#7 – Manages specialists: Oral Surgeon | Dental Practice Coaching

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#7 – Manages specialists: Oral Surgeon

Oral Surgeon

Get to know our Oral Surgeon

Our Oral Surgeon is ___________.  He performs extractions, bone grafts, implants, sinus lifts, biopsies (hard tissue and soft tissue), and other surgical procedures under both local and IV anesthetic.

Your responsibilities as the Oral Surgery Coordinator include :

  1. Keep the schedule full
  2. Make sure all new clients are scheduled correctly – have referral forms filled out
  3. Check in and out clients
  4. If Dr. is running behind, communicate between Dr., assistant, and next patient.  If you are able to seat the next patient, do so and let Dr. and assistant know.
  5. Follow up on all unscheduled treatment plans
  6. Send and follow up on PTEs to schedule patients
  7. Schedule lunches with potential referral GPs
  8. Send thank you for referring letters to GPs
  9. Arrange finances for patients
  10. Provide end of month report to Dr. and Administrator

Dr. sees patients __________. He reserves _________ for consultations only.   He reserves time for surgeries on ___________.   He prefers to have 5-6 cases on treatment days, starting at 8am.  The day could end anywhere from noon to 1 :30, depending on the length of time needed for each appointment.

Managing our Oral Surgeon’s schedule

Monday/Tuesday

o   Review day sheet from last day worked.  Check daysheet for errors.

o   Review each patient seen to make sure appointments were scheduled, paperwork completed and scanned to document center, FAs for appointments set, PTEs sent.

o   Prepare paperwork for biopsies to be sent to the path lab through Fed Ex. (page ____)

o   In the morning on the day that our Oral Surgeon is seeing consultations, review the schedule to make sure all patients have health histories and referral forms scanned into their documents centers.  For new patients, make sure the New Patient form is also scanned to the document center.

o   The day after consultations, make sure all pre-anesthesia forms Dr. started during the consult are scanned to the document center to be completed at the surgery.  Make a note on the sheet as to when surgery is scheduled.

1-2 days before surgery day 

  • Confirm schedule. Assure added patients’ charts are pulled and all forms are there.  Check for referral forms.
  • Call in premeds/Halcion for Saturday appointments
  • Make sure Dr. is the provider in the Dentrix family file for all patients, and the correct fee schedules are selected in the family file.
  • Confirm all patients have the correct paperwork scanned into their document centers (health histories, referral forms, etc.)  This should have been done at the consult; however, it never hurts to double-check.
  • Check that started pre-anesthesia forms are available, as Dr. will need those the day of the surgery.
  • Confirm FAs are set for all surgery patients
  • Contact each patients scheduled for sedation to confirm appointment times, and remind them to be NPO (nothing to eat or drink) for 8 hours prior to their appointment time.
  • Confirm with each patient getting sedation that they have someone to drive them from the appointment.

Day of surgery

  • Huddle with Dr and his assistants to review the schedule for the day.
  • Bring the pre-anesthesia forms needed for that day and give to the assistant
  • Check in and out clients during the day
  • Print day sheet and review with Dr. at end of day
  • Prepare letters for patients who are not GP side patients, for Dr. to edit and sign before he leaves.  At each check-out, scan all consent forms and anesthesia forms to the patient’s document center, and record treatment done/treatment recommended in clinical notes.
  • Assist with taking patients out to their vehicles after surgery, as needed.

Monthly

  • Complete end of month report.  Give the completed end of month report to the administrator.  Instructions are on page ____.
  • Records any patients who have had extractions or other oral surgery recommended who have not scheduled treatment in the clinical notes so the hygienists have a record of it and can follow-up with the clients at their next recall.

Keep the schedule full

With this schedule, it is easy to look at his schedule in Dentrix and follow up on each individual patient.

You can use Dentrix to run a report to find code D0150.1 (Specialty Exam) completed in order to generate a list of patients who have been evaluated and use this list to fill the schedule. You can refer to prior months’ end of month reports and unscheduled/PTE lists for patients with outstanding treatment.  You can also maintain a broken appointment list for Dr.  (located in ______________).  You need to send PTEs for clients that want to know what insurance will pay. As the PTEs come back, they will be added to the weekly unscheduled list. Call the patients once they are returned in order to schedule.

Making sure patients are scheduled correctly

The day before Dr  works,  you need to review his schedule.  For consult days, confirm health histories for existing patients have been scanned to each patients document center, along with referral forms and, for new patients, the New Patient form.  If a referral form is not in the document center and not in the chart, you need to have the dentist fill one out.

Be sure to schedule from top down. For treatment, Dr. and his assistant can tell you how much time is needed.

  1. Huddles are fairly simple. Dr. doesn’t follow the GP side huddle sheet.
  2. Take the schedule on which you made all your notes.  Make note of which forms are already scanned into the document centers, so the assistants know to have them pulled up for Dr.
  3. Start with the first patient of the day.
  4. Review the referral form let him know if there are no x-rays
  5. For new patients, review how they were referred to the practice

Oral Surgery Huddle: 15 minutes before first patient on consult days, 30 minutes before first patient on surgery days

Did everyone clock in?

Review today’s schedule.

  1. Any past client problems?- upset, long wait, etc.
  2. Do we have lab cases that we are seating?
  3. Anyone to ask for a video testimonial?
  4. Anyone that will make a good blog story?
  5. New patients not referred by GP side: review who referred, what the concern is, X-rays needed?
  6. Surgery Days: present the pre-anesthesia forms that were started during the patients consultation appointment to the assistant so they are available for Dr. during surgery

Secretary: holes in upcoming two weeks of appointments that need to fill?

Other projects that Dr. needs to complete today (videos, photos, etc)?

Charts in Dr.’s bin that need follow-up or consultation with other doctors?

 

Checking in and out patients

Be sure to get a copy of their dental insurance card for the chart & confirm the information in the computer is correct.  For biopsys or treatment resulting from an accident also get a copy of the medical insurance.  Collect payments, set Fas, and manage contracts same as GP side financial policy for appointments today and future appointments.

 

Scheduling for our Oral Surgeon

To schedule a new oral surgery patient:

To schedule exam only:

  • Who: For wisdom teeth, multiple teeth extractions, or patients with health issues, biopsies
  • Code: Oral Surg – Specialty Exam alone D0150.1
  • Time: 1 units.
  • Fee: $78
  • X-rays: Pano needed (can be taken at appt)

Make notes in the appointment if panoramic x-ray available, what treatment is needed and referral source.

If not seen by an in office GP, you must ask the following questions: “Let me get some health information from you so the doctor can know what to expect”

  1. Do you have any medical problems?
  2. Do you have any chronic health problems?
  3. Are you under the care of a physician?
  4. Are you currently taking any medication? (Daily aspirin/blood thinners-physician may need to know about?  Insulin (for diabetes) requires physician consult?  Asthma inhaler-bring to appointment)
  5. Do you prefer IV or oral anesthetic?
  6. Do you have current x-rays?
  7. How were you referred?

* Our oral surgeon is a member of ________________insurance plans

Make sure you have a referral form and new patient form for all new patients.

 

To schedule surgery rechecks :

Dr. occassionally requests a 1 unit no charge After Surgery Recheck (Code D7900) one to two weeks following oral surgery. He will let you know when he wants a patient to return for a recheck.  All biopsy patients will need a recheck appointment at least 2 weeks after the surgery, to review the results of the biopsy.  The path lab generally gets the results to us within 5-7 days.  These appointments should be scheduled in Dr.’s column between surgerys, or on consultation days.

 

Patient Questions for Oral Surgery

Ask patient if they would like to have

  1. Local anesthesia
  2. Nitrous oxide
  3. Halcion (follow procedure in Assistant Level 2)

 

If patient has medical problems

Questions to ask patient to determine if there are any medical problems

  • Do you have any chronic health problems?
  • Are you currently under the care of a physician for any condition?
  • Are you currently taking any medications (including an aspirin a day)?
  • Do you have a Medical problem that will require a consultation with our oral surgeon and a medical clearance from your physician?

a. Aspirin or blood thinners – cause bleeding during surgery

If the patient is taking Aspirin or a blood thinner (Coumadin), the patient needs to consult their physician to see if they can be taken off their medication for a period of time. Their doctor must advise them. NOT US. The first sign should be – any heart problems. We will always do a medical clearance for this type of medical concern.

b.  Insulin (Diabetes)

  • If patient is diabetic and is taking insulin, we need to consult their physician for them to adjust their insulin. We will do a medical clearance.
  • Diet controlled diabetic – usually okay.
    1. If patient has inhaler, must bring it to their appointment.
    2. If patient calls complaining of having a cold, make sure they can breathe through their nose.
    3. If patient has Bronchitis, their appointment will need to be rescheduled.

c.  Inhalers (for Asthma)

 

To schedule for our Oral Surgeon in Dentrix:

  • Locate a date and time for the patient
  • Select patient name
  • Go to the tooth chart, select the teeth for treatment, and the correct treatment to be done (for surgery).  For consults, select the Speciality Exam.
  • Schedule in the appt book using the treatment plan you’ve created.
  • Select the length of the appointment
  • Click the staff button and select your name (to show who made the appointment)
  • Click ok
  • Put an appointment note with your financial arrangements stated clearly.

When scheduling, please advise patients the specialty exam may not be covered by insurance. Most insurance plans will only allow 2 exams per year. They may want to confirm coverage with their carrier should this be an issue.

To schedule surgery for our Oral Surgeon in Dentrix :

  1. Locate a date and time for the patient (surgeries are scheduled on Saturdays, starting at 8am and work down through the schedule)
  2. Select patient name
  3. Go to the tooth chart, treatment plan the correct treatment if not already planned by his assistant.
  4. Confirm the correct sedation is selected – Dr.  uses code D9220.1, with a fee of $450, for IV sedation.  Nitrous and Halcion should be treatment planned so the doctor and assistant are prepared for these patients when they review the schedule.
  5. Schedule in the appointment book using the treatment plan created.
  6. Select the length of the appointment.  Most surgeries Dr wants 45 minutes ; he or his assistant will let you know if the surgery needs to be longer.  He does not charge anything additional for anesthesia for longer surgeries.
  7. Click the staff buttons and select your name, to show who made the appointment
  8. Add appointment notes reflecting the patient estimated portion for the visit, and the financial arrangements you set.
  9. Click OK

No Shows / Cancelation Procedures

                                                                   No Shows

If a patient no shows you will need to mark the no show in the computer.  When you call them, please follow the GP side no show policy.  These patients will be added to Dr.’s broken list so we can attempt to reschedule them as time becomes available.  When rescheduling patients to whom you have given the no show/cancel speech, make a note in the patient alert that you gave them a no show speech and add procedure D9923 (discussed missed appts personally) to their ledger, same as with GP patients.

                                                                  Cancellations

If someone cancels an appointment more than 24 hours in advance, you can reschedule at this time.  If an appointment is canceled less than 24 hours, they will go on Dr.’s broken appointment list.

Once on the broken appointment list, you can call the client to reschedule 3 times.  Make sure each attempt to contact the patient is recorded in their clinical notes.  After 3 attempts, they can be taken off the broken list.

Insurance Estimates and claims

If you have coding questions refer to secretary level 4 – Maximum benefits for clients

Oral surgery

Get a copy of the medical insurance card for patients having their wisdom teeth extracted and for biopsies.

Create your estimate for the patient based on the dental insurance coverage only. The patient has to pay any amount not covered by their dental insurance (even if they think medical insurance might help pay for some of their personal amount). Explain to the client that we will submit to their medical insurance only as a courtesy and their medical insurance will send reimbursment to the patient if they will cover any of the treatment costs.

Many dental insurances do not cover the anesthesia charges.  Make sure any estimates you have reviewed with your patients are based on the anesthesia coverage being $0.  Once the pre-treatment estimate has been received, if the insurance plans to cover some of this cost, you can review the new estimate with the patient.

For most oral surgery claims and PTEs, a panoramic X-ray is required.

 

BONE GRAFTS

There are basically 3 reasons to perform a bone graft that dental insurance may cover:

  1. Replace bone destroyed by periodontal disease, trauma, or ill-fitting dentures.  We use code D4263 bone graft first site and D4264 bone graft additional sites.  The ADA describes these codes as:  A bone graft placed to stimulate periodontal regeneration when the disease process has led to a deformity of the bone.  The tooth number for each site must be indicated on the claim form.  The dental insurance companies will request a narrative on the diagnosis and treatment along with x-rays and periodontal charting.
  2. Increase the amount of bone in the sinus area for implant placement. The ADA code for the sinus lift is D7950 and is described as: A bone graft placed to augment the sinus cavity to increase the alveolar height for reconstruction of edentulous portions of the maxilla. The area (quad) must be indicated on the claim form.  The dental insurance companies will request a narrative on the diagnosis and treatment along with x-rays and periodontal charting.
  3. Preserve bone levels in an extraction site for future implant placement or to eliminate the need for an elongated pontic for a partial.  The ADA code for ridge augmentation is D7950 (the same as for sinus lift) and is described as:  A bone graft placed to increase the height, width and or volume of the residual alveolar ridge.  The tooth number must be indicated on the claim form.  The dental insurance companies will request a narrative on the diagnosis and treatment along with x-rays and periodontal charting.

IMPLANT BILLING

There are 42 implant codes available through the ADA for submitting to dental insurance companies.  We do not use that many! The ones we use (or could use) have been grouped into categories for better understanding:

  1. Pre-surgical services
  2. D0150.5 – Implant exam
  3. D0330 – Panoramic x-ray
  4. D0470 – Diagnostic casts/wax-ups
  5. D6190 – Surgical Guide
  6. Surgical services
  7. D6010 – surgical placement of implant body
  8. D6100 – implant removal
  9. Implant supported prosthetics
  10. Supporting Structures
  11. D6056 – prefabricated abutment – includes placement
  12. D6057 – custom abutment – includes placement
  13. Implant/Abutment supported removable dentures
  14. D6053 – for completely edentulous arch
  15. D6054 – for partially edentulous arch
  16. Both of these codes are used for removable overdentures that are supported by implants.
  17. Single Crowns, Abutment supported
  18. D6059 – abutment supported porcelain crown
  19. Transitional Removable Appliance
  20. D5820 – interim (temp) partial denture – upper
  21. D5821 – interim (temp) partial denture – lower
  22. This code is used when a front tooth (smile area) has been extracted and the area needs healing time.

 

Medical Insurance Billing – Implants and Bone Grafts

Typically, medical insurance companies will cover implants and bone grafts in case of trauma; however, the documentation must clearly show the medical necessity. Some of the medical insurance companies are beginning to cover implants not due to trauma but due to atrophy, congenital tooth lose, etc.

When medically necessary, replacement of teeth by dental implants is covered by the medical insurance company; however, the only procedure covered is the surgical placement of the dental implant body (replacement of the missing root) – our code D6010 for the root form implant.  The restorative procedure (replacement of the missing crown) is considered a dental expense and is our codes D6056 for the abutment and D6059 for the implant crown.

There are situations that will allow the medical insurance to be billed for an implant when a bone graft is necessary.  These are atrophy, congenital or traumatic loss of teeth, nerve pain due to denture pressure, and chronic mouth sores (stomatitis).

The Medical Cross-Coding Binder (located in Jamie’s office) will list the ICD-9 diagnostic codes such as:

525.21 minimal atrophy of the mandible

525.25 moderate atrophy of the maxilla

and the CPT codes such as :  21248 reconstruction of mandible or maxilla, endosteal implant, partial

These medical codes (and similar ones) would be used when the medical necessity is indicated on the treatment sheet by the dentist.

Medical claims are not sent electronically.  They must be completed on paper.

 

Preparing Biopsy Forms and Sending to path lab.

Dr. performs soft tissue and hard tissue biopsies. He will place the specimen in a specimen jar, which is then placed in a plastic biohazard bag.

Dr. will fill out the clinical section of the biopsy form that comes with the specimen jars.  You need to fill out the patient information on this form, including a copy of the medical insurance card for the path lab to use for their billing,  The copy of the medical insurance card can be cut out and glued to the form, to save copying it over.

Scan the completed biospy form (as all other documents are scanned – if you need a reminder, the instructions for the scanner are in secretary level one) to the patient’s document center.  Roll the completed biopy form along with a blank sheet of paper around the specimen jar, place everything in the plastic biohazard bag, and place the bag inside a FedEx envelope.  The University Path Lab provides pre-labeled Fed Ex shipping labels to be attached to the outside of the envelope.  Please call Fed Ex at 1-800-GOFEDEX and follow the prompts to arrange for pick-up of the package.

Shipping materials are kept in ________.  The pre-labeled FedEx shipping labels are kept in __________.  When you are running low on these supplies, please call the path lab at the number on the Fed Ex labels, or include a note with a sample being sent.

The path lab will generally fax results to us within 5-7 days.  A hard copy of the results will follow within a couple days.  Read through the results and, if any mention of malignancy is included in the write-up, please forward the faxed copy to Dr. immediately.  He may wish to follow-up with the patient before their scheduled re-check, or provide additional instructions to you or his assistant.

Consent forms

Dr. has a consent form for all his treatment. These consent forms are given to the client by the assistant at the beginning of their treatment appointment for them to review and sign.

Treatment Brochures:

Brochures for, extractions, implants, and any other treatment Dr. recommends to the patient during exams should be given to the patient by his assistant during the appointment.  This gives the patient the information regarding their treatment,so they can make an informed decision, and can explain to family members what they are having done.  His assistant is responsible to make sure the correct brochures are available.  Extra treatment brochures for procedures are kept in the lobby.  Please pop-quiz patients as they are leaving to assure they are getting their brochures.

Financial arrangements

Our oral surgeon follows GP side guidelines for collections.

At end of day – print a day sheet for Dr., review it for accuracy and give it to him (Office manager, Day sheet icon, Select provider _______, today’s date and ok then print from the office manager list).

Small cases $250 and under – to be paid in full

Large cases $250 and over – ½ down to schedule, balance due the day of appointment, or offer CareCredit

Rechecks have no charge – unless outstanding balance

For patients who do not have managed care insurance and have financial constraints, review the situation with Dr.   In some instances, he may be willing to offer a discount to the patient so they can get the recommended treatment done.  This is offered on a case by case basis at his discretion.

Insurance

Our insurance/billing person needs a copy of both the medical and dental insurance card for biopsy patients.

You will need to change the provider of record (in the family file) to Dr.  before you send insurance claims or PTEs.  This should be checked a day or two before Dr is in to make sure the correct provider and fee schedules have been selected. After the insurance claim is printed (or sent as an Eclaim), you can change the provider back to the original.

Medical insurance –These claims need to be printed to paper upon creating the claim. Our insurance person  will take care of sending these claims for you. She will copy to the medical HCFA form. Patients must pay their estimated portion their insurance will not cover, and their deductible.

Charge outs

Dr. does clinical notes and is chartless.

For consults: his assistant will bring the patient to you, as well as a pre-anesthesia sheet that Dr. has started.  The recommended treatment, sedation, and length of time of the appointment will be on this form.  Confirm today’s appointment is set complete, check that the treatment is treatment planned properly, review FA’s, send PTEs if requested, and schedule the surgery appointment.  If the patient chooses not to schedule, make a clinical note as to why and what follow-up is required.

For surgeries:  His assistant will let you know the patient is about ready to be released.  Call the parent/spouse to the check-out window, confirm treatment is correct, set the appointment complete, send to dental insurance, and collect any remaining balance.  Dr  will talk to the parent/spouse before the patient leaves, to review how the surgery went, medications prescribed, and after-care instructions.  Once you have completed with the family member, ask them to bring the vehicle around to the end of the wheelchair ramp, then go back to help transport the patient, if needed.

Dr.  will review consent forms and anesthesia records before he leaves and return them to you.  Make sure all documents from surgery are scanned to the patient’s document center.   For treatment done for GP side patients, notate on in the clinical notes what was done (Example: Patient saw Dr ____ on June 1 for surgical extraction of partial impacted #1, #16, complete impacted #17, #32.  Next visit: Recheck on June 14)

End of Day

Before Dr. leaves, print his day sheet.  Have him consent forms and anesthesia records, and sign letters being sent to referring doctors.  Make sure he has signed refund checks, completed any narratives for insurance, and responded to any consultation requests from our GPs.

To prepare a letter for a referring doctor outside of our group, you can use the template ________.  Locate the correct information for the patient’s GP.  The patient may know this information, or you may have to look it up through Google or whitepages.com.

Generally, you can use Dr.’s clinical notes to write the letter.  Make note in the letter as to recommended treatment, accepted treatment, next visit, and recommended follow-up.

Dr. will review the information you have provided, and make any corrections for you to type before signing.  If the corrections or additions are lengthy enough to have to be finished the next day you work, there is a signature stamp you can use.  Send the letter, as well as additional referral brochures, to the referring dentist.

Save the letter in _______.  Additional letters sent for each patient through-out the year can saved the same with the month added to the path.

For GP side patients, you do not need to prepare a formal letter.  Write up the visit with Dr. in the clinical notes as:

For evaluations/exams: Pt saw Dr. ____ on (date) for (type of exam).  Recommended treatment is: (treatment), NV: (treatment) on (date).  Include your initials

For treatment: Basically the same write-up as above.  Pt saw Dr. _____ on (date) for (treatment).  NV: (treatment or reason for next visit such as recheck) on (date).  Include your initials. 

End of month reporting

You are responsible for filling out an end of month report and giving a copy to the administrator and a copy to Dr. ______.  Use the instructions below:

 

Specialists End of Month

Start by creating new excel worksheet for Case Acceptance – and a new worksheet for the month

To find patients, run the following report for code D0150.1 (Specialty Exam) :

1)     Office manager, letters, Misc tab – highlight the letter that says “Stats Perio Case Acceptance” and click Edit

2)     Select Edit – the defaults are all correct, they are:

3)     Patient name: A – Z

4)     All providers

5)     Checkmark the patient box

6)     Uncheck all gender, position & balance aging boxes

7)     Do not check the “Guarantors only” box

8)     Billing type 1-4, 11-14

9)     Clear all the fields (starting with appointments and ending with zip codes)

10)  Click the button next to Procedures – this brings up a window “Select procedure range”

11)  Checkmark the Completed box

12)  Enter D0150.1 in the Beginning and Ending boxes

13)  Enter the month in the Beginning and Ending date boxes (for example 1/1/09 – 1/31/09)

14)  Click okay to close the window

15)  Now click OK again to close this window also.

16)  Click on Create/Merge – Select “Create data file Only” – click OK

17)  Now it counts – you can watch the numbers as it looks for the patients who have a continuing care appointment in that month. This takes a few minutes since it has to look at each patient in the system.

18)  Once the report is finished (the window showing the counting will disappear), then click View List – this will bring up your results in a window.

19)  In the window, choose Edit – Select all and then Edit – Copy

20)  Now, open Excel and click Edit – Paste under Comprensive Perio Exam

21)  Count the total number of new patients (not patients already established as HP patients) – enter this number on your end of month report.

22)  For any clients who have recommended extractions and HAVE NOT SCHEDULED, pull their charts and note on the hygiene pink control sheet what the recommended surgery is.  This will give the hygienists a heads up so they can continue to talk about it with the patients at recall appointments.

 

Scheduling T est:

  1. Schedule a patient for an exam – assume it is a referral from a GP dentist for thirds extraction
  2. Schedule a patient for extraction of #1, 16, 17, 32-all tissue impacted – with IV anesthesia
  3. Schedule a patient for a biopsy under local anesthesia
  4. Schedule a patient for ext of #1, 16 – Partial Bone Impacted, and #17,32 (Complete bone impacted) w/IV anesthesia

_________________________               ______________

Team Leader                                                                 Date