A client is unsure of some of the charges on their invoice following a recent appointment. To better understand the fee breakdown, they request a copy of their oral health record. The clinical notes provided only include the following related to the time spent on Dental Hygiene treatment:

• 3 units of scale (11113 or 00513)
• 1/2 unit of polish (11107 or 00537)

Do the clinical notes provide enough information for the client to understand the charges?

CDHO’s Records Regulation requires that the amount of time spent on each intervention be recorded.

While recording time in units and/or codes may fulfill this requirement, CDHO advises that recording only in units and/or codes is confusing to clients because:

• “Units” and “codes” are terms primarily used by the dental industry for billing purposes.
• The schedule is often booked in 10-minute units/intervals, but the procedural codes are always based on 15-minute units/intervals.

To avoid confusion, CDHO encourages RDHs to record in their clinical notes the time spent, in minutes, for each Dental Hygiene intervention they perform.

The following example may help support transparent billing and provide clients with a better understanding of the charges:

• Scaled for 43 minutes (3 units)
• Selective polished maxillary and mandibular facial anteriors using fine grit mint paste for 3 minutes (1/2 unit)

Please note that while an employer may request an RDH to record billing codes, this is not a CDHO requirement.

RDHs who bill for their services must remember that a client or their representative, such as an insurance company or power of attorney, has the right to receive honest and transparent information.

If you have any questions, please get in touch with our Practice Advisor at advice@cdho.org or call 1-800-268-2346 (press 2).