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When Coding Has Nothing to Do with Code Numbers

Continuing from Part 1: WHO


WHEN is the Coding Encountered?

So WHEN does the actual coding of a clinical procedure take place in your office? Pretreatment is an issue unto itself for a later discussion. However, at this time, I want to address the actual delivery of dental services. That’s right, I’m talking about the patient in the chair. This is not an orthodontic case, as that too is another discussion. Let’s address at what point in the treatment you encounter the use of a procedure code!

  • Is it when you start the procedure?
  • Is it when the procedure becomes an active irreversible treatment?
  • Is it when the procedure is actually done and finished?

In my many years with and within the overall benefit industry, I can safely share that there is little I have not seen or experienced. For example, workers compensation fraud, staged automobile accident rings, premeditated slip-n-falls, arson for profit, alleged spousal death, foreign offshore property/casualty claims and good old-fashioned medical quackery.

Yes – sometimes, I feel I have seen it all.

With experience behind me, I want to share with you one true fact and constant that will change your life. It will facilitate and simplify how you deal with any and all forms of third party, as well as patient-centered reimbursement. Follow this rule, and it will forever eliminate 98% of your payment headaches, once and for all. Here it is. It’s Rule #5 of my 7 Keys to Reimbursement Success.

“Bill and code for exactly what dated services are rendered as completed.”

In other words, don’t ever encounter a procedure code until the specific treatment is completed and finished. It’s not ever considered to be completed until it’s done and finished. It requires absolutely nothing further on the part of or from the clinical team. And I mean finished, completely done with nothing more to do. Think Revelations 21:6 or if you prefer John 19:30. Either way, “It is done.”

When you introduce procedure codes into the equation at the pre-treatment financial phase, you invite the patients to separate themselves from the specific unknown accountability of their own benefit plan. You know all too well that the minute you separate the total financial obligation of the patient into their portion and the insurance portion, your problems are just beginning. You started that by bringing the procedure code into the equation and the word “estimate.”

I don’t care how you say it or in how many languages you spell it out, the patient will not want to understand – in spite of their signature on the treatment plan. All they are hearing from you is simply, “my portion is only going to be $…”

As for the date of preparation with indirect restorations – forget about it from the point of procedure coding. If all you did was start, you have nothing to claim to an outside third party that is participating in the partial or even complete payment of the treatment. With the exception of CAD-CAM technologies, direct restorations are yet another story. If it’s prepped and returned to function on the same day, that will be the date of completion and subsequent coding. If the pathology is removed, restorative material placed, but the tooth is not returned to function, you are probably looking at only a partial filler or cement base, not a completed restoration.

Bill and code for only what is finished. What is finished is considered “global” in scope. So, if you did a restorative foundation and a restoration, the plan will consider the filler to be part of the restoration and will often not pay it as a separate component. Think “global” as to what is actually the overall completed procedure. Now do you see why a realistic fee schedule is so critical to today’s success? How are you recouping the expense associated with the foundation when the plan says, “you can’t charge the patient”?

It is the same for endodontic procedures. Don’t code for the completed endo simply because you opened the tooth. The patient may or may not return. The root canal may or may not ever be completed due to unforeseen complications. You may need to charge a more “reasonable” or higher fee due to ancillary canals or obstructions. The tooth may need to be extracted or more specifically and logically, encounter D3332. You see, when a plan tells you that you may bill and code when the procedure is started, at the same time, they are taking away from you the ability to comprehensively charge for the entire global procedure. They are looking for you to foolishly grab for and accept the short straw rather than more wisely and comprehensively seek reimbursement for your actual completed treatments.

The same criteria are applicable to surgical, as well as removable prosthetic procedures. The actual outcome is unforeseen until the incisions are made and all the fittings as well as appointments are concluded. In other words, you don’t know what exactly is done (procedure wise) until it is done and the treatment is completed.

If your office is contracted, or in network, these matters are already taken care of for you. The date of liability for most procedures is in fact, by contract, the date of completion. To generate and file the claim prior to the procedures completion is, in many cases, a violation of the signed contract you have with the payer. Collect whatever you want from the patient at or prior to the time of service, but the claim must wait till the end.

Here is where I see many of today’s reimbursement challenges begin for both the patient and dental office. As for the benefit plans, they were not affected in as many cases. Once the check was written, they were done with the claim.

Originally, the standard J510 American Dental Association claim form read as follows:

“I hereby certify that the procedures as indicated by date have been completed and that the fees submitted are the actual fees I have charged and intend to collect for those procedures.”

When J510 went away the terminology was changed to:

“I hereby certify that the procedures as indicated by date are in progress (for procedures that require multiple visits) or have been completed.”

Here is where the patient’s insurance (benefit plan) jumped leaps and bounds in front of the doctor’s recommended treatment plan. Once third parties and their benefit plans were pulled in front of the patient by the dental office attempting to secure outside funds for services not yet completed, we all saw the spiral begin. Patients were being driven by the misconception that their own insurance was determining appropriateness of care, and if the plan did not pay for it, the patient did not want to have it. Ever wonder why and where the problem actually began? Who was it that opened Pandora’s box? Well, here it is, and we did it to ourselves.

Now time for the WHAT…

Tom Limoli

Tom Limoli

“The Nation’s Leading Reimbursement Expert”

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