Writing Narratives That Will Result in Reimbursement

It is no fun to write a narrative. It takes an extensive knowledge of the procedure and what the plan is looking for as justification for the treatment provided. It also takes time, and time is one commodity that the typical dentist has little to spare. This article will take a close look at the construction of narratives. It will identify some of the challenges to writing a narrative. Finally, the article will provide information that will allow the dentist to prepare a narrative in such a way that the claim is paid or pre-determination is approved on first submission.

Here is a list that contains some frequent concerns, followed by recommended solutions.

Concern #1 - It takes too long to write

Keep in mind that if a narrative takes too long to write, it also takes too long to read. Those who review claims for dental insurance carriers have been confronted by office personnel who indicate that their boss didn’t have time to write a three-page letter explaining why the patient needed a crown. The dental consultant reviewing the claim can certainly appreciate that. In fact, he or she doesn’t have the desire or time to read a three-page letter either. The dental consultant just needs to know the pertinent details regarding the proposed service. The first thing to understand about narratives is that they should be concise and to the point.

You can be brief when writing the narrative, because it is another dentist who will be reading it. Since you both speak “dental,” you can write your narrative using the dental abbreviations that all dentists understand.

Concern #2 - The Provider is not sure what the dental consultant needs to know

The dentist reviewing your claim needs to know the specific diagnosis or condition for which the treatment is being performed. In the case of a crown or an onlay, issues that need to be addressed in a narrative include the following: Is there decay and if so, how much? Is there an existing restoration? If so, which surfaces are involved, and what is the condition of the restoration? Is any part of the tooth or restoration fractured off? How much healthy tooth structure is left? Is any cusp missing or undermined?

Given this list of questions, you are probably wondering how writing a short concise narrative in a reasonable amount of time is possible. In most cases, the doctor has performed a visual exam, a radiographic exam, a periodontal exam, and determined the need for pulp vitality tests of the tooth in question; however, the dental consultant doesn’t need all of the information you have gathered about the patient - just the part that explains why you determined the tooth should be restored with a crown or onlay (the criteria for benefit plan payment is generally the same for either of these procedures).

But how exactly do you relay this information in a narrative in a reasonable amount of time? Think about the last patient for whom you recommended a crown. After you gathered the clinical information about the patient, how long did it take you to decide the patient would be best served by placing a crown or an onlay? Based on my own experience and conversations with other dentists, I would estimate that it takes less than a minute.

After all of our years of training, dentists make those decisions so quickly and for the most part so easily. We barely realize how many pieces of information we evaluate to come to that decision. To create a narrative for a single crown or onlay, a dentist must separate out those particular pieces of information that are integral to making that recommendation and put those facts in a brief narrative.

For example: A patient comes in with the chief complaint that “part of his tooth fell off.” During the oral evaluation you review the patient’s health history and note that #30 has an MOD amalgam, and the ML and DL cusps have fractured off at the gum line. You order and evaluate the necessary radiographs. You perform six-point periodontal probing and other periodontal evaluations as necessary to determine the periodontal status of the tooth. You confirm the endodontic status of the tooth. You determine that a crown is necessary on #30 and that #30 is periodontally and endodontically sound, and that the patient’s general health is such that he can withstand the procedure. You recommend the crown to the patient, and the patient agrees to proceed with treatment.

Now, to write the narrative:

You have gathered the necessary information. Now, what do you include in your narrative? You include the information that made you decide to recommend a crown. Just by looking at the radiograph, could you have determined the need for the crown? No. The amalgam would obscure the fact that the ML and DL cusps were missing. If you can’t see the problem in the radiograph, neither can the dental consultant. So, your narrative only needs to communicate what cannot be seen in the radiograph. Your complete narrative would read, “ML and DL cusp fractured off at gum line.” Sending clinical photos of the tooth (along with your narrative) may also be helpful and is highly recommended.

Do you need to tell the dental consultant about the periodontal and endodontic status of the tooth? If the periapical radiograph you send shows that the tooth is periodontally and endodontically sound, you do not need to state this in your narrative; however, if there is significant bone loss then you need to explain what periodontal treatment has been completed or is planned. If there is an apical lucency or if the existing root canal is short, overextended, etc., a brief explanation of the existing symptom and endodontic status of the tooth is also necessary.

The treating dentist has the luxury of seeing the patient, hearing his/her story, examining his/her mouth, and reviewing the radiographs and any clinical photos before making a decision. With just a radiograph it is impossible for the dental consultant to know as much about the tooth as the treating dentist does. Writing a brief narrative allows the treating dentist to tell and/or show the dentist reviewing the claim what could be appreciated clinically that may not be obvious on the radiograph. If you, as the treating dentist do not see the information needed to make the treatment recommendation, unless a photo and explanation is provided the dental consultant, the dental consultant can’t appreciate what you heard or saw during the evaluation.

Finally, the clinical record should always mirror the information provided to the payer in the narrative. When writing your next narrative for a single crown or onlay, remember it best to remember the KISS rule, “keep it simple stupid.” What details did you see that were pertinent were pertinent in the treatment decision-making process? Always ask yourself, what information is not clearly evident in the images used to make your treatment decision? Compare your answer with the information you are sending with the claim. When submitting the claim or predetermination, include a periapical radiograph and a photo. Add to the radiograph and photo any additional information you appreciated that helped you diagnose the pathology, determine the appropriate treatment and make the treatment recommendation to the patient. When you routinely include this information in your narratives in a complete and concise way, you will be able to generate a narrative that will result in prompt and easy payment from the carrier.