The claim form (dental or medical) is a legal document, just like any document presented to a bank, a court or a mortgage company. It is vitally important that the doctor who provides the treatment, and the person who prepares the claim form to submit to the carrier for reimbursement, understands the claim form must accurately represent who received the care, who provided the care, the services provided using the most accurate code currently available from the CDT or ICD-10, and the fee that will be accepted as payment in full for the services provided … as well as several other things.
The bottom line is that everything on that claim form must be accurate. Having dealt with several questions from doctors and their business staffs, the one question that always sends chills up my spine is: “How can we get around this?” They question this as if there are shortcuts or some mystical way to be reimbursed more than is possible given the policy’s restrictions and limitations. Reimbursement for treatment provided hinges on the condition being treated and the coding that best describes the service provided, nothing else … certainly not what the carrier will reimburse. The doctor and staff need to completely and thoroughly understand the codes and how they are to be applied. The team must also realize that just because a code exists to describe a service provided, it may not be paid by the carrier due to limitations and restrictions established by that specific plan.
Ignorance is no excuse; ask a dentist who is also a convicted felon about the ignorance defense. Code for what you do, no more and no less. Do it accurately using the best code to describe the service provided and report the fee that represents what you will accept as payment in full for the service provided. This practice policy will protect and defend you every time.
Roy S. Shelburne, DDS
Interested in learning more about coding? Register for the Dental to Medical Cross Coding Webinar Series, available for purchase in the AGD Online Learning Center.