How to Navigate Cross Coding Speed Bumps
Part 1 of a 3 Part Series
Is frustration the name of the game? I am referring to cross coding to medical. As a cross coding coach, I hear that word “frustration” quite often. Due to the fact that there is such a divide between dental and medical, it becomes difficult to communicate through a medical claim exactly why a dental procedure has a medical necessity. Medical necessity is the key to cross coding and we try to prove medical necessity through the use of diagnostic coding, narrative information, and letters of medical necessity. That is one of the biggest hurdles in cross coding but there are many others. I call these other hurdles the cross coding speed bumps. Due to the fact that there are so many speed bumps, this will be the first article of three that will cover it all. So let’s examine some of these speed bumps.
Speed Bump #1: Cross Coding is just a front desk job.
Through my years coaching and speaking on cross coding, I see a common misconception. Many dentists and staff members believe that cross coding is strictly a business office (front desk) job and that they do not need to deal with it at all. That is far from the truth. Cross coding should be implemented with the knowledge that all staff members and the dentist(s) have an important role to play. Hygienists are quite often the first staff member to see new patients and they can be the first ones to evaluate medical history forms and also ask the types of questions that can indicate if a patient may need a medically necessary dental procedure. If that is the finding, then this needs to be communicated to the dentist who can then make a determination. Dental assistants can also do the same. Dentists actually have the most important role because it is the dentist who needs to make a final decision on whether claims should be submitted to medical, they need to make sure that thorough documentation is in place addressing that, and they must always be the ones to diagnose but then should be the ones to choose the appropriate ICD-10 codes (diagnosis codes) for that patient. Business office staff members have a HUGE role, in that they handle all of the rest.
Solution: Any practice that decides to implement cross coding needs to have a staff meeting to discuss the roles of each staff member. In addition, there should be cross coding instruction so that all staff members and the dentist are fully aware of how cross coding works.
Speed Bump #2 - Documentation
Documentation is one of the most important areas in cross coding and is probably one of the areas that is not handled well enough. Incomplete documentation can cause a myriad of serious problems:
- Creates difficulty in proving medical necessity
- Makes defending a law suit difficult
- Results in negative audits
- Can lead to improper coding choices which hinders insurance payments and even results in denials
- Improper coding choices leads to inconsistencies in a patient’s medical record
Solution:
Physicians have to follow a set protocol for their documentation and dentists need to follow that same protocol. There are levels of documentation that need to be followed:
- The extent of patient history gathering
- The complexity of the medical decision making
- The time that the doctor spends face-to-face with the patient
- Information obtained from physician
- Patient’s description of the problem
And then there are guidelines that need to be followed:
- Type of condition
- Onset – acute or chronic
- Etiology (cause) – e.g. infectious agent, congenital
- Anatomical location and laterality
- Severity – mild, moderate or severe
- Stages of healing
- Episodes of care – e.g. type of encounter
- External causes
Speed Bump #3 – Cross Coding can’t be that different.
It is! It’s a huge mistake to try to implement cross coding without instruction. There are so many differences between dental coding and medical coding that attempting to do this without training can result in denials and possible audits.
Solution:
Invest in training. Whether it be instruction manuals, courses, or on-site training; there are ways to tackle this. In addition, once training is completed, dental practices need to stay updated on any changes in cross coding, especially with the code sets. Diagnosis codes (ICD-10) update on October 1 of each year and procedure codes (CPT) update on January 1.
Speed Bump #4 – Not understanding medical necessity
Are you receiving EOB’s that deny claims because the carrier states that the claim is not medically necessary?
Solution:
One of the key areas in cross coding is proving medical necessity for dental procedures. One has to first understand how the carriers define medical necessity. The problem is that there is no single definition. What we have to do is find the common threads that apply to all of the definitions. These are:
- Procedures must be in compliance with recognized medical standards and be appropriate and necessary for:
- diagnosis or treatment
- prevention of a medical condition
- improvement of a condition
- rehabilitation of lost skills
Dentists need to apply that definition to a patient’s condition(s) and, if it does apply, then thorough the documentation that needs to take place, record how it applies for each patient. I believe that the majority of medically necessary dental procedures are the ones that help restore function to a patient (e.g. trauma, bone atrophy that affects a patient’s ability to masticate and get good nutrition, dental procedures performed due to congenital defects or metabolic diseases that have impacted the oral cavity, sleep apnea, and TMD). Other areas are pain, adverse effects of medication, surgical procedures, and medically necessary periodontal procedures.
Speed Bump #5 – There are SO MANY steps!
Yes, this is true.
Solution:
Unfortunately, I don’t have a solution. These many steps beyond the basics of setting up patient insurance information and completing claim forms are very important and need to be done. Certain steps should be taken pretty consistently with cross coding. Prior authorizations for high dollar cases, CT scans, and diagnostic testing should always be attempted. I highly recommend calling the carrier to determine eligibility, coverage, need for prior authorization, deductible, will they accept CDT codes, are there referral requirements, are there replacement time periods, is there a time limit on trauma claims, who will they send benefits to, and will your practice have to abide by their fee schedule if you check yes to accepting assignment. Depending upon what type of procedure(s), there may be additional questions to ask. Other steps include submitting letters of medical necessity, OP reports for surgical procedures, tracking and appealing denied claims.
Watch for part two of this article series in AADOM's 8/8/17 editon of Insights that will continue providing this valuable information to better enable your practice to manage cross coding implementation.
Marianne Harper is the owner of “The Art of Practice Management”, your BEST resource for cross coding success. Marianne’s specialty is coaching dentists and staff members in implementing dental-medical cross coding. She is the author of a dental-medical cross coding manual for dental practices titled “CrossWalking – A Guide Through the CrossWalk of Dental to Medical Coding” as well as an eBook series titled “Abra-Code-Dabra”, and she provides multiple resources to help dental practices implement cross coding. Marianne is also a published author of dental practice management articles and is a well-respected speaker and coach. For additional information, please check Marianne’s website www.artofpracticemanagement.com.