Compliance & Charting Protocols with Evan Sampson | Part 1
How to transform your progress notes into a strong legal shield, navigate high-risk CDT coding audits, and clear ledger landmines before they damage your practice valuation.
Why Charting is Your Best Legal Shield
On this episode of the Dental Digest Podcast, healthcare attorney Evan Sampson joins Dr. Melissa Seibert to reframe a tedious administrative task into an essential asset-protection strategy. When a state board or insurance auditor reviews your practice records, they operate on a strict baseline: if it isnβt documented in the chart, it legally never happened.
Your progress notes are not just internal paperwork. On audit day, they stand as the definitive legal evidence of your professional competence. Sampson reminds clinicians to author every single chart entry under the firm assumption that an auditor, a state board member, or an opposing attorney will eventually read it out loud in a court of law. If you wouldn't feel comfortable having a regulator read your note to a room full of people, it needs more objective detail.
The single greatest documentation liability for general dentists is upcoding simple extractions into surgical extractions. Because surgical codes carry higher reimbursement rates, insurance payers monitor statistical outliers via data algorithms. To defend a surgical extraction code in an audit, your note cannot simply list the code; it must explicitly record the reflective tissue flap, bone removal, or tooth sectioning that occurred.
Finally, avoid the temptation to retroactively alter a note if an administrative mistake is discovered. Modern electronic health records (EHR) generate a permanent backend audit trail. In regulatory reviews, an unannounced, unexplained modification can escalate an innocent coding discrepancy into a serious investigation. In dental compliance, the cover-up is always worse than the original mistake.
The Reality of Modern Non-Clinical Compliance
Many general practitioners focus entirely on perfecting clinical outcomes or maximizing patient satisfaction, completely overlooking the administrative habits that quietly generate severe regulatory exposure. In this episode of the Dental Digest Podcast, healthcare attorney Evan Sampson and Dr. Melissa Seibert unpack the high-risk operational landmines that threaten both solo practices and large organizations.
The Template Vulnerability: When Auto-Notes Backfire
Many modern dental practices rely heavily on automated templates inside their practice management software to expedite clinical data entry. While auto-populated text blocks save time, using identical, generic notes across multiple patients creates a massive compliance risk. If an insurance auditor notices a repetitive pattern of unedited, clone-stamped text entries, it signals that individualized patient care was not actually evaluated or recorded. To protect your license, your progress notes must always be personalized to reflect the unique clinical realities of that specific visit.
The Silent Financial Leak: Unreturned Credit Balances
An overlooked financial liability that routinely damages dental practice transitions is the accumulation of unreturned patient credit balances on the accounting ledger. When a patient or insurance overpayment sits on your books indefinitely, it legally represents an outstanding debt. Under state dormancy laws, failing to actively clear, track, and refund these balances can result in severe state regulatory penalties and drastically lower your total practice valuation at the time of a sale. Regularly auditing your ledger is a strict compliance obligation, but it also serves as an excellent marketing opportunity to invite past patients back into the office for outstanding treatment.
Accurate Production Billing and Specialist Referrals
Compliance dictates that your billing operations exactly match your physical production. For example, if a general practitioner begins a complex molar endodontic treatment but encounters an anatomical anomaly or a separated file and must refer the patient to an endodontist, the practice cannot legally bill for the full, completed procedure. Clinicians can only contractually bill for the precise clinical steps they successfully executed prior to the referral. Maintaining strict administrative discipline ensures your practice remains fully compliant with insurance provider contracts and state board rules.
Clinical Takeaways
- Write notes for the courtroom: Author every single chart entry under the assumption that an auditor or opposing attorney will eventually read it out loud in a legal setting.
- Document extraction components: Surgical extraction notes must clearly document the specific physical steps performedβsuch as reflective soft tissue flaps, ostectomies, or sectioningβto defend against upcoding audits.
- Avoid unbundling: Do not bill separate individual components of a single, comprehensive procedure. A classic example is billing separately for local anesthesia when it is legally bundled into the primary surgical code.
- Personalize automated text: Customize generic electronic health record templates for every patient visit to show clear proof of individualized care.
- Audit your ledger regularly: Clear out accumulated credit balances on your books to satisfy state regulatory requirements and preserve your practice's valuation.
Chapters & Timestamps
| Timestamp | Topic Covered in Episode |
|---|---|
| [00:00] | Introduction and Legal Disclaimer |
| [03:45] | Why Documentation is the Leading Compliance Risk for General Practices |
| [08:20] | The Training Day Rule: Proving Your Care via Specific Progress Notes |
| [12:40] | The Legal Vulnerabilities of Automated, Non-Personalized EHR Templates |
| [17:15] | Managing High-Risk Coding Categories: Defending Simple vs. Surgical Extractions |
| [22:30] | The Mechanisms of Unbundling and How to Prevent Payer Invalidation |
| [28:10] | Credit Balances as a Silent Compliance Landmine and Practice Valuation Threat |
| [33:55] | Partial Incomplete Procedures: How to Bill Correctly Prior to Specialist Referral |
| [39:15] | Building a Culture of Office Compliance: Handbook Execution and Team Training |
Resources
- Post & Schell β Evan Sampson's law firm (Philadelphia)
- ADA CDT (Current Dental Terminology) β official coding manual
- ADA guidance on dental coding and insurance compliance
- State Board of Dentistry β disciplinary action and complaint procedures
- Dental practice credit-balance management and state dormancy law
- Fraud, Waste, and Abuse (FWA) compliance training for dental practices
Evan Sampson, Esq.
Healthcare Attorney Β· Post & Schell
Evan Sampson is a healthcare attorney with more than a decade of experience advising dentists and other healthcare providers on regulatory compliance, fraud and abuse risk, the corporate practice of dentistry, and complex business and transactional matters. He has served as general counsel to one of the largest dental support organizations in New Jersey and has previously held senior compliance leadership roles within the largest municipal hospital system in the country.
Post & SchellDr. Melissa Seibert
DMD, MS, FAGD, ABGD
Creator and host of the Dental Digest Podcast β the #1 clinical dental podcast worldwide and a top 1% global podcast. Dr. Seibert is a former active-duty U.S. Air Force dentist, internationally sought-after speaker, Key Opinion Leader, and published author in top dental journals. She is passionate about equipping general dentists with high-level, evidence-based clinical skills.
Publications & SpeakingFull Episode Transcript
Dr. Melissa Seibert: Welcome to the Dental Digest Podcast β a show with a mission of enabling you to stay on the cutting edge of evidence-based dentistry. I'm your host, Dr. Melissa Seibert. This is Part 1 of a two-part series with Evan Sampson β a healthcare attorney with over a decade of experience advising dentists and other healthcare providers on regulatory compliance, fraud and abuse risk, the corporate practice of dentistry, and complex business and transactional matters. He has served as general counsel to one of the largest dental support organizations in New Jersey and has held senior compliance leadership roles within the largest municipal hospital system in the country.
Dr. Seibert: Evan is going to start by doing something no other guest has ever done β go ahead with your disclaimer.
Evan Sampson: Thank you for having me. I do have to give this disclaimer: this conversation does not constitute legal advice and does not create an attorney-client privilege. Should any of your listeners need an attorney, I would encourage them to contact me or any other attorney.
Dr. Seibert: How do dentists stay out of trouble with notes? Many under-document. Some agonize and hemorrhage practice profitability over documenting.
Evan Sampson: The fraud-and-abuse angle from coding and documentation is probably the biggest risk dentists face. There's always room for improvement. From a legal perspective, more specificity is always better. A lot of dentists now use electronic systems with auto notes, which can be a crutch β if every note looks the same, if you're not personalizing each note, it can create problems from a regulatory or payer perspective. Every dentist has heard "if it's not documented, it didn't happen." That is 100% true. But I have two other rules I give my clients.
Evan Sampson: The first is the training day rule: it's not what you know, it's what you can prove. Whatever you have documented is sometimes the only evidence that a procedure happened. If there are no radiographs, the chart is all you have to rely on. That can make a big difference if a regulator or payer is ever looking at your documentation. The second rule: don't put anything in writing you wouldn't want someone who doesn't have your best interests in mind to review later. Anything can be misinterpreted. Be specific, descriptive, matter-of-fact. Sufficient, but not something you'll regret later.
Dr. Seibert: A great piece of advice is to write as if in a court of law, someone is reading your note out loud.
Evan Sampson: Exactly. Your progress notes are going to be evidence in a case later β that's how you should treat them.
Dr. Seibert: What about when adverse things happen β an inadvertent sinus exposure during an extraction?
Evan Sampson: Be as accurate as possible. Describe what occurred. If you misrepresent what happened, that information might come out down the line. Every system today has audit trails β there are procedures to amend a note properly. If something's unclear, be open about updating it. But trying to hide something or going back to obscure it can itself be a crime. The cover-up is often worse than the crime.
Dr. Seibert: How granular should documentation get on a procedure like suturing? Some clinicians list every site, every suture type, every count.
Evan Sampson: It depends. My concern from a legal standpoint is high-risk incidents and high-risk procedures. For procedures I know to be particularly high-risk from a fraud, waste, and abuse standpoint, I tell clients to be as detailed as humanly possible. Same with problematic patient encounters β abusive language toward staff, patients you're considering dismissing. Be detailed, because that note may very well be read in a courtroom or before a board of dentistry.
Dr. Seibert: When you say "high-risk," you mean from a fraud-waste-abuse standpoint β not necessarily a technically complex procedure?
Evan Sampson: Correct. From my vantage point, high-risk means fraud, waste, and abuse risk. There are a few highly risky codes. The single most-audited one I encounter is upcoding from simple to surgical extractions. My advice: be as detailed as humanly possible when documenting a surgical extraction. Another high-risk area is caries risk assessment, particularly in pediatric dentistry.
Dr. Seibert: So if the procedure was straightforward β elevators and forceps, no flap, no ostectomy β and you're still coding for a surgical extraction β
Evan Sampson: That's upcoding. If you're submitting a claim or billing a patient at a higher reimbursement rate than the procedure actually performed, that's upcoding. It doesn't have to be intentional β it can be poor clinical documentation. If your progress note just says "surgical extraction" with nothing supporting it, that can be problematic in an audit. The other category is unbundling, where component steps of a procedure are billed separately to generate a higher reimbursement rate. One example: billing anesthesia separately when it should be included in the procedure.
Dr. Seibert: An example of unbundling β coding for a pulpectomy alongside the full endo. And I would imagine most dentists doing this are doing it inadvertently β they think they're coding for everything. But if you look in the coding manuals, they explicitly tell you these codes don't go together.
Evan Sampson: Correct. The ADA has put out guidance on a lot of these high-risk coding issues. There are also coding associations that advise on this. Even when coding is appropriate, it may come down to lack of specifics in the progress note. The more accurate and detailed your documentation, the lower your risk.
Dr. Seibert: Some oral surgeons code every extraction as a complete bony or full bony β "I'll let the insurance figure it out."
Evan Sampson: That's fraud. "Let me see what I can get away with" is not proper coding. When you submit a claim or bill a patient, you are making a representation of what services you provided. If that representation isn't accurate, you could be committing fraud. You may have to pay the money back, face disciplinary action by the board, or worse. I don't want to scare every dentist β most of this is inadvertent. But inadvertence doesn't always mean a pass. That's why this matters.
Dr. Seibert: And there's an upside β when dentists learn coding properly, they often find they were downcoding, leaving money on the table.
Evan Sampson: Absolutely. A compliance program can identify inefficiencies. I encourage every practice, no matter the size, to invest in creating a culture of compliance β you never know what you'll catch. It's not just a cost or a headache; it can open your eyes to real business opportunities.
Dr. Seibert: If a dentist charges a patient for a surgical extraction expecting it to be challenging, and it turns out to be straightforward β you refund the patient?
Evan Sampson: Absolutely. That brings up another topic β credit balances. They're a real compliance issue. Credit balances are a debt you owe to your patients. You're obligated by law to either credit it back to them or deposit it with the state (dormancy requirements vary by state). Most patients don't know they have a credit balance unless the front desk tells them, so balances pile up over years. When practices go to sell, this comes up β sometimes tens of thousands of dollars of unreturned balances surface. Some practices don't have the cash on hand to return it. And it can decrease the value of your practice at sale. My advice: audit your credit balances regularly. It's also a marketing opportunity β every credit balance is a reason to invite a patient back into the office.
Dr. Seibert: Last scenario β a GP starts a molar endo, gets in over their head, a file breaks, and they refer to the endodontist. They should not bill for having done the procedure, correct?
Evan Sampson: Correct. You can only bill for what you can accurately represent that you performed. If you didn't perform the procedure, you can't bill for it. That's fraud 101.
