For any dental practice, an audit is not a possibility; it is an eventual certainty. Many reasons trigger an audit. Some are random checks, while others result from payors flagging unusual coding patterns. Sometimes, a patient complaint can initiate the process. Whether you are in-network or out-of-network, and regardless of whether the plan is commercial or federally funded, an audit can happen to you.

While some are random checks, others result from payers flagging unusual coding and billing patterns or from patient complaints. A variety of issues may prompt a closer review of records.

Key triggers can include:

• The clinical documentation fails to support the services or diagnosis reported on the claim.
• Evidence of poor record-keeping.
• The use of incorrect or improperly reported codes.
• Service utilization consistently appears higher than that of your peers.
• Unbundling of services.
• Reporting the treating doctor as the one who actually rendered the services (i.e., reporting the owner doctor when the associate performed the service during the credentialing process).
• Providing treatments that are not medically necessary.
• Poor patient communication, especially regarding billing, might lead a patient to contact their insurance carrier to file a grievance.
• An external referral or tip from a patient, staff member, another dental office, the Board of Dentistry, or law enforcement.

Enhance Your Clinical Documentation

In dentistry, strong documentation is your most powerful tool. It is also the most common reason for claim denials, unfavorable audit results, and investigation outcomes. Your clinical notes tell the story of every patient encounter. Each entry must be accurate, clear, precise, and detailed enough to paint a complete picture. It should answer who received treatment, who provided the care, the procedure rendered, how it was delivered, and why it was necessary. Anyone reading the chart – be it a patient, an auditor, or a court of law—should understand the encounter without any questions.

What’s Missing from Your Patient Stories?

The most frequent error in dental documentation is failing to explain the “why.” What was the reason for the visit? What condition requires treatment? In short, what was the diagnosis? Every patient seeks care for a reason, whether it’s for preventive care, a specific problem, pain, or cosmetic purposes. Documenting this “why” is fundamental to establishing medical or dental necessity.

Not only does the chart note ensure continuity of care, but it also serves to establish and prove medical necessity. We often fail to document the patient’s symptoms. For example, if a patient presents with pain, the chief complaint should detail their description of that pain. This information justifies diagnostic procedures like radiographs, diagnosis, and the treatment plan and/or treatment.

Besides a missing diagnosis, other documentation errors include:

• Failing to document the extent of decay.
• Lacking a detailed periodontal assessment.
• Omitting teeth numbers and surfaces treated.
• Failure to record discussions with the patient about findings and recommendations.
• Leaving template prompts blank.
• Missing provider signatures.
• Including images that are not of diagnostic quality.

Supporting Documentation

Supporting documents like periodontal charts, radiographs, and intraoral photos are vital, but they do not replace detailed clinical notes. Their purpose is to support the diagnosis and treatment plan as documented in your notes. The written record should describe what is seen, heard, felt, measured, or smelled. For instance, instead of assuming an X-ray speaks for itself, a note should state, “Radiographs for tooth #14 show 3mm of bone loss.”

Consider how other healthcare providers document. You would never see a physician’s note that says, “EKG results: See EKG report.” Instead, the provider documents their impression and a summary of the findings. As healthcare professionals, our clinical notes should meet the same standard.

Coding with Precision

You can only code what you have documented. First, document what you do and why with the highest level of specificity. Then, code to that same level of specificity based on your documentation. Every code set, from CDT, CPT, to ICD-10-CM, has general guidelines, guidelines specific to chapters, categories, subcategories, and even guidelines within the code language. Follow these guidelines regardless of whether an insurance claim is submitted. When using CDT codes, read the full nomenclature and descriptor to select the one that most accurately reflects the procedure performed. Ensure your documentation fully supports your choice. Persistent coding errors can lead to costly and serious problems during an audit.

The main goal of coding is to maintain an accurate patient health record. Following proper coding guidelines is essential to achieving this.

How to Prepare for an Audit

Being prepared for an audit or investigation starts with meticulous documentation. Dental practices are busy environments, but cutting corners on notes is a risk you cannot afford to take.

Consider adopting the S.O.A.P. (Subjective, Objective, Assessment, and Plan) note format. While not legally required, it is the recognized standard across healthcare that promotes clear, organized, and detailed records. Anyone reading a clinical note following the S.O.A.P. method will know the story of that encounter. 

To avoid a negative audit outcome, invest in your practice’s compliance.

• Provide your team with proper education on documentation and coding.
• Implement a daily review of all patient record entries.
• Conduct internal audits to catch errors early.
• Foster a culture of compliance where every team member understands their role in maintaining accurate patient records.

Remember, you are not just treating patients; you are populating a legal healthcare record. It must be accurate.