Ch 14 Third Party Reimbursement and Coding

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Third-Party Reimbursement
and Coding
Chapter 14
1

Learning Objectives
Lesson 14.1: Third-Party
Reimbursement and Coding
(Slide 1 of 2)
1. Define the key terms in this chapter.
2. Understand and use the appropriate terminology
when speaking about third party reimbursement
and coding.
3. Understand how easily and often fraud can occur
and what to do to avoid it.
4. Discuss reasonable and customary or usual and
customary (UCR) fees and other concepts related
to fees and third parties.
5. Learn the role of codes and the power of metrics.
2

6. Identify the steps in accurate filing of American
Dental Association claim forms.
7. Discuss coordination of benefits.
3
Learning Objectives
Lesson 14.1: Third-Party
Reimbursement and Coding
(Slide 2 of 2)

Third-Party Reimbursement
 With healthcare reform, people are becoming
much more informed and engaged when it
comes to healthcare decisions
 No profession of dental coding
 “Third-party reimbursement” is more global
and accurate terminology
 Codes are involved with every patient
encounter
 Duty of practice to use most accurate codes
4

Fraud by Accident or Ignorance
(Slide 1 of 2)
 Without knowledge of codes and how they are
being applied, there is a likelihood of insurance
fraud being committed
 American Dental Association (ADA) “Golden
Rules” for coding:
 Code for what you do
 After reading full nomenclature and descriptor, select
code that matches procedure delivered to patient
 If there is no applicable code, document service using an
unspecified, by report (D_999) code and include a
clear/appropriate narrative
 Existence of a code does not mean procedure is covered
 Treatment planning is based on clinical need
5

Fraud by Accident or Ignorance
(Slide 2 of 2)
 Fees: Practice can choose to charge fees they want;
should be based on cost of doing business with
reasonable profit
 Codes: CDT codes support uniform, consistent, and
accurate documentation of services delivered
 Coverage: Contract between third-party carrier and,
most often, a patient’s, spouse’s, or parent’s employer
 Insurance: Coverage by contract whereby one party
undertakes to indemnify or guarantee another against
loss by a specified contingency or peril
 Third-party reimbursement: Payment made by third
party to beneficiary or dental practitioner
6

A Deeper Dive: Fees
 ADA cannot quote fees for dental procedures
because practitioners can charge what they
want
 ADA provides fee schedules based on
collection of data from dental practitioners
across the country
 Not the best method for setting fees in your office
 Practice fees should be based on cost of doing
business plus a reasonable profit
7

Reasonable and Customary/Usual
and Customary (UCR) Fees
 Usual: a fee an individual dental practitioner
often charges for a specific procedure as
measured by a dental plan often based on zip
codes
 Customary: a fee decided the administrator of
a dental plan that establishes a maximum
benefit
 Reasonable: a fee charged for a specific
procedure that has been modified by
complications as decided by a dental plan
8

Challenged by Fee Questions
 How objections are handled tells your
patients a lot about the kind of professional
you are
 Financial coordinators and ever team
member should rehearse in the mirror how
they will quote the fees
 Important to be able to quote fees confidently
without any hesitation
9

A Deeper Dive: Codes
 Any claim submitted on a HIPAA standard
electronic dental claim must use dental
procedure codes from the version of CDT
codes in effect on date of service
 Accurate coding can:
 Close loop between diagnosis and treatment
 Elevate standard of care
 Bridge gap between oral and systemic health
 Ensure earlier intervention and disease prevention
 Boost the bottom line of the practice
 Provide powerful metrics
10

The Power of Metrics
 Metric: standard of measurement
 Metrics provide power to quickly arrive at a
data-driven decision that can:
 Improve outcomes and performance
 Drive cost saving
 Enhance quality of care and patient satisfaction
11

Licensed to Teach Codes
 Coding world in dentistry is filled with
misinterpretations, myths, and misinformation
 ADA developed and owns the Current Dental
Terminology
 Dental professionals need to use caution
when presented with coding information and
look for the information source’s license
12

Codes Updated Annually
 Using an old code reference is like using an
expired cartridge of anesthetic
 Continuous training is needed
 ADA provides updated materials each year
13

CDT Codes Not Limited by Provider
 Third-party carriers have yet to fully include
dental hygienist as a designated provider
 Hygienist takes on added role of being the
patient advocate between the patient and
carrier
 Some procedures may be considered tied to
a dental diagnosis and therefore can only be
billed by a dentist
 Need to be aware of limitations to inform
patients of potential costs
14

Using the CDT Code Set
 CDT code supports uniform, consistent, and
accurate documentation of services delivered
 When filing for benefits using the correct
code, key to successful claim submission is
the use of narratives that can fit into Box 35 of
the ADA Claim Form
 A longer narrative on a separate page can delay
processing by 2-3 weeks
15

Important Boxes for Clinicians
on ADA Claim Form
 ADA Claims show two important boxes:
 34A: Diagnosis codes
• Adding this simple step can optimize dental claims and
have a step-up on medical cross-coding
• Both ADA Dental Claim Form and HIPAA standard
electronic dental claim transaction can report up to four
diagnosis codes
 35: Remarks
• Be sure to cut unnecessary words
• Do not use acronyms or abbreviations
16

Structure of a Dental Plan
 Numerous limitations and clauses on the
average dental plan
 Patients often have misinformation
 Patient’s third-party carrier has zero
responsibility in communicating with a dental
practice
 Dental practice’s best course is to help
patients understand their responsibilities for
their own dental plan
17

ADA Dental Claim Form
Completion Instructions
(Slide 1 of 4)
 Header Information
 Box 1: Type of transaction (3 choices)
 Box 2: Predetermination/preauthorization number
 Insurance Company/Dental Plan Benefit
Information
 Box 3: Must always be completed
 Box 4: If there is other coverage, mark the correct
box
 Other Coverage
 Boxes 5-11: Do not need to be filled out if nothing
is marked in Box 4
18

 Policy Holder/Subscriber Information
 Boxes 12-17: for insurance carrier in Box 3
 Patient Information
 Boxes 18-23: Information that pertains to patient
 Record of Services Provided
 Box 24: Procedure date is for actual date of care
 Boxes 25-28: Area of oral cavity
 Box 29: There is always a code
 Box 29A: Diagnostic pointer (block capital letter)
 Box 29B: Number of times procedure performed
 Box 30: Description is provided
19
(Slide 2 of 4)

 Record of Services Provided
 Boxes 31, 31A, 32: Fees
 Box 33: Missing teeth information
 Box 34: Diagnosis code list qualifier
 Box 35: Remarks
 Authorizations
 Box 36: Signature of both patient and treating
provider
 Box 37: Authorize direct payment
 Ancillary claim/treatment information
 Box 38: Place of treatment
 Boxes 39-47: Should not be skipped
20
(Slide 3 of 4)

 Billing Dentist or Billing Entity
 Box 48: Treating dental practitioner and treatment
location can be different from treating dental
practitioner location
 Box 49: National Provider Identifier (NPI)
 Boxes 50-52A: Include all accurate up-to-date
provider numbers
 Treating Dentist and Treatment Location
Information
 Boxes 53-56A: Differences between treating
dental practitioner, treatment location, and treating
dental practitioner NPI must be noted here
21
(Slide 4 of 4)

Steps to File Accurate Claims Forms
 Patient treatment plan should be based on
the patient’s clinical needs
 Not all procedures are covered
 ADA owns dental codes
 Fill out the claim as accurately and
completely as possible
22

Coordination of Benefits
 Coordination of benefits (COB) is the process
of paying healthcare expenses when a
person is covered by more than one plan
 Dental benefit carriers follow rules
established by state law to decide which plan
pays first (primary carrier) and how much the
other plan (secondary carrier) or plans
(tertiary carrier, and so on) must pay
23

Best Coding Practices
 Best practices evolve through the efforts of many
 Dental practitioner who provided service is legally
responsible for any coding submitted for service
 Dental practitioners document in the dental record
and provide justification where needed
 Code appropriately for different types of encounters
 Always use a CPT modifier when billing for medical
procedures
 Dental practitioner should review charges and codes
used in the office periodically with office manager
24

Continuing Evolution
 Coding competency is extremely important in
revenue cycle
 Coding will continue to evolve, as will best
practices
 Number one best practice must be continuous
learning as key to success
25

Questions?
26

Ch 14 Third Party Reimbursement and Coding

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