55 Pa. Code § 1149.43

Current through Register Vol. 54, No. 49, December 7, 2024

Section 1149.43 - Requirements for dental records

In addition to the recordkeeping requirements set forth in Chapter 1101 (relating to general provisions), dentists shall maintain a dental record for each MA recipient in accordance with the following requirements:

(1) The record shall contain a tooth chart indicating the condition of the patient's teeth as observed on the initial oral examination. The dentist shall clearly indicate on the tooth chart:

(i) Missing permanent teeth.

(ii) Permanent teeth to be extracted.

(iii) Teeth to be restored by surface.

(2) The record shall note the condition of the oral supporting tissues.

(3) For each service rendered, the record shall note:

(i) The type of service.

(ii) The date the service was rendered.

(iii) The tooth number or letter, if applicable.

(iv) The surfaces restored, if applicable.

(v) The types of material used in the final restoration, if applicable.

(vi) The type, concentration and amount of any anesthetic agent used in providing a service, if applicable.

(4) The record shall contain a proposed plan of treatment, if applicable.

(5) If dental radiographs are taken, they shall be part of the patient's record and shall be properly processed, dated and identified with the patient's name.

(6) If radiographs are requested by the Department for prior authorization purposes, the radiographs shall be properly mounted and include the patient's name, case number and the provider's name. If radiographs are requested for a record review or for an onsite review, sufficient time will be agreed upon between the provider and the Department to allow the radiographs to be properly mounted.

(7) Documentation of prescriptions for drugs shall be part of the patient's record whether prescribed orally or in writing and shall contain:

(i) The date of the prescription.

(ii) The drug, dose and amount prescribed.

(iii) Instructions for the administration of the drug.

(iv) The prescriber's name.

(8) If the services of a dental technician or dental laboratory, or both, are used as defined in § 1149.2 (relating to definitions), the dentist shall furnish the dental technician or the dental laboratory with a written prescription which shall contain the following items listed in The Dental Law (63 P. S. §§ 120-130b):

(i) The name and address of the dental laboratory technician or dental laboratory.

(ii) The patient's name or identification number. If a number is used, the patient's name shall be written on the prescription retained by the dentist.

(iii) The date on which the prescription was written.

(iv) A prescription for the work to be done with diagrams if necessary.

(v) A specification of the type and quality of materials to be used.

(vi) The signature of the dentist and the dentist's license number.

(vii) A copy of the prescription shall be maintained as part of the patient's record.

(9) Pathology reports are required for surgical excision services.

(10) Pre-operative X-rays are required for surgical services.

(11) Postoperative X-rays are required for endodontic procedures.

55 Pa. Code § 1149.43

The provisions of this § 1149.43 adopted January 25, 1985, effective 1/15/1985, 15 Pa.B. 255.

This section cited in 55 Pa. Code § 1149.42 (relating to ongoing responsibilities of providers); 55 Pa. Code § 1149.43a (relating to clarification of the terms "in writing", "written" and "signature"-statement of policy); and 55 Pa. Code § 1149.57 (relating to noncompensable services and items).