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The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.
The assessment begins with a dental-health questionnaire, including questions about toothache, hoarseness, dysphagia (difficulty swallowing), altered taste or a frequent sore throat, current and previous tobacco use and alcohol consumption and any sores, lesions or bleeding of the gums.
A medical biller then takes the coded information, combined with the patient's insurance details, and forms a claim that is submitted to the payors. [2] Payors evaluate claims by verifying the patient's insurance details, medical necessity of the recommended medical management plan, and adherence to insurance policy guidelines. [4]
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In addition, payment to dental professionals is based on the CDT code(s) reported on the ADA Claim Form, so using the most current codes helps to maximize reimbursement and minimize audit liability. [6] In the near future, dental professionals will be required to use diagnosis codes in support of the procedures and services they provide.
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According to Shivam Shah collaborative care is a form of systematic team-based care involving: A case manager responsible for the coordination of different components of care; A structured care management plan, shared with the patient; Systematic patient management based on protocols and the tracking of outcomes;