Common Adjustments & How to Use Each One

For Office Managers to Decide which Adjustments to Use for your practice

In order to have accurate patient ledgers and reports, you will need to use the proper adjustment - depending on whether you want to impact production or collection and whether you want to increase or reduce the patient account. Dentrix Ascend provides a set list of adjustments and in this article we will review each one and provide detailed information and a sample use case so you can decide how you want to use these adjustments in your practice. 

If you are coming to Dentrix Ascend from a server-based program, you may be used to creating lots and lots of adjustments - often for the purposes of tracking. One unique difference of Dentrix Ascend is that our power reporting module is robust enough that you do not have to use custom adjustments for tracking. This provides you a benefit of actually using fewer adjustments. 

In this article, we will review each type of adjustment in Dentrix Ascend and how they can be applied.

To help you wrap your head around where to start looking for the adjustment you need, Dentrix Ascend starts you off with a choice – do you want to increase or add to the balance? If so, choose Charge (+) Adjustment. Here is an image that shows how each adjustment is defaulted in our system:

Or, if you want to reduce the balance on the account, choose Credit (-) Adjustment. To identify whether these adjustments impact production or collection, use this graphic. The green side impacts production, while the red side impacts collection.

Customize Your Use

Before we start this review of each adjustment, I want to highlight the fact that you can decide how to use each one of these adjustments in your practice. Although you cannot edit the labels, you can change whether each adjustment impacts production or collection. Be sure to coach your team on which ones to use when.

To change whether an adjustment impacts production or collection, go to Settings, then Ledger Options - and  you will see this screen:

Now, you can change each one - and you can also uncheck any adjustments you do not want your team to use. Be sure to click save at the bottom of the page.

For new office managers just getting comfortable with the adjustments available in Dentrix Ascend, this is the perfect time to re-evaluate “the way we’ve always done things” by looking through the adjustments you used in your legacy software and choosing the adjustments you will use moving forward.

To enter adjustments – go to the ledger – and then you’ll see two options:

Charge (+) Adjustment

Credit (-) Adjustment

Charge and Credit Adjustments (Impact production)

If you want to increase or decrease a patient account and impact production, then you’ll use charge and credit adjustments.

To increase the account balance:

Charge (+) Adjustment – and then choose type Charge Adjustment

To decrease the account balance:

Credit (-) Adjustment – and then choose type Credit Adjustment

One best practice you may want to consider implementing in your practice is to require all team members to enter a note with their initials for every type of generic adjustment entered. This provides more detailed information to anyone reviewing the ledger – and for more questions, the team knows who entered this adjustment in the first place.

Initial balance forward; Initial credit balance forward (Impact production as default - recommend change to collection)

These Initial balance adjustments are often used at conversion. Let’s say you are working down your accounts receivable in your legacy software program. Many offices prefer to move patient balances over to Dentrix Ascend as quickly as possible to reduce the amount of time that team members are working in both systems. In the legacy system with a patient balance of $100, the manager would enter an initial balance credit of $100 to reduce the account to $0.

Then, in Dentrix Ascend, the manager would choose Charge Adj+ and then choose the type “Initial Balance Forward” for $100 to make the account show $100 due.

Our recommendation for setting up these adjustments is:

Initial balance forward – default to production

Initial Credit balance forward – default to collection

If your practice recently converted to Dentrix Ascend and you will be manually bringing over patient balances from your legacy software, you may want to consider how these adjustments are set up and how to maintain accuracy of your doctors compensation reporting.

For practices that pay providers on net production, when you enter the initial balance forward adjustment (and it is set to impact production), this would inflate the provider's production - on treatment the provider has already been paid for. To avoid paying your provider twice, we recommend using a custom report based on transaction date and including a filter to exclude the initial balance forward adjustment. To review this article: Pay Providers on Net Production.

For practices that pay providers on collections, there is no impact when the initial balance forward adjustment is set to impact production. 

Transfer Charge Balance and Transfer Credit Balance (Impact production)

We also have adjustments labeled Transfer Charge Balance and Transfer Credit Balance – these could be used between patients, perhaps in the case of a divorced family where you need to move money. Both of these adjustments impact production. For impacting collections, use Offsetting Credit Adjustment.

Courtesy Adjustments: Family / Friend, Full Payment, Professional, Senior Citizen, Staff (Impact production)

These are some of the most common adjustments used in dentistry, and all of them impact production. To find these, choose Credit (-) Adjustment and then select the one you need.

As you look through the adjustments in your legacy system, you may find some custom adjustments that don’t have a perfect match – often, professional courtesy can be used with an explanatory note to handle these.

Often, dental offices use adjustments as a mechanism to run reports. In one office I worked with, they had a specific broken appointment courtesy adjustment in their old system and we decided to use the professional courtesy adjustment instead. In Dentrix Ascend, it’s not necessary to use a specific broken appointment adjustment because we can track broken appointments without using an adjustment in the ledger.

In fact, if you look at Power Reports / Schedule / Missed appointment – this is a pre-built report that shows you each of your missed appointments (both broken and no show).  Using this missed appointment power report, you can see the patient name, status reflecting broken or no show, the appointment date/time, if a reason was documented and the fee.  

Another popular marketing approach was the “Care to Share card” – practices gave these cards to existing patients who could hand them off to friends to come in to the office at a steep discount. For this or other similar marketing programs, just use Credit (-) Adjustment and then choose Professional Courtesy. And, to track any of these marketing initiatives, you can use payment tags.

Discount Adjustment (Impact production)

More and more dental practices are offering in-house dental benefits / discount plans as an option for patients who do not have dental insurance. These programs invite patients to become a member of the dental practice’s in-house plan for a fee and then the patient receives a discount on treatment provided.

Often, dental practices want to see the adjustments provided to patients as part of this program. This can all be handled through Ascend’s power reporting – in fact, please see How to Use an In-House Benefits Plan in Dentrix Ascend for specific instructions on how to set this up and report accurately.

Looking just at the adjustments piece here, you can automatically post a discount into the patient ledger by choosing the Discount plan fee schedule in the patient’s basic information. In this example, I created a New Patient Discount fee schedule – and then selected this under the Discount plan field. For specific instructions on how to set up a discount fee schedule for new patients, please see How to Set Up at New Patient Discount.

Then, when I enter a procedure code with a discounted fee – the discount will automatically be created in the ledger. The line in red was automatically created when I posted the Comprehensive Evaluation D0150.

If you do not set up a Discount fee schedule to use the automated approach, then you can also handle this manually. To manage account balances when patients come in and have treatment done – you would choose Credit Adj – and then type Discount to bring down the fees in any one-off type situation.

Insurance Adjustment (Impact production)

A popular way to track insurance adjustments for each carrier is to create a custom code for each one – for example, “Delta Dental Adjustment”. However, in Dentrix Ascend, we use a standard insurance adjustment code – and we can use power reports to track each carrier. 

To find the insurance adjustment, select Credit (-) Adjustment and choose type Insurance Adjustment.

In fact, in Power Reports / Insurance / Insurance utilization – this is a pre-built report that you can see each carrier, plan and the adjustment (in the column named Discount/Patient) for each.

Finance charge, Late fee, Collected Bad Debt Adjustment (Impact production)

For practices that want to add a finance charge or late fee, there is no specific label that matches these terms. Since you want to increase the patient’s account balance, you’ll choose Charge (+) Adjustment  and then Charge Adjustment to impact the account properly. You may want to make a note to explain why this generic adjustment code was applied.

Here’s a sample showing a $10 late fee – and a note with my initials explaining the adjustment:

Next, if you are successful at collecting bad debt – you have a matching Dentrix Ascend adjustment to use for that. This is often used when an account balance is at $0 because the account has been “written off” and sent to a collection agency. Once the collection agency is successful, the manager can go back into that patient’s account and use this Collected Bad Debt adjustment to put the charge back onto the account so that when the payment is entered, the account balance is back to $0.

Sales Tax (Impact production)

You can use this adjustment, found under Charge (+) Adjustment if you need to add sales tax to a patients’ ledger.

NSF Bank Fee (Impact production) vs. NSF Check Fee (Impact collection)

You’ll use the Insufficent Funds “NSF” Bank Fee adjustment when a patient bounces a check and you are hit with an additional fee from your bank. This adjustment impacts production and by selecting Charge (+) Adjustment and then NSF Bank Fee, you will increase the patient balance.

On the other hand, the NSF Check fee adjustment impacts collection – so this will be used to put the money back onto the account when patients bounce a check. Again, you’ll choose Charge (+) Adjustment and select NSF Check fee.

Offsetting Adjustment (Impact collections)

You can use this offsetting adjustment in several ways to impact collections. One way is when you need to reduce collections for a provider that is re-doing treatment. This is part of a 4 step process outlined in this article: https://support.dentrixascend.com/hc/en-us/articles/115015427807-Transferring-Money-between-Dentists-After-a-Re-do

Another possible use for this type of adjustment is for offices that use CareCredit and want to enter the adjustment in the patient ledger. Let's say you charge out a crown for $1000 and the patient uses CareCredit. One way to handle this is to enter a payment of $900 (assuming CareCredit in this example charges 10% fee) and then enter a Credit (-) Adjustment, then select Offsetting Adjustment for the other $100. If your provider is paid on collections, then when you run this report, you can exclude the offsetting adjustment from your provider compensation report. 

As an aside, there is another way to handle CareCredit fees if you do not want to enter them into the patient ledger. In this approach, you enter the entire $1000 as a Carecredit payment and then outside of Dentrix Ascend, you find the CareCredit fees and deduct them from your provider's compensation. No matter which approach you use, you will want to use a payment tag - and we have a CareCredit tag pre-built for you to select. 

Insurance Charge Offsetting Adjustment (Impact collections)

Found under Charge (+) Adjustment, this adjustment code is rarely used. One situation it might apply is if you have an insurance company paying you interest – you could apply the extra amount using this adjustment.

Patient Refund and Insurance Overpayment Refund (Impact collections)

When you need to send a patient refund or refund back to the insurance company, you can see that we have adjustments for both. The key is to select Charge Adjustments + first because by giving a refund, you will be increasing the account balance (often increasing it up to $0 from a negative).

Credit Card Refund and Credit Card Void (Impact collections)

If your office guidelines prevent you from giving credit card refunds on the credit card terminal or through your credit card processing system or you decide that you prefer to document credit card refunds through your ledger, then you can choose Charge (+) Adjustment and select either of these adjustments, which impact collections.  Best practice suggests adding a note with your initials to explain why the credit card was refunded or voided. For instructions to create a report showing these (the deposit slip will not reflect these adjustments): https://support.dentrixascend.com/hc/en-us/articles/360058403233 

Posting an insurance credit card: https://support.dentrixascend.com/hc/en-us/articles/360058874193-Posting-insurance-credit-card-payments 

Electronic Check Credit (Impact collections)

This adjustment is rarely used. It could be used to post an overpayment for an EFT. Choose Charge (+) Adjustment and select Electronic check credit. This impacts collections. 

Write off, In-office write off, Bankruptcy write off (Impact collection as default - recommend change to production) 

These adjustments are default to impact collection –and if you pay your doctors on collection, these adjustments would impact the applied collection report that is generally used for doctor’s compensation. So, if you pay your dentist on collection and you do not want their compensation to be impacted by these write offs, then set them to impact production. 

On the flip side,  if you pay your doctors on production and you do not want their compensation to be impacted by these write offs, then you may want to leave them as defaulted to impact collection. 

Since most dental practices are used to writing off any unpaid balances after collections attempts are exhausted, just be sure you set the adjustments to your office's preference. 

Use Tags to Track Bad Debt

Once you determine which adjustment you will use when you adjust off an outstanding balance after sending the account on to collections, or simply exhausting your collections efforts - you can use adjustment tags to report on this. For example, you could create a mandatory adjustment tag requiring a selection of "Sent to Collections Agency" or "Not Sent to Collections Agency" and this is reportable through power reports. 

Charitable contribution (Impact collection as default - recommend change to production) 

Many practices provide some free dentistry to patients from time to time. If you pay your doctors on collections, then you can set this Charitable contribution adjustment to impact production and then  that will not influence their compensation, but allow you to track charitable work. 

To do after reading this article:

• Review your Ledger Options adjustments settings, uncheck any you do not want to use and go through each one based on reading this article - set each to production or collection.
• Create a training flyer for your practice - capture a screenshot of your adjustments and insert into a document, at the bottom of the document describe how each adjustment will be used
• Review your doctors compensation reports - exclude any adjustments necessary
• Create a training protocol for how you will handle sending accounts to a collections agency or small balance write off; this will also include your setting up the tags for the adjustments

(Article authored by J. Alldredge, J. Nesbitt 2018)