnea, infections, or systemic conditions tied to oral health.
The trap? Many dental teams default to a “limited exam” dental code, missing legitimate opportunities to use medical E/M codes that better reflect the work performed. The 2021 E/M guideline updates shifted focus to medical decision-making and total time—which means dentists who document carefully can bill correctly, and often at higher value.
Tooth Loss Classification: More Than a Checkbox
Tooth loss documentation is frequently overlooked, but it’s critical for both medical necessity and treatment planning. Payers want to know:
Was tooth loss due to disease, trauma, or congenital absence?
Is it localized or generalized?
Does it impact function, mastication, or systemic health?
Accurate ICD-10-CM coding matters. For example:
K08.101: Partial loss of teeth due to trauma, class I
K08.122: Complete loss of teeth due to periodontal disease, class II
K00.0: Anodontia (congenital absence)
Misclassifying tooth loss can result in denials—or worse, allegations of upcoding.
The Cost of “Close Enough”
One office I worked with submitted implant claims marked “tooth loss, unspecified.” Every single claim was denied. Once documentation was corrected and the proper K08 subclassifications were used, approval rates jumped significantly.
“Close enough” doesn’t work in today’s payer environment. Precision does.
Action Steps for Your Team
Audit your notes: Are SOAP elements present and signed/locked the same day?
Review your E/M coding: Do providers understand 2021 rules on time vs. decision-making?
Check your ICD-10-CM use for tooth loss: Are you specific, or defaulting to “unspecified”?
Crosstrain admin and clinical staff: Billing accuracy begins chairside.
The Bottom Line
Getting it right the first time isn’t about perfection—it’s about process. Documentation, E/M codes, and tooth loss classification may seem like details, but together they form the backbone of compliant, profitable billing.
The payoff? Faster payments, fewer denials, and stronger patient trust.
