Dental Office Procedures for Dental Assisting Exam Study Guide

Working with Dental Office Documents

The assistant must understand the importance of the Health Insurance Portability and Accountability Act (HIPAA). This is a federal act that requires the dental office to transmit certain patient health information electronically to protect the health information. This act also covers keeping the patient’s personal and financial information private.

The patient’s record consists of many documents. These records can be kept on paper, in electronic form, or both. The health history and registration form is completed on the patient’s first visit to the office. The clinical chart is where the assistant and doctor note the findings of the examination and indicate all procedures completed. There are three different tooth numbering systems, and charting symbols are used along with clinical abbreviations to note information in the patient’s clinical chart.

Parts of the patient’s clinical record include:

Health History

The health history gives the doctor an overview of the patient’s past and present medical conditions, medications, and allergies.

Registration Form

The registration form provides the patient’s personal and financial information. This includes facts such as address, employer, birth date, insurance information, and so on.

Clinical Chart

The clinical chart identifies any of the patient’s pre-existing conditions, and it is also here that the dentist outlines the treatment plan and services rendered.

Treatment Plans

Once the dentist has thoroughly examined the patient, he or she will prepare a written treatment plan that outlines the proposed treatment, an estimate of the costs, and any other options. Dental assistants must be familiar with all dental terminology to be able to understand and explain treatment plans. For example, if a plan shows an MOD restoration on tooth #3, that is a three-surface restoration on a maxillary molar. Then, if it calls for a PFM crown on tooth #30, the assistant should know that is a porcelain-to-metal crown on a mandibular molar. Similarly, treatment for tooth #19 in the Universal Numbering System refers to the mandibular left first molar. An assistant can explain how pit and fissure sealants prevent decay on the developmental faults on both primary and permanent teeth.

Prescriptions

Dentists write prescriptions for medications as needed, and a copy is usually made and stored in the patient’s dental chart.

Lab Requisitions

The dentist must create a written requisition for each appliance to be fabricated in the dental laboratory. This includes partials, dentures, crowns, bridges, surgical stents, athletic mouth guards, and bleaching trays.

Radiographs

Radiographs are usually taken on new patients and periodically on returning patients at their recall appointments. Radiographs may be taken digitally or with film. There are two types of radiographs: intraoral or extraoral.

Intraoral Pictures

The dental office may utilize an intraoral camera to document the patient’s intraoral condition. These pictures are either printed or stored electronically in the patient’s chart.

Referrals/Correspondence from Other Doctors

The office may receive letters or radiographs from specialists or referring doctors that may become part of the patient’s chart.

Consent Forms and Other Non-Clinical Documents

Once details of the dental treatment plan have been explained, the patient must then sign an informed consent form. Minors must have a parent or guardian sign the consent form. No work can be done without a signed consent form. For example, if a 14-year-old arrived at the dental office for a scheduled treatment without the forms signed by a parent or guardian, the dental assistant would have to reschedule the patient.

The ledger, which shows the financial record of the patient’s dental care, is part of the patient’s record; however, it is not part of the clinical record.

Filing systems are used to store records. There are different types of filing systems used in a dental office. These include: alphabetical, numerical, chronological, subject, and geographical. The alphabetical system places charts or documents in alphabetical order by the last name, then first name. Chronological filing would be by the date (1–31), and is used when storing insurance claims. Subject filing is also done alphabetically by the name of the subject. Geographical filing is done by a division of territory (state, city, or street).

Recall cards are filed in a chronological file system, patient records are filed in an alphabetical file system or a numerical filing system, and the contents inside the patient’s record are filed in chronological order with the most current contents at the top.

A tickler file is a chronological file used to remind the assistant of daily, weekly, or monthly tasks to be completed.

Appointment Management

The dental office’s success pivots on the appointment scheduling. This task may be assigned to one individual in the practice who then can implement the practice’s scheduling policies. The usual sequence of an appointment is:

1. Initial examination appointment
2. Diagnosis and formulation of treatment plan
3. Consultation with patient regarding treatment plan
4. Treatment appointment scheduled

Appointment books are either traditional paper books or computerized. There are many advantages in using the computerized book. These advantages include neatness and legibility, ability to access the patient’s record and treatment plan, and various screen viewing modes. Additionally, operators or treatment rooms can be color coded, daily and monthly production can be monitored and scheduled, procedures can be posted to several different records from only one entry, and searching for appointment openings can be made easier. The one advantage a paper book has over a computerized book is if the power goes out or the computer crashes, there is still a way to see who is scheduled to come in. Some dental practices still use paper appointment books as a backup to the electronic system, while others perform a daily electronic backup.

Dental assistants must be familiar with logistics to ensure proper timing of appointments and managing time slots accordingly. For example, bridge work is generally done in two stages. The dental assistant must know how long the lab needs to prepare and then return the denture to the dental office in order to book the cementation appointment for an appropriate date. It is frustrating for everyone if the patient turns up for an appointment but there is no denture to be placed. Therefore, a crown cementation appointment is usually scheduled two weeks after the preparation appointment to allow the lab sufficient time.

It is best to schedule young children in the early morning so as not to interfere with their nap times. Older patients often like appointments in the late mornings or early afternoons to avoid rush hour traffic, and sometimes find it difficult to move quickly in the early morning. Late afternoon and evening appointments are good for working adults. Patients with special needs should be accommodated. For example, diabetic patients should be given early morning appointments. That way, patients can have their medication and eat a normal breakfast so that their sugar level is not compromised. If the surgery is completed at 8:30, the patient will be able to have lunch and keep glucose levels stable.

Emergency patients are asked specific questions on the phone when they call, such as:

• “How long have you been in discomfort?”
• “Which area of the mouth are you experiencing discomfort?”
• “Is the discomfort a sharp pain or dull ache?”
• “Is the tooth sensitive to hot, cold, or pressure?”

Emergency patients should be reassured that the dentist will see them as soon as possible to help relieve their discomfort.

The appointment book has a matrix, which is the framework or outline of the schedule. Holidays, lunch hours, starting times, ending times, vacations, continuing education seminars and meetings, and buffer times are all elements of the matrix.

A unit is an increment of time used when determining the length of the particular appointment. Most dental appointment books are made up of ten- or 15-minute units.

A buffer period is a short period of time in the day that is left open for scheduling emergency patients or used as catch-up time for the dentist and chairside assistant in a busy schedule. When a patient does not show up and does not call to cancel, this is known as a broken appointment. Skilled assistants are able to juggle these open time slots so that the dentist and staff are never idle. The assistant and dentist can use any extra time in the open schedule to write up charts, pour models, return patient phone calls, or make lab pick-up arrangements.

Prime time is the time most requested by patients. This is usually the first and last appointments of the day. Many working patients or parents prefer early morning or late afternoon appointments. This way, they can stop at the dental office before work or school, or leave straight from their dental appointment and go home in the afternoon.

A treatment plan is a list of the dental procedures to be completed for the patient, and it is divided into appointment visits with specific time allotments for each visit. The appointments are made based on the treatment plan. They are listed from most urgent to least important or elective procedures.

Short appointments can be dovetailed, which means working a second patient into the schedule during another patient’s long treatment appointment, either at the beginning or end of the long appointment. The second patient is booked so that the chairside assistant can remain with the fi rst patient while the dentist examines the second patient.

Production goals should be considered when appointing patient treatment. The office usually sets a minimum figure of how many new patients, units of crown and bridge, and hygiene production are done on a daily basis. This minimum goal is what covers the office overhead.

Continuing Care/Recall Management

A continuing care or recall system notifies patients when they are due to return to the dental office for routine dental care. This system helps patients maintain good oral health for a lifetime.

A routine cleaning and examination is the most common reason for the patient’s recall visit. However, the patient may need to return to the office for other reasons, such as a limited exam of the treatment site after surgery, a limited exam of an eruption of a particular tooth, exam of a full or partial, follow-up on an endodontic treatment, or follow-up on an implant. There are three types of continuing care/recall systems:

• Advanced Appointment Recall System
• Telephone Recall System
• Mail Recall System

Advanced Appointment Recall System

The recall visit is scheduled before the patient leaves the office. A continuing care/recall postcard is mailed out as a notice or reminder of the patient’s pre-scheduled appointment. The advantage is that no extra cost or time is involved for the business assistant, and it projects future production in the appointment book.

Telephone Recall System

The business assistant calls patients when they are due for their recall visit and schedules the appointment. The disadvantage is that this system is very time-consuming.

Mail Recall System

A recall postcard is mailed to patients notifying them that they are due for their recall appointment, and they call the office for an appointment. Recall/continuing care postcards are filed in a chronological file and mailed out two weeks prior to the appointment date. These should be issued according to HIPAA guidelines. The disadvantages of this system are that it is costly and time-consuming.

Accounts Receivable Management

Accounts receivable is the total amount of money owed to the dentist for services rendered. The daily charges (fees for dental services) are posted onto the patient’s ledger. The payments received are also posted to the patient’s ledger. The total balance on all the patient’s ledgers is the accounts receivable. The total accounts receivable is either owed to the doctor by the patient or the patient’s dental insurance company.

There are times when patients cannot afford to pay for all services received, in which cases financial arrangements must be discussed with the patient. These arrangements often take the form of a payment schedule. These can be tailored based on the patient’s ability to pay versus the dental office’s need for income. As creditor or lender, the dental office is required to complete a Truth in Lending form, which is a federal document used when a treatment plan is extended to four or more monthly payments.

Bookkeeping is the process of recording financial transactions. Keeping accurate records is essential in account management. It is always best to take your time and double check the entries. For example, at the end of the day, all money, checks, and credit card slips must be deposited with a proper deposit slip. The total amount on that slip should agree with the payments column on the day sheet.

All daily charges are posted to the patient’s account ledger. All payments made are also posted to the patient’s ledger as they are collected. The total amount of the checks, cash, and credit card payments made must agree with the total of monies posted as payments in the computer that will be printed on a daily transaction sheet.

A debit balance is the amount owed to the dentist for services rendered. A credit balance is a total of what the dentist owes a patient. Credit balances usually stem from patients paying for services in advance (before the services are completed).

Statements or bills are mailed to the patients to show them their financial status and amount owed to the dentist. The statement indicates the charges, payments, and adjustments made to their account. Adjustments to the patient’s accounts include professional adjustment, senior citizen discount, family discount, returned check fee, and, in some offices, service charges for balances that are over three months old.

The balance on the statement or ledger is the total amount of money owed to the dentist. The balance is aged into categories showing the patient how long the balance has been owed. The aging categories are current, 30–60 days, 60–90 days, and over 90 days.

An accounts receivable report is generated monthly so that the business assistant can follow up on the money owed by call or sending letters to the patient and/or the insurance company. Legal guidelines must be followed to avoid harassment of patients when collecting overdue amounts. When you have exhausted all other avenues trying to collect a patient’s debt, the final step is to contact a collection agency. When working with accounts receivable, it is important to follow the Fair Debt Collection Practices Act, a federal act passed to protect the patient from unethical collection procedures.

Financial arrangements or payment plans can be arranged with the patient. Credit bureaus can be called for credit reports on patients that are setting up payment plans with the office if the business assistant has obtained the patient’s consent.

Accounts Payable Management

Accounts payable refers to the amount of money owed by the dentist to others to run the dental practice. This is often referred to as overhead. The office overhead is much like running a household. The income is portioned out to cover monthly expenses. The following are some costs that dental businesses must consider.

Office Mortgage or Lease

The cost of the office space, whether it be leased (long term) or purchased through a mortgage, is an office expense. It is the most costly of all of the doctor’s overhead expenses. Some dentists will share office space or building space with other medical/dental professionals in order to cut down on this overhead expense.

Utilities

The utilities are the same as your water and electric bill at home. The dentist must pay for the electricity, water, and sewage for the dental practice.

Dental Supplies

Dental supplies are an ongoing overhead expense. These are usually divided into two categories: expendables and capital expenses. Capital expenses include big ticket items such as equipment, computers, etc. Expendables are those consumable supplies that are used daily and must be replenished.

Staff Salaries/Payroll

Staff salaries are a major portion of accounts payable. To attract the best employees, you have to pay the best salaries. Employee benefits range from medical coverage to retirement plans, and this is often a large part of payroll expenses. A benefit plan summary is a description of the benefits that the employer offers to the employee.

Additional payroll expenses include preparing paychecks, making deductions, and completing the necessary forms, all of which are time-consuming. The Federal Insurance Contributions Act (FICA) is the federal law that requires employers to withhold taxes for Social Security and Medicare programs.

Payroll Taxes

A yearly wage and tax statement for each employee is made on the W-2 form, showing the income, taxes, and other deductions.

Insurance

The dentist may pay all or a portion of medical insurance premiums for the staff.

Petty Cash

A small amount of money is kept in the office for incidental expenses or making change for cash-paying patients.

Dental Insurance Management

Many patients have dental insurance and, as a courtesy, the dental office will often bill the insurance company directly for the dental services rendered using a claim form. A claim form is generated for every date of service. The claims are either printed on paper and faxed, or mailed to the insurance company, or created digitally and sent electronically to the insurance company using the computer. Electronic claims are either sent to a clearing house or directly to the insurance company. A clearing house pre-screens the dental insurance claim to ensure that all pertinent information is complete and correct.

Under the HIPAA, all healthcare providers, health plans, and healthcare clearing houses that transmit data electronically must use a universal language and a standard format. The universal language is the American Dental Association (ADA) Current Dental Terminology (CDT) Code on Dental Procedures and Nomenclature. Each specific dental procedure is identified by a code.

The codes start with a D, are followed by four numerals, and are categorized according to the type of procedure. The CDT has a complete list of the current dental procedure codes, along with a description of the procedure.

Dental insurance policies can be quite complex, and there is a wide variation in procedures covered from one insurance company to the next. Dental insurance plans outline payments based on a set fee allowance for each dental procedure, known as a fee schedule. Benefit plans often have certain restrictions or limitations that may include age limits for particular procedures, waiting periods, and frequency of certain services.

The percentage of the insurance claim the company will pay depends on the type of procedure and the insurance contract. Because of the complicated nature of insurance policies, it is difficult to predict which procedure and what percentage a particular policy will cover. That is why dentists submit treatment plans to the insurance companies before starting work to get an estimate of how much of the treatment will be covered. This is known as predetermination of benefits.

The highest total amount an insurance carrier will pay toward the cost of dental treatment in a given benefit period is known as the annual maximum allowable amount. Dental procedures must be properly categorized for insurance purposes. For example, adult prophylaxis and study models are considered preventative/diagnostic services.

If a patient has two insurance policies, this is termed dual insurance. The two insurance companies coordinate their benefits. The first company billed is the primary carrier and the other is the secondary carrier. When more than one carrier is involved, benefits are coordinated in two possible ways:

• Standard coordination of benefits
• Non-duplication of benefits

The subscriber is the person who owns the insurance policy, and a dependent is a spouse or child of the subscriber. The subscriber signs the assignment of benefits line on the dental insurance claim form. The assignment of benefits is the authorization by the subscriber for the dental carrier to issue benefits directly to the provider, who is the treating dentist. When the assignment of benefits line is signed by the patient, the payment on the claim is paid directly to the dental office.

The insured person must pay the deductible portion of the total dental treatment costs before the benefits go into effect.

Generally, dental insurance plans cover minor children, but adult children may be covered by the parent’s policy if they are full-time students. When both parents have dental plans, the primary carrier is determined by the parents’ birth dates. The one with the birthday closest to January is the primary carrier. This is known as the birthday rule. Children of divorced parents, each with a dental plan, are generally covered by the plan of the parent with whom the child lives. This is known as the primary carrier. The plan of the other parent is known as the secondary carrier.

There are many abbreviations used in dentistry and dental insurance. For example, UCR stands for usual, customary, reasonable. For more about commonly used abbreviations, consult the appendix at the back of this book. Every dental procedure has an ADA code that is required on each dental claim form for each procedure billed to the insurance carrier. Each procedure description and procedure code is listed on a single line on the claim form.

“Signature on file” is written on all claims instead of the subscriber’s signature so that the claim forms can be billed electronically. A “signature on file” card is signed by the patient on the first visit and kept inside the record.

The provider is the attending dentist who performs the dental treatment. The provider’s name, address, license number, tax ID number, and phone number are all listed on every claim form.

Supplies/Inventory

Dental supplies can be divided into three categories: expendable, non-expendable, and capital.

Expendable Supplies

Expendable supplies are single-use items that are disposable and thrown away after one use. Examples include cotton rolls, gauze, local anesthetic, stationery, plastic barriers, gloves, and headrest covers.

Non-Expendable Supplies

Non-expendable supplies are reusable items that are not a major expense. Examples include most dental instruments, curing lights, and hand pieces. These supplies are sterilized and then reused.

Capital Supplies

Capital supplies are the more costly items that are seldom replaced, for example, computers, sterilizers, dental chairs, and dental units.

An inventory system is a list of all supplies used in the dental offi ce that includes capital, expendable, and non-expendable items. Capital items are usually tracked on a spreadsheet or individual cards. Expendable and non-expendable items are tracked using either a computerized inventory system, or a manual card or list inventory system. If a card system is used, an individual card represents each item.

Inventory system information is usually tracked according to the minimum order amount, maximum order amount, date ordered, amount ordered, unit price, and arrival date of the item, along with the product name, brand name, supplier name, and the supplier’s address and phone number.

The amount ordered of each item is based upon the shelf life of the item, the rate of use, the amount of money available for purchase, the amount of storage space, the supplier’s delivery time, and the special pricing of the item.

Purchase orders are used for large institutions and often include standardized order forms for the supplies. A packing slip is enclosed with the items when they arrive, and it specifies the contents of the package, the amount of items enclosed, and any items that are on back order. An invoice is a list of the cost of the contents in the package, and can also be a statement unless the supplier sends separate statements. The invoices must be compared to the statement that is received at the end of the month, and they must correspond. If an item ordered is not in stock and will be shipped at a later date, a back order memo is issued and the supplier will ship the item when it becomes available.

If an item is returned to the supplier, a credit memo is issued for the amount of the item.

Any supply that contains hazardous material must come with a material safety data sheet (MSDS). This sheet is provided to the purchaser by the manufacturer, and it provides information about the hazardous material. The U.S. government requires that MSDS sheets be saved and filed for employee and Occupational Safety and Health Administration (OSHA) reference. All team members must know where to find the MSDS book in an office. Biohazard labels must be affixed accordingly to any items that are transferred to alternate containers.

Practice problems for this study guide can be found at:

Dental Office Procedures for Dental Assisting Exam Practice Problems