Episode 102 | If Your Chart Notes Aren't Specific, You Can Bet the Audit Will Be

Dental documentation isn’t just “paperwork.” It’s your clinical defense, your reimbursement justification, and the only voice you’ll have when no one remembers what actually happened five years from now.

In this episode, Kara Kelley and Amy Wood sit down with Dilaine Gloege, CDA, CPC — one of dentistry’s leading authorities on documentation, coding, billing, payer audits, and cross-coding — to talk about what happens when chart notes are vague, templated, AI-generated, copy/pasted, or written like no one will ever read them.

We discuss:

- Why specificity in clinical notes matters more than ever

- CDT, CPT, and ICD-10 — what they actually do (hint: it’s not just getting paid)

- Where documentation breaks down between front desk → clinical → billing

- Why the narrative is the chart note (not a separate paragraph you recycle forever)

- How AI can help - and how it can immediately get you in trouble

- The real-world consequences of sloppy notes: recoupments, board complaints, audits, and yes… sometimes worse

If you’ve ever said, “We’re just dentistry,” this is your wake-up call. You are a healthcare provider - and the record you create is a legal healthcare record. If it’s not accurate, complete, and specific, everything downstream (coding, claims, reimbursement, liability, clinical continuity) starts to wobble.

This is the episode that will make your documentation habits suddenly feel… very seen.

About our Featured Expert:

Dilaine Gloege, CDA, CPC - Dental coding & reimbursement educator, former Practice Booster co-author, and compliance analyst supporting dentists during payer audits.

Website: www.tidewaterdentalconsulting.com

Who Should Watch: Dental leaders and healthcare executives, practice owners, office managers, billers/coders, hygienists, assistants, and anyone who wants accurate reimbursement without audit heartburn.

Top Takeaway: Specificity isn’t bureaucracy. It’s patient care. It’s accuracy. It’s protection.

If your chart notes aren’t specific, you can bet the audit will be.

Disclaimer: This podcast is for educational and informational purposes only; it should not be considered legal, medical, or coding advice. Consult qualified counsel and credentialed coding professionals for your specific situation.