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When Coding Has Nothing to Do with Code Numbers

  • It sHuh?tarts with WHO (does the coding).
  • Then moves to WHEN (the code is encountered).
  • And ends with WHAT (code to use).

Here we go again. The American Dental Association has yet another revision to Code on Dental Procedures and Nomenclature.

Is it going to make your life any better? Will it bring you any additional revenues? Was the word “surgical” really that offensive thus requiring the redefinition of over three dozen procedure codes? Let’s move beyond the scope of NDR and address the real heart of the reimbursement challenge.


WHO Does the Coding?

So WHO does the actual coding of clinical procedures in your office? Is it your administrative team? Is it your practice management software? Of utmost importance is the question: Who is responsible for monitoring, as well as measuring the coding accuracy in your office?

Let’s start with the end and work our way forward.

The doctor is ultimately responsible for the overall, as well as specific, coding accuracy of the office. It may have been the practice management software or even Gertrude, the Insurance Coordinator who selected and billed the procedure – it matters not. The doctor is responsible. Thank you, Doctor, for taking a more active role in the overall reimbursement management of the practice. Your next step will be in regularly reviewing all of the EOBs (explanation of benefits) that arrive daily at your office – but more on this during our conversation.

If the administrative team is doing the coding, what data are they using to determine the appropriateness of the specific code? The administrative team should never bill a procedure code based solely upon the recommendation of a benefit plan representative. “Oh, we don’t pay for perio maintenance, so bill it as a prophy.” Or worse yet when they say, “The insured gets only one D4910 and one D1110 per year.” Remember, it’s D4910 only if additional documented site-specific root planing took place. Otherwise, the appropriate code should have been D1110. But what ever happened to once a perio patient, always a perio patient? More on this during our conversation, too.

Most clinical support team members say, “I don’t have anything to do with the patient’s insurance. They handle all of that up at the front desk.”

Nothing could be further from the truth. To not embrace the significance of the clinical team’s role in simplifying the overall reimbursement process is maddening and bridges on the realm of insanity. Coding needs to take place based upon the documentation as generated specifically by the clinical team – AND NOTHING MORE.

If and when a third party requests additional information concerning a completed or anticipated procedure, don’t waste time trying to dig up or concoct a magical narrative report generated by some shyster of misguided practice management. The one and only narrative report that an administrative team will ever need is the one that reads:

“Attached is a copy of our clinical documentation from the dates of service.”

Now do you see that if your clinical teams existing documentation does not address the specific informational needs of the third party, how you have documentation and not “we need an insurance narrative” problem?

Today, payers are recouping hundreds of thousands of dollars from inaccurately submitted yet paid claims. Just because the check is written does not mean the funds are not recoverable. Don’t look for this trend to change. Health insurance, including its dental subcomponent, will continue to fall under federally mandated guidelines.

The earlier example with the alternating of perio maintenance and prophylaxis is but one scenario. Others include inlays, onlays, three-quarter crowns, as well as appliances for bruxism, TMJ, snoring and the ever popular, and many times confusingly fraudulent, “sleep apnea.”  Adding to these complications are in-network vs. out-of-network fee discounting, along with date of completion and identification of treating doctor manipulations.

Let’s move on to WHEN…

Tom Limoli

Tom Limoli

“The Nation’s Leading Reimbursement Expert”

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