Document first, code second: why the clinical note comes before the claim.

By Dilaine Gloege, CDA, CPC

"Document what you do and why to the highest level of specificity. Code for what is documented to the highest level of specificity."
    - Dilaine Gloege

Proper coding begins with clinical documentation. Historically in dentistry, we have coded based on the services the patient was scheduled to receive, and I still find claims submitted before the chart note was complete, reviewed, and signed by the treating provider attesting to its accuracy. The order matters: document with the highest level of specificity, review for accuracy, and then select the correct procedure and diagnosis codes.

Many hygienists work in school-based sealant programs, community clinics, and mobile units, often under general or public health supervision, where you may be the only provider documenting the encounter. When Medicaid funds are involved, every code you report tells a government payer that the service was necessary and was delivered as described. Our clinical note must prove it. Everyone involved in the encounter shares responsibility, and if your name is on the note, your credential stands behind it.

WHAT DOES SPECIFICITY LOOK LIKE?

The note must be specific to each patient, their condition, and any medical conditions linked to the diagnosis and treatment. It must establish medical necessity, explain the rationale for each procedure, and reflect the clinical decision-making that led to the diagnosis and treatment. We are held to the same documentation standard as our medical colleagues. We are storytellers, and the note must tell the whole story of the encounter.

EVERY NOTE ANSWERS

WHO was treated, and who provided the care
WHAT was recommended and/or rendered, by tooth or area
HOW the service was performed, including any complications
WHY it was necessary: the condition or diagnosis

Anyone reading the note should know the full story without the provider in the room to explain it.

Simply documenting "occlusal caries" does not tell that story. For example, when assigning a diagnosis code to describe the extent of decay on the occlusal surface of a posterior tooth, the codes are specific to caries on the pit and fissure surface. Whether the caries are limited to enamel (K02.51), penetrate dentin (K02.52), or reach the pulp (K02.53), your note must describe the extent of the caries. The routine preventive care visit is no different: Z01.20 (dental examination and cleaning without abnormal findings) tells a very different story than Z01.21 (with abnormal findings), which requires an additional code identifying what was found.

Caries risk works the same way. Risk documented as low, moderate, or high (Z91.841, Z91.842, or Z91.843) must be supported by a recognized caries risk assessment tool, as the CDT code descriptors require, and the completed assessment is part of the patient record. This applies every time a caries risk determination is documented, not just a one-time assessment performed at intake. The date on the assessment must match the date of service where the risk was stated.

Some state Medicaid programs already require diagnosis codes, and that requirement is likely to grow. You cannot assign an accurate diagnosis code when the note lacks specificity.

WHY THE CLINICAL NOTE MATTERS

The clinical note ensures continuity of care, which is essential in public health, where patients may see a different provider at every visit. It is the only legal record of the clinical encounter; it tells the story of the encounter, and anyone reading the note, whether the patient, a Medicaid auditor, or a judge, should know the full story.

We never know who will read our note, or why. I once gathered records to document neglect in a custody matter. I knew the child's mother had been told repeatedly to stop putting her to bed with a sippy cup of juice, and the child had rampant caries. Yet when the dental record was subpoenaed, none of those conversations were documented.

THE SOAP NOTE

While no legal requirement dictates how a healthcare provider creates the clinical note, the recognized standard across healthcare is the SOAP note. The SOAP note method is recommended because anyone reading the note can follow the encounter, whether the reader is the patient, a judge, or an auditor.

* Subjective: the reason for the visit, the chief complaint and symptoms in the patient's own words, and a summary of the medical, dental, and social history review. Ask open-ended questions to confirm the patient's reported information.

* Objective: vital signs and the clinical facts, including abnormal findings (or absence of abnormalities) from oral, radiographic, and periodontal evaluations. What is seen, heard, felt, measured, and smelled.

* Assessment: the diagnosis or condition by tooth or area, and why treatment is required.

* Plan: treatment planned and rendered by tooth number, consent, discussion with the patient or guardian, referrals, and recommendations for the next visit.

COMMON DOCUMENTATION ERRORS

The most common error is failing to document the why. Examples I see repeatedly in all types of dental clinics, whether it be private or public health:

* Caries arresting medicament (D1354): The record must show an active carious lesion, on which tooth, and that the medicament was placed to arrest it. "SDF placed" does not support necessity, and payments can be recouped in an audit.

* Sealants (D1351): Document each tooth and surface, the condition of the surface, the caries risk, and the isolation and materials used. The tooth number supports each unit reported.

* Behavior management (D9920): "Tell, Show, Do" is not enough. Document what was attempted and why it was unsuccessful, any supporting medical conditions, the Frankl score, the techniques used, and the outcome.

Routinely billing behavior management to Medicaid invites an extensive review, which can lead to audit and recoupment.

* Canned notes: Template prompts left blank, entries left unedited, and notes that look the same for every patient are patterns that increase your risk for an audit.

WE CODE FOR WHAT WE DO. THE CONTRACT DECIDES WHAT WE BILL.

Only what is documented may be reported, and no code should be reported for the sole purpose of gaining reimbursement. We document and code what we do from the current CDT code set, regardless of benefits, but that does not mean we can bill it. Review your contracts and your state Medicaid provider manual. For example, many Medicaid programs prohibit billing behavior management with nitrous oxide on the same date of service, a highly monitored coding and billing pattern.

HOW CAN WE AVOID ERRORS?

1. Enter the note at the time of service and finalize it before the claim is submitted.

2. Review notes daily for accuracy and specificity.

3. Invest in current CDT resources every year. A single changed word in a code nomenclature and descriptor can change how a code is utilized and how it must be documented. Remember, Google and Facebook are not reliable coding sources; reference the CDT manual instead.

4. Make coding and fraud, waste, and abuse training part of annual compliance training for every team member.

5. Audit internally, with documented corrective action, as part of a compliance program built on the seven fundamental elements.

WHEN SHOULD THE CLAIM BE SUBMITTED?

No claim should be submitted until the note has been entered, reviewed by the treating provider for accuracy, signed, and locked. An unsigned clinical note is not valid.

ABOUT THE AUTHOR

Dilaine Gloege, CDA, CPC, has spent nearly four decades in dentistry and is nationally recognized for her expertise in dental coding, documentation, and insurance. She has taught dental teams medical billing for more than ten years. She has contributed to industry resources including Coding with Confidence, Administration with Confidence, and Medical Dental Cross Coding with Confidence. As founder of Tidewater Dental Consulting, she supports dental teams, including public health programs, through speaking, writing, and consulting, and also serves as a subject-matter expert and legal analyst.

[email protected] | www.tidewaterdentalconsulting.com
Disclaimer: The information presented is intended for educational and training purposes only. It is not legal advice. The author is not an attorney. For any legal questions, please consult a healthcare attorney. Always document and report what you do using the CDT, CPT, or ICD-10-CM code that most accurately describes what you did and why, selected from the current code set.

CDT codes and nomenclature are from CDT 2026: Current Dental Terminology, (c) 2025 American Dental Association (ADA). All rights reserved. ADA is the exclusive copyright owner of CDT.