9.22.17 Issue #811 info@mckenziemgmt.com 1-877-777-6151 Forward This Newsletter

Belle DuCharme, CDPMA
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Avoiding Coding Calamities
By Belle DuCharme, CDPMA

A couple decades ago, the Current Dental Terminology codes didn’t change frequently and you could memorize them to speed up processing claims. New computer technology and newer evidence in healthcare has not only created the need for more codes and nomenclature, it has afforded a “better mousetrap” in how we can create claims and store the codes.

For the last few years we have seen an increase in updating the American Dental Association’s code on dental procedures and nomenclature. 2016 saw 19 new codes, 12 revised codes, and eight deleted codes; 2017 saw 16 code changes, which include an addition of 11 new procedure codes, five revisions of existing codes and one deletion. 2018 will usher in 18 new code changes. It is no longer a great idea to memorize codes because of yearly changes. It is imperative that practices become familiar with these changes every year, particularly those that impact the type of practice – such as whether general or specialty.

Though this information about yearly coding changes has been around for many years, it is still very common to see practices using outdated coding books to create dental claims. Some practices that do not update to the latest version of their software will also not benefit from the software updating the codes to the latest version. If you think the insurance company will help you when you file a claim with a deleted code, think again.   One of the top reasons for claim denials is the use of deleted codes, followed by using codes that have been revised to be used differently than they were before.

A patient’s treatment plan should always be based on their clinical needs, not their particular plan’s covered procedures. If a code is not a covered benefit of the policy but is exactly what was performed as treatment, changing the code to a covered code so it gets paid may be considered fraudulent. It is important to know that not all procedures are covered under every plan – some have annual or lifetime limitations and exclusions, and limitations vary greatly from plan to plan. For instance, you file a claim using a deleted code that was once a benefit of the policy. When you refile the claim you use the proper code but it is not a benefit of the policy. This can result in not only a claim that isn’t paid but a very unhappy patient. Patients are looking to the practice for expert care in the area of dental insurance filing.

Dental plans may not allow benefits for all treatment options. A least expensive alternative may be the choice of the insurance company. This is called “downgrading” or LEAT, Least Expensive Alternative Treatment. At first glance the patient may feel that the claim was submitted improperly. For instance, the patient had treatment for a three unit fixed bridge which was listed as a benefit of the policy, only to have the insurance company downgrade the charge to that of a removable partial denture for half the cost. This is not an example of choosing the wrong code, and the dentist did not do anything improper. It is now up to the dental practice to support the treatment with a strong appeal backed by unquestionable clinical evidence as to the reason for the care provided.  

If the Insurance Coordinator does not see a procedure listed in the coding book that matches the services delivered, the use of 9999 codes is often the choice. There have been many changes recently that have provided codes to replace what used to be a “by report code”. This is another reason to have the most current CDT Manual available. The use of “by report” or 9999 codes always requires a detailed narrative, and they are often not covered benefits. When choosing the proper code, always ask whether the most appropriate code has been chosen. That includes reading the nomenclature and the code descriptor provided in the latest CDT Manual.

Insurance claim filing still continues to be where many practices struggle to receive payment for services rendered in the best interest of the patient. Many rules affecting adjudication have come about because some practices have been lax in filing claims with enough information and correct information for the insurance companies to pay the claim. Eliminating coding calamities by having the latest coding books and newest software version installed is the best insurance to help avoid denials and delays in payment.

Want help with this critical issue? Call McKenzie Management today and schedule a Business Training Course to review your insurance systems.

If you would like more information on McKenzie Management’sTraining Programs  to improve the performance of your team, email training@mckenziemgmt.com

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