Dental Office Chart Audit Checklist

Dental office chart audits are an invaluable way to ensure patients’ records contain accurate and up-to-date records, while also helping reduce inaccurate coding and billing claims.

An ideal purchase can begin by conducting a chart audit, reviewing the seller’s fee schedule and appointment book, as well as assessing practice management software. An on-site quality assessment review can also prove invaluable in providing valuable insight.

1. Review the Day Sheet
Every practice should run the Day Sheet report at the end of every day to provide financial data related to production, collection, adjustments and providers over a specified range of dates.

This report is essential for balancing, proof-of-posting and receivable control of accounts receivable. It documents what was charged, collected and posted during each day as well as carrying forward balances for month end closing.

Clicking the Report button on Oscar’s navigation bar, and choosing Day Sheet from its dropdown menu, brings up all appointments for any date specified in the Day Range field, based on which physician was selected from Physician dropdown menu. Appointments information updates in real-time as ERAs/EOBs are posted, cash payments recorded or insurance payments arrive – providing real time insight.

2. Review the Patient’s History
An extensive dental patient history is key to providing effective diagnosis and avoiding potential harm during treatment, such as avoiding medications to which someone has an allergic reaction. Furthermore, it provides useful insights into family medical histories which may assist in risk stratification for certain illnesses that run in families.

An effective clinical audit program can be invaluable in helping your practice identify problems and enhance processes and systems. However, chart audits alone cannot uncover every issue within your practice and should only be seen as one tool among many.

Conduct both prospective and retrospective chart audits to ensure that only work completed is being billed, with the latter selecting samples of claims that have already been submitted for reimbursement and paid back out.

3. Review the Treatment Plan
Treatment plans are important documents that outline any proposed services or changes to existing services that need to be provided or altered, and it’s vitally important that they are reviewed to ensure clients fully comprehend what will be done and why.

Review results can assist the practice in making improvements to its operations and alter patient management practices. This may involve looking at recruitment tactics for new patients, what referral sources have the highest success rates and how well the office manages patient records.

Chart audit results can also assist the dental office in identifying areas that need improvement, whether that means improving clinical care quality or simply tweaking practice systems to prevent mistakes. Prospective audits help ensure all work completed gets billed appropriately while retrospective audits select a sample of services already submitted and reimbursed by payers. It’s essential for practices to have both prospective and retrospective chart audits in place – prospective audits ensure billings get submitted properly while retrospective audits test reimbursement rates.

4. Review the X-Rays
X-rays should always be processed according to the film and processing machine manufacturer’s recommendations, in order to maintain diagnostic quality images while limiting patient exposure to unnecessary radiation.

As soon as a type of X-ray or film changes, the technique chart should also be updated. This helps avoid inaccuracies due to incorrect charting and ensures radiographs of diagnostic quality.

Make sure your daily deposit report runs regularly to check that amounts posted match what has actually been received from dental plans, this will help avoid billing mistakes and potential fraud as well as preparing you for potential insurance audits; auditors look for consistency and accuracy so performing routine audits may catch many errors before they cause issues.

5. Review the Records
Conducting an audit of each patient record in your dental practice is of utmost importance, not only because it allows you to stay abreast of treatment plans but also in case of malpractice suits. A chart audit can reveal important details like amalgams being documented but not present or planned restoration being completed with different materials than stated.

As part of your chart audit, try to review patients who were seen within the last year. This can provide an indication of whether your office is adhering to proper coding and billing practices as well as analyze how many of your existing patients are returning on time for preventive appointments and if there is any outstanding work that needs completing.