Remember tug of war? Your team pulling as hard as possible to make the dangling middle string cross the line before the other team out-maneuvers you resulting in your teams’ demise! Medical insurance billing for dentistry can also feel like that, except the scene is that the cause of your patients’ oral difficulties stem from their medical condition and/or medication use… Maybe there was an injury and the oral cavity sustained trauma? Or, maybe intervention is required prior to surgery or chemotherapy treatment? Yet, when you bill medical insurance, there is a tug of war with you on one side and the insurance company on the other! Here are some tips to reduce the “pull” to get your claims paid faster.
Sequence Your Diagnosis Codes
Sequence your diagnosis codes correctly by telling your story backward. For instance, you see a patient that needs extractions, bone grafting, membrane and implants due to sustaining trauma in the anterior region. The first code will be the worst condition you will be treating them for, i.e. partial loss of teeth due to trauma class I. Then, we work on the why.
Say, this patient fainted while using the toilet and their mouth struck the tub as they went down. We will code the fall off the toilet with striking object due to syncope (fainting) in a single-family dwelling. Here is how it would look:
This is the story: John Doe was in his Hover me to open tooltip single-family house, fainted while using the toilet, and struck his maxillary and mandibular arches on the bathtub causing a partial loss of teeth due to trauma class I.
This is how the codes would be listed:
K08.411 – Partial loss of teeth due to trauma class I
W18.12XA – Fall from or off toilet with subsequent striking against object, initial encounter
R55 – Syncope
Y92.012 – Bathroom of single-family (private) house as the place of occurrence of the external cause
Does explaining your story both ways make sense? Medical billing for dentistry is all about making sense for each service line using up to four diagnosis codes.
Chart note verbiage is incredibly important. No matter if you are submitting to dental or medical, make sure that your diagnosis codes match your SOAP notes (subjective, objective, assessment, plan). This documentation will support the diagnosis codes and is an area that needs continual reinforcement. When our doctors were in dental school, they wrote volumes of chart notes! But, now that they are in private practice, we are seeing text messages–and some of them are so cryptic and illegible. The best practice is actually something in between the two. All while remembering that the more you use the word “teeth”, the more medical will say that your practice is focusing on the dental issue. Instead, bring to light the stabilization of the bone or reconstruction of the maxillary or mandibular arches along with the causality of the assessment.
Here is a sample for a chart note for bruxism:
Chart Note Example
Jane Smith DOB – 12/27/55
Exam Date – 3/19/19
Chief complaint: Patient awoke to jaw pain approximately 3 days ago and feels like somehow her jaw is swollen. No notation of any trauma to the area yet patient notes that she has had a shift in family dynamic with her in-laws moving in to live at her residence. She states that getting used to other people in her house has not been easy.
Blood pressure is slightly elevated at 135/70 (bp taken at last recall appointment on 12/29/18 showed consistent with prior levels of 120/60). Pulse was consistent with prior levels at 76. Patient states she has been taking 3-200mg Ibuprofen every 4 hours and does not feel that she has had relief.
Health History & Medication review:
Sinus problems – sinusitis (past)
Progesterone – menopause (current)
Estrogen – menopause (current)
Complete maxillary and mandible periodontal charting were taken along with a Previser risk assessment and a CBCT per doctors’ orders.
Health history review with Dr. Wells and the patient displayed that she is overall in good health with no prescription medication and only over the counter daily vitamins. Dr. Wells notes that right mandibular is tender to touch and that patient has increased sensitivity to pressure.
Discussed with the patient that this is likely a jaw sprain due to increased stress causing sleep-related bruxism. Treatment recommendations are to fabricate an appliance to reduce pressure on the right condyle.
The patient agreed with treatment and an impression was taken to fabricate the appliance. The appliance was adjusted and delivered in 30 minutes.
NV – patient to be seen in approximately 4 weeks for follow-up adjustment.
Be clear, concise, and not repetitive. There is nothing more frustrating to medical insurance staffing than when we wear our dental hat and send everything… claim, periocharting, pano, bitewings, narrative, chart note, etc. You should be able to explain without any of that. If medical wants any additional documentation, they will ask for it. Additionally, if your procedure code description states “bone graft mandible”, you do not need a modifier telling them it was in the mandible.
For medical billing in dentistry, less is more.
Honesty is the Best Policy
Finally, be honest. Do not commit fraud just to get your claim paid. Insurance fraud is not a laughing matter and is punishable by jail, fines, and even a loss of license for your doctor. NO claim is worth that risk! Here are some of the key things that are considered fraud:
- Billing for services not performed
- Up Coding
- Waiving co-payments and deductibles
- Not disclosing payment from other insurance
- Unbundling or improper use of codes
If you put these tips to use, they will help get your claims paid faster. But, if you are not billing medical, we encourage you to attend a course as soon as possible because you will be outmatched in tug of war. Just picture this, if it is you, alone, against the insurance company in a tug of war match, who would win? Getting the education and learning the rules will give you the “big guns” on your side of the rope!