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Tip: Documentation skills don’t have to be hard.

Evidence based medicine such as the updated periodontal staging and caries lesions also gives well defined information about the clinical condition itself. You cannot just look at the codes, you need to check the policy. When I am coding or teaching coding you need to use clinical indications when working with documentation improvement. Ask your self if you would accept having a surgery without the doctor using tests to help diagnosis and check on results and use that for a reason to do treatment.

Would you do an implant without an x-ray to diagnosis, x-ray to make sure placement is correct, and then a follow up for healing?

The clinical indicator will help you find a primary and secondary causes of the conditions and treatment you will be providing.

I recommend that the team help with all documentation since they answer the phone to make an appointment so their ability to get signs and symptoms will help you understand what the patient is dealing with, obtain per-verification and pre-authorization for tests that may be necessary to diagnosis your patient with a primary and secondary diagnosis. The symptom codes will move to the back of the line after you read your x-rays, CBCT or any other tests your office uses to help diagnosis patients.


Patient called with swelling and pain upper right. Office asked if they take medication for any reason. Patient explains they have diabetes and uses oral medication. Just that tells you this is a high-risk patient, who is in pain and needs to be seen fast. You contact the medical provider to include them in a collaborative treatment and ask for a list of medications and existing diagnosis.

Contact Christine ctaxin@links2success.biz to learn how to never forget what your documentation needs to pass an audit.

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