Billing and Coding in Your Dental Practice
THE NEXT DDS
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.
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.
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
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
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.
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
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
- 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
- Misrepresenting patient
- 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.
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.
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
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
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.