Preventing Dental Coding Errors
Coding errors can be costly in a myriad of ways—from delayed or denied payment of claims to fines, a revoked dental license, and/or imprisonment. Regardless of who assigns codes to procedures, it is critical to remember that the dentist is legally responsible for the accuracy of all dental claims that leave his/her office.
Dental billing is often handled by business staff members. The fortunate ones have received training about codes from a knowledgeable dentist, experienced administrative staff, newsletters, and/or comprehensive coding workshop(s). The unfortunate ones learn by trial and error, which is dangerous to the practice, the dentist, and the staff person submitting claims. To help our readers avoid some of the most common dental coding errors, we asked the Insurance Solutions phone support staff and three experts in the dental industry with different perspectives to identify the most troublesome dental codes. With this input, we created the Quick Reference Chart: Common Dental Coding Errors on page 4, which highlights both the problems and solutions for many of the codes that are commonly billed incorrectly.
We asked the following experts to share their opinions on what they consider to be the most problematic codes and suggestions on how dental practices can improve their billing systems and communication:
Wayne S. Silverman, DDS, a practicing dentist, professor, former dental director for a large dental plan, practice management consultant, and expert witness for dentists facing insurance audits and/or miscoding allegations (email@example.com);
Roy S. Shelburne, DDS, a former practicing dentist who endured the ultimate chart/records review—a criminal trial. The result was a guilty verdict and prison sentence imposed, in some degree, from inadequate or inaccurate billing, coding, and record keeping systems. Dr. Shelburne now lectures about his legal ordeal and provides in-office coding/documentation reviews for private practitioners (www.royshelburne.com);
Charles Blair, DDS, a former practicing dentist, now a business finance management consultant and author of four editions of Coding With Confidence (www.drcharlesblair.com).
Dentists are legally responsible for improperly coded claims– even unintentional errors
According to Dr. Blair, there are four levels of coding compliance:
1) The legal requirements regarding the reporting of CDT codes;
2) Third-party contract requirements (and any subsequent updates);
3) The ADA’s membership requirements under the Principle of Ethics and Code of Professional Conduct;
4) Adherence to a fundamental moral standard of fairness.
Dr. Blair also notes that state dental boards hold dentists responsible for all occurrences in their offices. He advises dentists to review the sanctions on their state board website to fully understand the serious nature of improper coding and insufficient chart documentation.
All three experts acknowledged that most dental schools do not adequately teach dental coding. However, as emphasized by Dr. Silverman, it is incumbent upon every dentist to learn proper coding since it is the dentist’s name on the claim form. Therefore, it is the dentist’s responsibility to verify that all procedures are coded correctly. Dr. Silverman also cautions that accepting payment in error, whether intentional or not, is fraud. “Very sadly, fraud investigations can take on a life of their own. Once it begins, it is difficult to stop.”
Dr. Roy Shelburne knows all too well the horror of enduring a fraud investigation. Presently, he is completing his three-year probation after serving two years in federal prison for healthcare fraud. He feels like the poster boy for unintentional errors that, in reality, constitute fraud. During sentencing, the government bore the burden of establishing the overpayment that Dr. Shelburne received. The amount of overpayment was established to be less than .5% of the gross payments received during the period in question. An error rate of this amount would be acceptable and expected in most industries. However, Dr. Shelburne learned the hard way that healthcare billing is similar to filing a tax return with the IRS—no error rate is acceptable.
Know the codes
All three experts urge dentists to attend coding courses. Dental coding errors can reap serious consequences, and even though most state dental boards do not specifically require dentists to receive CDT training (or even accept CE credit for such), there are serious sanctions for misreporting dental codes. Drs. Silverman and Blair note that medical doctors typically know their codes very well, and they believe that dentists should too. Dr. Blair adds that third party contracts always have language allowing the carrier to audit a practice, and improperly using codes or over-utilizing codes could trigger an audit.
Drs. Blair, Silverman, and Shelburne also agree that every dentist needs to realize the seriousness of their responsibility to ensure that procedures are coded correctly. This requires dentists to know coding well and have systems in place to catch coding errors. It is dangerous to rely solely on office staff or benefit claims processors to catch coding errors. Dentists should have a system in place to verify that claims are coded correctly on a daily basis and periodically conduct a coding and documentation audit (or hire an outside source) to find coding errors and insufficient documentation.
Practice analysis reports
Drs. Blair and Silverman suggest a quick way to find coding errors is to periodically run practice analysis reports. Practice analysis reports are available on most practice management software programs and can point to problems with either coding or practice management issues. For example, a practice summary report showing only code D7210 billed for extractions indicates a potential problem because it is extremely unlikely that every extraction performed in a practice would be surgical—whether a general practice or an oral surgery practice.
To further ensure correct coding, Dr. Blair recommends that practices deactivate unused codes in their software billing programs, leaving only the procedure codes that are actually performed in the practice. There are currently just under 600 dental codes available in CDT, but the average general dentist regularly uses only about 90 codes. “Only display a code and fee in your computer system for those procedures that you regularly perform and block out the other codes. This simple step will reduce the possibility of coding errors significantly,” said Dr. Blair.
Integrate the entire billing process
Dr. Shelburne believes that everyone—clinical staff and office staff—shares responsibility for both the continuum of care for the patient and ensuring that procedures are coded correctly. The doctor is not only responsible for appropriate patient care. He/she is also responsible for accurate documentation and proper reporting. Administrative staff are not only responsible for processing the paperwork, they must also understand dental procedures well enough to accurately code them on dental claims. When consulting with a practice, Dr. Blair insists that both administrative and clinical staff participate in his CDT training because of the migration of computers into operatories and the evolution towards electronic health records and paperless practices. “The clinician needs to be an expert in coding the procedures they perform.” Ideally, the dental assistant or hygienist should enter codes after procedures are performed, the business staff should review the charts and codes for accuracy, and the doctor should review a report at the end of each day to ensure that the codes listed on claims match the procedures that were performed. “Scanning this report typically only takes a few minutes for the doctor,” said Dr. Blair, “and it is a good practice management technique to ensure that the treatment plan was followed, the procedures were coded correctly, and all procedures performed that day were actually billed.”
Dr. Silverman does not necessarily agree that all members of the team need to know CDT codes. However, he does agree that business staff must have a thorough understanding of CDT codes and have an adequate understanding of the procedures performed and terminology used so that they do not miscode something due to a lack of understanding. “Clinical staff must chart accurately and completely and must be aware of potential coding errors that their notes could generate.”
According to Dr. Silverman, an essential ingredient to proper coding is thorough record keeping. He tells his dental students and clients alike, “If you do not write it in the chart, it did not happen. It’s all about good record keeping. Whether you want to make more money (and it is okay if you do), or if you want to reduce exposure, you have to accurately describe the treatment you rendered in the chart, and then sign the chart. Record keeping is the backbone of a practice.” The patient’s chart must identify all procedures performed, progress notes, and necessary information to document and justify to the benefit plan, the state dental board, or any other entity, that the treatment performed was necessary and appropriate. Also, it should be documented that various treatment alternatives were offered to the patient. Dr. Silverman uses routing slips on the outside of charts with necessary billing and coding information, since it is inappropriate to place billing information in charts. This brings up the final key issue: communication.
Clear communication is essential
Dental teams must design processes to ensure the transfer of necessary information from the doctor to the billing staff in order to code accurately. Many computerized billing software programs have no explanations associated with a procedure. The billing staff matches the terms in the chart with the terms on the screen. This could be a costly mistake. While made innocently and understandably, some mistakes are not only incorrect, they may be considered fraudulent. Clinical staff cannot simply rely on the billing staff to decode chart notes. They must verbally communicate billable versus non-billable treatments billing information like Dr. Silverman suggests.
For example, when the notes in the patient’s chart indicate a surgical extraction of an erupted tooth and alveoloplasty was performed, the doctor has used both correct terminology and charting procedures. However, Dr. Shelburne cautions that unless the doctor removed a significant amount of bone, beyond what was needed to remove the tooth, reporting both codes would be upcoding. Unless the procedure and the chart notes reflect that the alveoloplasty performed was significant (and why) the service performed does not rise to the surgical level associated with a separate code (D7310/D7311). Since all treatment rendered must be entered into the patient’s chart—and because notes on financial information are prohibited in the patient’s chart—the doctor needs to communicate verbally with billing staff (or use a separate note) that the minor alveoloplasty is included with the extraction and should not be billed separately. Inherent in all of this is that the doctor must first recognize that CDT extraction codes (D7140 and D7210) include minor alveoloplasty. Second, the doctor must understand that it is considered upcoding if minor alveoloplasty is billed separately. Finally, the doctor must recognize that the billing staff may not know the distinction between minor and significant alveoloplasty and when alveoloplasty should be billed separately.
Dr. Silverman becomes concerned when he hears doctors say they are too busy to write their charts each day. “The dentist needs to communicate what was done in the clinical area to the business staff who bill, and the chart may be the only communication tool used. With incomplete or poorly worded charts, the business staff may interpret them incorrectly. The practice may lose money from undercoding or not coding for things performed, or it may get into trouble for upcoding.” Dr. Silverman maintains the problem is easily solved by attaching routing slips or something as simple as post-it notes to charts with the proper codes needed for each procedure. “When an office lacks good communication, coding errors are more likely to occur, which can cause serious problems for the doctor.”
Billing errors are a big deal—even unintentional ones
Drs. Blair, Silverman, and Shelburne warn that it is dangerous to assume that billing errors are no big deal. Even dentists who do not participate in dental plans must accurately report every procedure and are subject to audit by the patient, state board, and other agencies.
According to Dr. Shelburne, the United States Attorney General’s office announced in a recent press release that it is no longer interested in repayment and restitution. It intends to send providers to prison for healthcare fraud. Dr. Shelburne has been tracking prosecutions similar to his own ever since his release from prison and notes a disturbing trend. Not only are dentists facing prosecution, billing staff are too. In the last six months, three more dentists have gone to prison. Two of the three prosecutions included an office manager and a dental assistant. “Every dentist needs to be able to explain to a prosecutor what he/she did to ensure that the billing in the office was being done correctly.” On the witness stand during his trial, Dr. Shelburne had to admit that he did nothing to monitor the billing/coding/claims submission systems in his office. He wants everyone to learn from his mistakes and not endure his nightmare.
Correct coding often results in increased income
According to Dr. Blair, correct coding often results in higher revenues as practices obtain reimbursements that were once left unpaid because of misunderstanding or misreported codes. All three experts agree that better CDT training, better chart notes, better communication within the office about billable and nonbillable procedures, and periodic internal auditing of a practice’s coding and documentation systems will create more successful practices. Dentists will rest assured that they are receiving legitimate reimbursements when they thoroughly document treatment in patient records, understand the proper use of CDT codes, adequately train staff, and have a system in place to verify that procedures are being correctly coded.