Most practices are seeking ways to get patients to accept treatment, to be paid in a complete and timely manner, get more patient referrals of friends and family, have improved collegial relationships with physicians, and receive compliments from patients and the feeling of a job well-done. This requires ongoing training for the entire team. Spending any money when the schedule is slow can seem just plain stupid, yet how can your practice stay relevant in a changing world without essential learning? Learning is much more than fanny time â¦ it has to be practical and applicable.
Taking the necessary steps to provide your entire team the needed tools that will move you into the wellness model is the basis of success and, more importantly, profitability. Courses, webinars, seminars, academies, books, articles, and videos abound with costs ranging from free to thousands of dollars. What is the return on investment (ROI)? The answer is often unfortunately not what is hoped. The difference is the delivery of data versus creating useable information. Data is raw, unorganized facts that need to be processed by the individual. Data can be random and useless until the individual knows how to organize it. When the individual processes, organizes, and structures data for the needs and direction of your wellness practice, it becomes “information.”
Many procedures performed in the dental office may qualify for wellness benefits through medical insurance. Medical may reimburse for oral disease complications or causes of other medical problems. Dentists can and should bill for all services performed with the understanding that each state has a statute specifying that medical insurers cannot deny a claim based solely on a provider’s degree and license if the care is within the scope of practice and the treatment is a medical necessary. In other words, the oral cavity is our scope of practice. For example, the ADA Council on Dental Care does not define implants as routine, therefore you should file implants to medical first if the diagnosis is medical in nature. Both TMD and implants have previously put us into the “no insurance coverage zone.” However, many states have added laws that do not allow jawbone and/or jaw joint treatment to be excluded if bones and joints in other parts of the body are covered.
Coding involves the entire team because the answer to nearly every benefit coding question is diagnosis and dental-medical necessity. No one in the practice can be hands-off with coding. Christine has been consulting on medical cross-coding for many years. The biggest problem she finds is that information is consistently left out. A whole team system for data collection and documentation is needed for determining dental-medical necessity.
Medical-dental necessity isn’t as complicated as it might first appear. Our weapons for identifying the clues to the most accurate dental-medical necessity are:
Service provided is the most appropriate
Diagnosis is consistent with the symptoms
Treatment is consistent with the diagnosis
Treatment is not primarily for the convenience of the patient or provider
Treatment is good dental-medical practice
The idea of dental-medical necessity shouldn’t be foreign to dental professionals. It’s simply requires documenting the reason a procedure is needed.
Most of us have played the game of Clue, have watched the Sherlock Holmes movies, or seen the recent TV show Elementary. The object is to bring together different ways of thinking to provide the answer. Every case is different just as every patient is different.
Detectives need to answer the questions:
Which one of the several suspects did it?
In the insurance game, we need to answer these questions:
Who is the patient?
What condition is putting them this patient at risk?
Where in overall system are there conditions and diseases affecting oral health?
What weapons are needed to assess risk, perform the right tests, and gather all the clues to make the diagnosis?
In real criminal cases, we treat everyone as if they are guilty until we prove they are not. In a wellness practice, we also treat everyone as if they qualify for medical coverage until we prove they do not.
We have created books and courses that are going to rock the dental world with the simple steps. We play a detective game starting with why and the detective role each team member (including the dentist) plays on billing. We end up with how-to dental-medical billing for TMD, sleep apnea, implants, periodontal risk patients, pediatric, trauma, and more. Learning the practical, applicable steps to fill out the forms leads to making life easier and more profitable with a team excited about the future. That’s ROI on every level.
Editor's Note: For more information on these authors, check out their book, DentalCodeology: Jump Start Diagnostic Coding, which is available at www.DentalCodeology.com.