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Billing and Coding in Your Dental Practice

Introduction  

One day you may be an independent businessperson. As an employer, you will have business expenses such as rent, staff wages, supplies, and your own salary to cover. You will need to bring in revenue on a consistent basis to pay these expenses. The days of private pay practices are gone where your patients pay their bill in full at the exit window for your services rendered. You will be dealing with third party payers, and you must learn nuances of billing and coding to be paid for your hard work and expertise. Dentists must learn to develop a budget based on fixed and variable expenses, and then optimize revenue while avoiding errors in billing for services.

Changing Landscape  

Besides your own salary, staff wages will likely make up the majority of your expenses. Practicing dentists face the challenges of making ends meet on a tight budget, and every dollar becomes important. To make matters more “interesting”, the expectations placed on dental practices in terms of billing and coding continue to evolve. As an example, the American Dental Association (ADA) sells a procedure codebook that describes appropriate billing procedure codes for a dentist’s work. This codebook changes every year with new codes added and older codes removed regularly as technology and science changes. For the 2015 edition, the ADA describes “code changes [which] include: 16 new procedure codes, 52 revised procedure codes, and 5 deleted procedure codes” relative to the 2014 edition.1 Without appropriate systems in place to remain current with the nuances of billing and coding, it can seem daunting.

A fundamental rule for any small business owner is that he or she must create an operating budget. Budgeting assumes a sound understanding of the business’s profit and loss statement and having knowledge of fixed and variable production and expenses. This is a critical first step in running your business that you cannot afford to leave up to your software or your accountant. Time invested in learning about this important information will save you significant dollars, and possibly your business, in the future.

Accurate Documentation  

Billing and coding requires accurate documentation of the results of every patient visit. The adage “if it isn’t documented, it didn’t happen” applies not only to professional liability but also to billing and coding. Third party payers will require that adequate documentation exists regarding the diagnosis and associated procedures when they pay your claims. If an insurance company audits your practice, you will need thorough documentation of your decision-making process, diagnostic testing, discussions with the patient, alternative treatment options offered, and informed consent. Along with this information, you will need thorough documentation of the procedure itself in order to justify your claim. If you wait until an insurer requests your records, it is too late to document what you did.

There are certain rules in place as pertains to billing and coding. Some codes may only be used once or twice per year for a patient depending on their insurance coverage. Billing higher levels of service on every visit (so-called over-coding) can raise red flags, making your practice vulnerable to an audit. On the other hand, under-coding leaves money on the table.

Accuracy and Completeness  

Accurate and complete documentation facilitates reimbursement by third party payers.2 Determining and documenting dental and medical necessity is the basis for successful coding. In most states, determination of the correct diagnosis and the appropriate level of service for billing is solely the responsibility of the dentist.

Dental practitioners are most likely to be most successful in their billing if they can show:

  • that they are providing the most appropriate service;
  • based on a diagnosis that is consistent with the symptoms and findings;
  • utilizing treatment that is consistent with the diagnosis;
  • utilizing treatment that is not primarily for the convenience of the patient or provider; and
  • utilizing treatment that is consistent with good dental practice.

In order to facilitate accurate billing for a service, dentists often rely on encounter forms or charge slips containing the most relevant diagnostic and procedural codes for their practice. These billing forms can be custom-designed for your practice showing the diagnoses and procedures that you encounter most frequently in your own practice. The encounter form becomes an accurate method of communication between you and your business office.

Accuracy in documentation and billing implies professionalism and sound judgment. Completeness of records tells insurers what they need to know to justify payment for your services in a timely fashion. Many dentists rely on the use of digital photography to aid in documentation, although its use has been controversial in some segments.3 Delays in appropriate billing will result in delays in payment and increase rejection rates of valid claims. 4 In some medical and dental practices, overwhelmed staffers have been known to put piles of claims in drawers rather than telling the provider that they are behind. Dental claims have a finite window of time in which they may be filed after a visit, and working a rejected claim requires time and diligence. Adequate and accurate documentation along with appropriate selection of billing codes improves first-pass payment rates, reduces claim rejections, and eases the workload of your billing staff.

Other than assigning a diagnosis and level of service, much of the work of billing can be delegated to staff members. Most busy practitioners do not have the time or expertise to do their own billing or claims follow-up. Electronic record-keeping software can reduce some of the work and time involved by interfacing with electronic billing systems. You will likely have staff members dedicated to billing and working rejections, but you as the dental professional and business manager are be accountable for timely and appropriate documentation.

 

Diagnosis Codes  

The use of diagnosis codes in dentistry is a relatively new concept. Diagnosis codes are not mandatory yet, but likely will be soon. The new ADA claim form has boxes for diagnosis codes, and it is advisable to become familiar with diagnostic codes now. The use of these codes encourages scientific accuracy by practitioners and facilitates appropriate payment for services rendered.4 Diagnostic codes are complex and evolving. The current standard “International Classification of Diseases” (ICD) revision 9 has 14,000 codes, while the upcoming revison 10 has over 69,000 codes.5 The vast majority of these codes do not apply to dental practices, however, and using a custom-designed encounter form can dramatically ease the complexity of using diagnostic codes.

Cross Coding  

Cross coding is the practice of billing some portion of dental procedures to medical insurances. Such billing practices may help to improve reimbursement for the work you do.6 One example might be billing dental trauma codes to medical insurance. There are also a number of dental conditions that interplay with underlying medical conditions including HIV, diabetes, cancer, autoimmune conditions, and substance abuse. Billing both dental and medical insurances can significantly impact reimbursement so long as each insurer is aware of the other and can coordinate benefits payments. Cross coding is more complicated, but again software tools can help. The NextDDS will publish more information on cross coding in future issues.

Fraud and Abuse  

Health care professionals may find themselves vulnerable to accusations of fraud and abuse.7 Billing fraud is not easy to define, but most consultants say “I’ll recognize it if I see it”. Charges of fraud are difficult to defend against, and the fear of such charges can make some dental practices undercharge for their services rather than call attention to themselves.4 The most common causes for fraud accusations include:

  • Billing for services not performed
  • Upcoding (charging for a higher level of service than was actually performed)
  • Waiving copayments or deductibles (violates the contract between the patient and their insurance company)
  • Altering dates of service
  • Unbundling or improper use of codes
  • Misrepresenting patient identities
  • Not disclosing existence of additional or primary coverage

Diligent and accurate documentation of the office encounter provides the best defense against such allegations.7 Sound record-keeping policies and procedures can help you remain successful and keep your staff honest.

Electronic Aids  

You will likely rely on various electronic aids available to help you bill and code accurately and efficiently. There are a number of applications written for smart phones the help select the best diagnostic code, some of which are provided by the ADA. In addition, desktop and web-based references are fast and updated in the background with the most current rules and guidelines. An electronic health record system can facilitate documentation and billing and provide secure encrypted claims submission as required by HIPAA regulations. For example, MicroMD by Henry Schein integrates medical and dental practices, EMR, and billing and coding, facilitating cross coding and allowing seamless coordination of benefits between different insurance carriers. As mentioned, rapid and error-free claims submission will bring in practice revenue consistently so that your practice can meet its financial obligations. Ensure that you subscribe for software updates as they become available to help maintain the latest security upgrades and changes in coding and tax laws.

Conclusions  

Appropriate billing and coding require due diligence in diagnosis, diagnostic test selection, documentation of history and findings, and proper procedural documentation. You will need systems in place to facilitate appropriate coding ranging from simple encounter forms to electronic health records depending on your office budget. Dentists often need a staff member devoted to submitting claims, working rejections, billing for co-pays and deductibles, and reducing accounts receivable. Improper billing and coding results in rejections, loss of revenue, and even claims of fraud. Follow NextDDS for articles, workshops, and learning aids.


References  

1.            Association AD. CDT 2015 Products. J015 - CDT 2015: Dental Procedure Codes. 2015; http://www.ada.org/en/publications/ada-catalog/cdt-products. Accessed 06/18/2015, 2015.

2.            Finkbeiner BL, Finkbeiner CA. Practice management for the dental team. Elsevier Health Sciences; 2015.  

3.            Chowdhry A, Sircar K, Popli DB, Tandon A. Image manipulation: Fraudulence in digital dental records: Study and review. J Forensic Dent Sci. Jan 2014;6(1):31-35.  

4.            Naran S, Hudovsky A, Antscherl J, Howells S, Nouraei SA. Audit of accuracy of clinical coding in oral surgery. The British journal of oral & maxillofacial surgery. Oct 2014;52(8):735-739.  

5.            Harper M. The gift of an extra year before cross coding and ICD-10 implementation. 2014; http://www.dentistryiq.com/articles/2014/06/the-gift-of-an-extra-year-before-cross-coding-and-icd-10-implementation.html. Accessed 06/18/2015, 2015.

6.            Harper M. Dental-Medical Cross Coding 101. 2013; http://www.dentaleconomics.com/content/dam/de/print-articles/Volume%20103/Issue%208/ceocourse.pdf. Accessed 06/18/2015, 2015.

7.            Brown L. Inadequate record keeping by dental practitioners. Aust Dent J. Nov 27 2014.  

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