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When Coding Has Nothing to Do with Code Numbers

Continuing from Part 2: WHEN

 

WHAT Code is Used?

As we always begin with the end in mind – let us now end with what was originally intended to be the beginning of this series on procedure coding.

So exactly WHAT procedure code number do we use? One would think this would be the easiest part of the equation. However, this is not always the case if the first two parts of the previously discussed equation are not followed. The application of Rule #5 is always to be paramount. You have to act accordingly, and code for exactly the specific procedure that is completed. Completed when? Completed today. In other words, the patient walked out the door with (having received) WHAT procedural treatment?

Here is a recent example of an issue involving a multi-specialty group dental practice. Many times during the course of routine endodontic therapy, a root canal obstruction is encountered. While most often done under microscope in a single visit, the office routinely billed for both the treatment of the obstruction (D3331) as well as the completed root canal. Early on, third-party payers were excluding benefits for the separate D3331 and declaring the procedure non-billable to the patient. In error, the office stopped submitting for the treatment of the obstruction and billed the patient directly. All it took was two patient inquiries to the plan administrator, the office was audited, and the overpayments were secured.

Three specific problems occurred with this office.

First – billing the patient and not generating a claim for the actual service (they were calling it an upgrade) to the plan is never a good idea. The audit also revealed a similar fraudulent practice of direct patient billing for pulp caps, cavity liners, cement bases, etc. — all “upgrades” directly paid for by the patients as “pulp protection.

Second – since most all of the root canals were actually finished in single seating, the additional time and expense of addressing the obstruction was part of and considered to be the “global” completed root canal. The real kicker occurred when the clinical documentation failed to address the extent, as well as treatment modifications necessary to an obstruction.

Third – the owner doctors were unknowingly yet intentionally being kept away from the daily “explanation of benefits” or EOBs. When the postman arrived at the office each and every day, a non-owner administrative team member would snatch up the mail and pull out the checks, as well as any insurance company communications. Of course, all the owner doctors would get were the bills to be paid and any second-rate junk magazines. Go figure.

Unknowing to the owner doctors were multiple requests from payers for patient specific additional information and clinical documentation, as well as line itemed non-payable as well as non-billable statements concerning contracted violations. The EOBs provide a plethora of information as to what is and is not payable/collectable, as well as any clinical team weaknesses that can easily be corrected with specific procedural documentation. Statements as to what can and cannot be claimed to a secondary payer are also specified on the EOB.

Cash flow is the lifeblood of any and all business. Owners have to be aware of the strengths, weaknesses, vulnerabilities, and challenges being faced. A world of information is available on the EOB. We too can talk about this and the legitimacy of upgrades during our conversation.

When all is said and done, the benefit plan has to remain nothing more than a term of payment for the patient’s bill. Never should an account be separated into patient portion vs. insurance portion. It’s the entire patient’s portion and the plan does nothing more than help offset the total cost of care. As concerns procedure coding – bill and code for exactly what you did based upon the patient’s documented needs. Plan specific limitations and restrictions are nowhere in the equation. Put the insurance back in its place.

Let’s talk. In the next issue we put to rest the fallacy of medical dental cross coding.

Until the next issue,
Tom M. Limoli, Jr.

Tom Limoli
Tom Limoli
“The Nation’s Leading Reimbursement Expert”
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