Files > DENTAL TREATMENT (AMIS)

name
DENTAL TREATMENT (AMIS)
number
221
location
^DENT(221,
description
The Treatment file contains all dental treatments for each patient entered by the date of treatment and the provider ID #. This is the core of the dental package where all dental activities are recorded. Entries are usually recorded in this file on a daily basis.
Fields
#NameLocationTypeDetailsIndexDescription
.01date(+)0;1DATE-TIME
.3station.division(+)0;40FREE TEXTThis is the three digit station number.
.4provider number(+)0;10FREE TEXTCENTER IN THIS FIELD THE PROVIDER CODE NUMBER
.5dental provider(+)0;3POINTER220.5This is the dental provider. Names are entered lastname,first name.
1ssn(+)0;2FREE TEXTD
2dental patient(+)0;39FREE TEXT
3patient (pointer)(+)0;4POINTER2E
4.5patient category(+)0;19POINTER220.2Category 19 includes only priority 1, continued after priority 1 inpatient care. Category 21 includes only priority 2, continued after priority 2 inpatient care. Category 22 includes only priority 3, continued after priority 3 inpatient care and active duty military personnel, military retirees, and CHAMPVA.
5bed section0;6POINTER220.4
6screening/complete exam0;7SET OF CODESS:SCREENING
C:COMPLETE
SCREENING EXAMINATION The screening examination includes an evaluation of the oral and perioral soft tissues and a visual estimate of dental status without a tooth by tooth charting. Radiographs usually will not be taken, but may be if PROFESSIONALLY DETERMINED to be necessary as for an emergency. A chart review (patient not present at time of review) is also classed as a screening exam. When a chart review is entered the provider must also mark ADMIN PROCEDURE on the screen to avoid a "patient visit" count. Note: Providers must be aware of significant medical problems; therefore, a medical and dental history and/or medical record review must be included. Recall examinations (may be less than six months) would be included in this area. The screening examination is an essential part of the admission physical examination. All INPATIENT screening examinations will be placed in a Priority 1 Category. If the inpatient does not fall into Emergency, Extended Care, NHCU, Dom, or Special Provisions, s/he would be placed in the Compelling Medical Need Category. All OUTPATIENT screening examinations will be placed in Priority 1. COMPLETE EXAMINATION A complete examination includes dental charting on a tooth by tooth basis as well as the comprehensive evaluation of the oral and perioral soft tissues. A head and neck exam is included as an essential portion of the complete examination. A thorough review of the medical chart and medical history with the pertinent medical findings noted on the dental record are included in the complete examination. A complete examination will be accomplished for a patient who is to receive treatment other than emergency care. Complete examinations will be recorded in the appropriate inpatient or outpatient category/priority.
6.2interdisciplinary consult0;42SET OF CODES1:INTERDISC. CONSULT
Count those that were instituted via Form 513 (Consultation Request), a telephone request with following Form 513 and Form 10-10 or 10-10m with progress notes attached. All INPATIENT interdisciplinary consultations will be placed in a Priority 1 category. If the inpatient does not fall into Emergency, Extended Care, NHCU, Dom, or Special Provisions, s/he would be placed in the Compelling Medical Need Category. All OUTPATIENT interdisciplinary consultations will be placed in a Priority 1 Category.
6.4evaluation0;43SET OF CODES1:EVALUATION
No more than one evaluation per provider can be counted on the same visit. Evaluations are identified as medical/dental workups, (e.g., periodontal, surgical, endodontic, etc.) on those patients for whom a complete screening examination has already been performed. Evaluations may be in conjunction with review of a medical record, the initiation of an interdisciplinary consultion or with a medical or dental emergency workup on a patient for whom no definitive treatment is delivered. An evaluation made by the staff mentor for trainees at a scheduled treatment visit prior to carrying out a specific treatment procedure is counted as education time. All other INPATIENT evaluations will be placed in a Priority 1 Category. If the inpatient does not fall into Emergency, Extended Care, NHCU, Dom, or Special Provisions, s/he would be placed in the Compelling Medical Need Category. All OUTPATIENT evaluations will be placed in a Priority 1 Category.
6.6pre auth/2nd opinion exam0;44SET OF CODES2:PRE-AUTH/2ND OPINION
A pre-authorization exam is performed on a fee basis patient in order to determine treatment needs prior to authorization of the patient to a fee- for-service provider. A second opinion exam is performed when the original estimate on a fee basis dental case exceeds $500.00.
6.7spot check exam0;27SET OF CODES1:STAFF
3:FEE
6.8spot check discrepancy #0;45NUMERICThe DISCREPANCY categories are defined as follows: 1 = MINOR discrepancy only 2 = MAJOR discrepancy-- QUALITY ONLY 3 = MAJOR discrepancy- MISREPRESENTATION ONLY
7admin procedure0;8SET OF CODES1:ADMIN PROCEDURE
An entry should be made in this field when a case, a service or a procedure has been administratively completed or terminated without an actual patient visit (i.e., chart review, telephone call, death, etc.).
7.1completions/terminations0;41SET OF CODES2:COMPLETION
3:TERMINATION
COMPLETIONS A case is completed when all treatment authorized has been accomplished. Only one count should be taken for a patient during any single period of hospitalization unless the patient is under long term care. In the case of long term care patients, including NHC and Dom patients, a count for a completed case may be taken once in each six months if re-examination indicated need for another episode of care. For outpatients, only one complete case count may be taken per episode of care for which a treatment plan was established, even if there were intervening terminations. If, after an outpatient case has been completed and s/he is eligible for recall, another episode of care may begin with the recall examination if treatment is indicated. Treatment plans will not be segmented for the purpose of multiple completions during an episode of care. For cases administratively completed, also make an entry in the ADMIN PROCEDURE field. TERMINATIONS A case is terminated when an episode of care is interrupted or stopped short of completion of the authorized treatment plan. Examples of this would be the death of a patient, discharge to OPT status, closure of the case due to failed appointments, health reasons, or at the patient's request. For cases administratively terminated, also make an entry in the ADMIN PROCEDURE field.
8x-rays extraoral #0;9NUMERICEnter the number of EXTRAORAL radiographs taken on this patient for panoramic, cephalometric or other extraoral procedures.
10x-rays intraoral #0;11NUMERICEnter the number of INTRAORAL radiographs taken for this patient for PA, bitewing, occlusal and other intraoral procedures.
11prophy natural dentition0;12BOOLEAN1:YES
In special circumstances, when a patient is of such a difficult nature that two or more appointments are needed to complete the prophylaxis,credit for each treatment episode may be recorded. If a patient is on a formal recall status, such as head and neck cancer patients who are being followed after radiation treatment,credit may be taken at each prophylaxis appointment. A prophylaxis will include a complete review of preventive oral disease instructions.
12prophy denture0;13BOOLEAN1:YES
If a patient had a prophylaxis of natural dentition and a removeable prothesis cleaned on the same visit, an entry can be made for both procedures.
14neoplasm confirmed malignant #0;15NUMERICActivities surrounding the confirmation should include patient/family counseling and discussion with other hospital services (laboratory, surgery, etc.) for diagnostic interpretation and treatment planning. All confirmed malignant neoplasms on INPATIENTS will be placed in a Priority 1 Category. If the inpatient does not fall into Extended Care, NHCU, Dom, or Special Provisions, s/he would be placed in the Compelling Medical Need Category. All confirmed malignant neoplasms on OUTPATIENTS will be placed in the appropriate Priority 1 Category.
15neoplasm removed #0;16NUMERICAll neoplasms removed for INPATIENTS will be placed in a Priority 1 Category. If the inpatient does not fall into Extended Care, NHCU, Dom, or Special Provisions, s/he would be placed in the Compelling Medical Need Category. All neoplasms removed for OUTPATIENTS will be placed in the appropriate Priority 1 Category.
16biopsy/smear #0;17NUMERICEnter the number of incisional biopsies (separate lesions) plus the number of cytological smears (one smear per patient) taken. All biopsies and cytological smears performed on INPATIENTS will be placed in a Priority 1 Category. If the inpatient does not fall into Extended Care, NHCU, Dom, or Special Provisions, s/he would be placed in the Compelling Medical Need Category. All biopsies and cytological smears performed on OUTPATIENTS will be placed in the appropriate Priority 1 Category.
17fracture #0;18NUMERICFor multiple fractures in the same bone (e.g., bilateral condylar or a bilateral combination of body and condyle) count only as one fracture reduction if only one surgical site/procedure was used. The computer generated weighted value includes all post-operative visits. All maxillofacial fractures reduced for INPATIENTS will be placed in a Priority 1 Category. If the inpatient does not fall into Emergency, Extended Care, NHCU, Dom, or Special Provisions, s/he would be placed in the Compelling Medical Need Category. All Maxillofacial fractures reduced for OUTPATIENTS will be placed in the appropriate Priority 1 Category.
19other signif. surg. (ctv) 0;20NUMERIC OTHER SIGNIFICANT SURGERY CTV'S 1. Salivary Gland Surgery 16.0 2. Dislocation 3.0 3. Laceration/suturing 6.0 4. Incision and Drainage 4.0 5. Orthognathic Surgery 65.0 6. Frenectomy* 6.0 7. Alveoplasty* (per quadrant) 4.0 8. Exostoses removal* 4.0 9. Apicoectomy 10.0 10. Tooth hemisection, Root amputation* 10.0 11. Vestibuloplasty* Sulcus revision, Ridge extension (W/O skin graft) 12.0 Graft procedure 16.0 12. Endosteal Implants** 9.0 13. All other surgeries 6.0 * These procedures will be reported at one-half of the listed units when done in conjunction with a quadrant of periodontal surgery. ** Requires VAMC Research and Development Committee approval.
21surfaces restored #0;22NUMERICDO NOT record the number of teeth restored or the number of restorations or temporary restorations in this field. They must be recorded under Other Significant Treatment.
22root canal therapy #0;23NUMERIC
23periodontal quads (surgical) #0;24NUMERICA quadrant may have fewer than eight (8) teeth present or treated, that is, a full quadrant of teeth is not required. If two to eight teeth are present in the same arch and any number cross the midline, count as only ONE quadrant. DO NOT INCLUDE SCALING AND CURETTAGE IN THIS AREA EVEN IF LOCAL ANESTHESIA IS USED. If scaling and curettage are done as part of the surgical procedure, do not take additional credit by entering both the periodontal surgery and the scaling. Included in the periodontal surgery is the chart review, local anesthesia, post-operative instructions, treating of complications, suture removal and pack changes. NOTE: ADDITIONAL SURGICAL PROCEDURES, FRENECTOMY, ALVEOPLASTY, EXOSTOSES REMOVAL, TOOTH HEMISECTION, ROOT AMPUTATION, AND/OR VESTIBULOPLASTY, WHICH ARE PERFORMED AT THE TIME OF PERIODONTAL SURGERY ARE ENTERED AS A SEPARATE PROCEDURE UNDER OTHER SIGNIFICANT SURGERY AND ARE WEIGHTED AT ONE-HALF THE LISTED VALUE IF PERFORMED IN THE SAME SURGICAL SITE.
24perio quads (root plane) #0;25NUMERICThis must not be part of a periodontal surgery procedure performed in the same quadrant on the same visit. A quadrant may have fewer than eight (8) teeth present or treated, that is, a full quadrant of teeth is not required. If two to eight teeth are present in the same arch and any number cross the midline, count as only ONE quadrant. If nine or more teeth are present in the same arch, count as two quadrants. DO NOT COUNT AS QUADRANTS OF ROOT PLANING AND CURETTAGE A PROPHYLAXIS PERFORMED BY A DENTIST, EFDA, OR HYGIENIST. That is, do not count a supragingival scaling (such as using a cavitron alone) and polishing as a curettage.
25patient ed. (ctv)0;26SET OF CODES0:NONE
3:INDIVIDUAL
4:GROUP
Enter the weighted value of preventive dentistry instructions. DO NOT LIST THE NUMBER OF MINUTES. These instructions may be given by any provider. However, NO CREDIT IS RECORDED AT THE SAME APPOINTMENT when a prophylaxis or another treatment procedure is being accomplished by the same provider (an increase in CTV credits recognizes time spent for patient instruction during other scheduled treatment procedures). The main pupose of this field is to record a specific appointment scheduled for a single patient or for a group training session to provide oral hygiene instructions, diet counseling, plaque scoring, etc. For an individual patient, enter the service code, a weighted value of three (3), and the patient's name for each instructional session. For a group session, enter the service code, a weighted value of four (4), and the word "GROUP" in place of a patient's name for all instructional sessions. All group instructions will be entered under the appropriate patient category for the majority of the group in attendance. The patient category determination for individual instructional sessions will be reported the same as for other services provided for that individual. Preventive Dentistry instructions presented for employees are recorded as education/training time.
27individual crowns #0;28NUMERICThe crowns cemented are not part of a fixed prosthesis. Included in this field are all types of permanent crowns such as, 3/4, porcelain fused to metal, porcelain jacket, full gold, etc. Temporary crowns are NOT to be counted in this field.
28post & cores #0;29NUMERICEnter a post/core or overdenture coping regardless of whether that tooth will have a crown as part of a fixed prosthesis or have an individual crown placed on it. This field includes all types of posts/cores (i.e., cast, pre-prepared types, and/or threaded systems).
29fixed partials (abut) #0;30NUMERICTemporary bridges for this treatment episode are NOT counted in this field. This category includes all types of fixed prostheses with the exception of Acid Etched, Resin Bonded Retainers. These types of prostheses are recorded under Splints and Special Procedures.
30fixed partials (pont only) # 0;31NUMERICPONTIC UNITS of temporary bridges for this treatment episode are NOT counted in this field. This field includes all types of fixed prostheses except Acid Etched, Resin Bonded Retainers. These are reported under SPLINTS AND SPECIAL PROCEDURES.
31removable partials #0;32NUMERICAcrylic R.P.D.'s may be counted here ONLY if the clasp assembly contains definitive occlusal rests. Transitional (temporary) tissue supported partials are counted in the SPLINTS AND SPECIAL PROCEDURES field. R.P.D. relines or rebases are counted under OTHER SIGNIFICANT TREATMENT.
32complete dentures #0;33NUMERICAll COMPLETE DENTURES are counted at the time of insertion or disposition of the dentures. Complete Denture relines or rebases are to be credited under the field OTHER SIGNIFICANT TREATMENT.
33prosthetic repair #0;34NUMERICEach repair is counted at the time of delivery to the patient or other disposition. Fixed prostheses with broken facings which have been repaired are reported in the Other Significant Treatment section. If the patient does not come to the clinic for the prosthetic repair, an entry must be made in the Admin Procedure field.
34splints & spec. procs. (ctv) 0;35NUMERIC WEIGHTED VALUES (CTV'S) 1. Periodontal or trauma splinting, orthodontic bands and/or brackets 1.0/tooth 2. Flouride carriers (custom) 3.0/patient 3. Facial moulage 9.0 4. Tissue borne partial prosth. 12.0 5. Oral hygiene aids for handicapped pts. 9.0 6. Acrylic cranial plate 18.0 7. Mandibular guidance appliance 36.0 8. Radiation stent 12.0 9. Surgical stent or night guard 9.0 10. Dynamic bite opening device 36.0 11. Intraoral obturator (includes basic prosthesis) 50.0 12. Speech aid prosthesis (includes basic prosthesis) 50.0 13. Palatal lift prosthesis (includes basic prosthesis) 50.0 14. Stock occular prosthesis 50.0 15. Ear prosthesis 50.0 16. Custom occular prosthesis 75.0 17. Facial prosthesis 75.0 18. Resin bonded retainers 3.0/unit 19. Orthodontic appliance adjustment 2.0/visit
35extractions #0;36NUMERICThese extractions are considered as simple extractions since no flap was necessary for surgical exposure to extract the tooth or root. Flaps in conjuction with an alveoplasty do not indicate a surgical extraction. This entry includes all post-operative care and instructions.
36surgical extractions #0;37NUMERICThis includes any type of impaction or an erupted tooth for which an intentional flap is required. This entry includes all post-operative care and instructions.
37other significant treat (ctv)0;38NUMERIC WEIGHTED VALUES (CTV's) 1. Blood pressure recording 1.0/patient. 2. Topical flouride treatment 2.0/patient. 3. Drug injection (not local anesthetic) 1.0/patient. 4. Prescription writing (Pharmacy) 1.0/patient. 5. Temporary restoration 2.0/patient. 6. Nitrous oxide sedation 2.0/patient. 7. Complete or partial denture adj. (not constructed by treating clinic during this episode of care.) 2.0/patient. 8. Occulusal equilibration (not isolated adjustments) 2.0/quadrant. 9. Recementation of crown 2.0 10. Recementation of fixed bridge 3.0 11. Crown or bridge facing repair or recementation 3.0 12. Tissue conditioning or chairside reline 3.0/visit 13. Temporary crown (not constructed by treating clinic during this episode of care.) 3.0 14. Temporary bridge (not constructed by treating clinic during this episode of care.) 6.0 15. Bleaching of teeth 4.0/visit 16. Attachments (intra or extra coronal, semi-precision or precision) 5.0/attach. 17. Full mouth periodontal charting 6.0/patient. 18. I.V. sedation/medication 6.0/patient. 19. Dental admissions (no O.R.) 9.0/patient. 20. Reline or rebase of a complete or partial denture 12.0/unit
38operating room0;14BOOLEAN1:YES
These cases will not be credited to a resident provider. They must be credited to a dental staff provider or a dental consultant or attending.
39factor (not used)0;21NUMERIC
40change/delete0;5SET OF CODESC:CHANGE
D:DELETE
60released by.1;1POINTER200
61date released.1;2DATE-TIME

Not Referenced