January 26, 2023 • 10 mins read

Updated Medical Records are the Key to Success in Medical Billing in Dentistry!

Stay up to date with the latest medical billing trends in dentistry. Learn how to keep medical records upto the mark with the successful keys.



Danielle Duncan

Medical Billing in Dentistry

When it comes to running a successful dental practice, there are a lot of gears and moving parts that keep it running smoothly. Providing the best possible dental care is the cornerstone of any dental practice, one of the biggest foundation pieces in creating a smooth process for a dental practice and the patients that they see is keeping detailed medical records on hand. 

Not only does having a detailed medical record for each patient help during treatment and keep you compliant with local and federal regulations on record keeping, but it can also help you in your journey of billing medical insurance for dental treatment. 

There is a balance in keeping medical records updated, some practices may update them too frequently, while others do not update them enough. So, what is the sweet spot in keeping a patient’s medical records fresh? 

How often should a medical history be updated? 

While there is no set-in-stone frequency of updating medical records from a legal standpoint, it is important to find the best interval to balance between patient experience and appropriate record keeping. 

Some practices may take the approach of updating their medical records at every visit, this may sometimes be a put-off for patients who just want to get their dental treatments completed as quickly and efficiently as possible. However, others may wait two to three years before asking patients to update their health records. 

The sweet spot for updating medical records for patients is to follow an annual schedule. This allows patients to update records with any changes that may have occurred in the last year, without bombarding them with paperwork at the start of every visit. 

Of course, medical records can be updated more frequently if a patient’s medical history dictates it. If you have a patient with a history of chronic conditions, it may be best to update your records on a semi-annual basis instead of an annual basis. 

Who should complete the medical history?

Every patient that walks through the door should have a well-documented medical history. Adult patients will typically complete their own medical histories, while minor children will have a parent or legal guardian complete the medical history for them. 

There are two main methods to gather these medical histories from patients. The traditional method is to provide patients with a medical history form to fill out before their scheduled appointment, while other practices that have embraced the use of modern technology may opt to send their patients’ online forms to complete prior to their appointment date. 

Regardless of the method of collection, some patients may need help in completing their medical histories. This is where dental assistants come in. These office superheroes will assist patients in completing all sections of the medical history, addressing any questions they have, and any conditions that should be brought to the dentist’s attention highlighted before the appointment. 

When should the history be completed?

A patient’s medical history should be updated at least annually and preferably, any time there is a new medical event that could impact the overall health of the oral cavity. 

When a patient’s history is collected largely depends on the collection method. If you provide paper medical history forms, patients will typically fill them out in the dental office prior to their appointment. However, online forms will typically be completed at the patient’s discretion once received before the appointment. 

Offering an online patient portal can also help streamline the process of maintaining and updating medical histories, allowing patients to update their histories immediately after any health changes. 

One thing to note, while it may be tempting to get an emergency patient through to treatment right away, they also need to have their medical history updated before treatment to prevent any potential avoidable risks during treatment. 

Getting Patients on Board:

Sometimes patients simply don’t want to comply with updating their medical records or may feel that they are being forced to fill out too many forms. In cases like this, it is important to explain to the patient why having an updated medical history is so important. 

Not only does a complete medical history help dictate the overall treatment, but it can also give a dentist insight into what may be causing problems in the oral cavity and prevent future degradation of the teeth and gums. 

Make Sure Patients Understand the Questions on your form

Some medical jargon is expected on medical history forms, but it should still be easy to read. Along with an easy-to-read medical history form, making yourself available to answer any patient questions while filling out their medical history can ensure that you have a clear picture of your patient’s medical history. 

Make sure those forms are filled out fully!  

Some patients may pass the buck and fill out what they deem absolutely necessary. They may breeze through the easy questions and gloss over any medical conditions they may have. 

Unfortunately, it is common for patients to not realize just how much medications and chronic conditions can impact their overall oral health. 

After the medical record paperwork has been turned in, a dental assistant should take a little time to read through the patient’s answers to ensure that nothing is missed before the appointment. 

Get their autograph! 

Getting a signature at the end of any medical paperwork makes it official. If a signature is missing, ask the patient for their autograph!

Keeping up-to-date records that include the date and signature will help keep a solid timeline of the patient’s medical history. 

What to include in a patient’s medical history: 

There are several details that need to be included in a patient’s health record to ensure that they get the best possible care at your dental practice. 

Some issues that should be covered in the health history form and records should include: 

  • Health conditions and illnesses. These can be transitory or chronic conditions. 
  • Contact information to any primary care physician and specialists that are coordinating to provide medical treatment. 
  • A current list of any medications that the patient is taking. This should include any prescriptions and over-the-counter (OTC) drugs taken on a regular basis or are currently being taken on a short-term basis to treat current health issues. 
  •  The reason(s) the patient is seeing their dental professional. 
  • An area of the form should include additional information so that the dentist can make notes during their Q&A with the patient. 
How updated medical histories can help with billing medical insurance for dental treatments: 

Billing medical insurance for dental treatments is a relatively new phenomenon. Dental practices that are new to billing medical insurance for dental treatments to provide their patients with the best possible coverage should keep their patients’ medical histories in mind. 

Having a detailed medical history for each patient can be the difference between being denied or approved when submitting a claim to medical insurance. 

Having a diagnosis code that could impact the overall oral health of a patient can lead to more treatment acceptances by your patients if they don’t have to worry about paying for a treatment they may not get covered otherwise. 

Learn more about how Devdent can help you with gathering the information you need for a patient’s medical history for medical billing in dentistry by signing up today! 

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