Diagnosis codes are perhaps the most undervalued part of any medical claims. Providers and coders put agonizing thought into selecting the perfect procedure code. The CPT code that personifies the work they have done for the patient. Convinced if they select just the right one then payment will be decided expeditiously and their claim will be paid promptly. They hurry through the diagnosis codes, throwing the same ones they’ve used a hundred times before onto the claim. Impacted teeth. Jaw pain. Cracked tooth. The claim is sent and…denied. Could it have been avoided?
Most billers don’t understand that sometimes the only justificiation the insurance will see for those painstakingly selected CPT codes is the diagnosis codes that are listed alongside them. Well-selected diagnosis codes can paint a thorough picture of a patient’s current state and their need for the procedure(s).
Diagnosis codes should not only illustrate the patient’s current situation: missing teeth, decay, cracked tooth, trauma, cyst/lesion, etc. but also any secondary symptoms. Jaw pain, tempromandibular dysfunction, headaches, migraines and others can be considered secondary to dental issues. Coding comorbidities is also a must. If a patient has had cancer, radiation/chemotherapy treatment, GERD, ulcers, Sjorgen’s syndrome, etc. those can be important “support beams” for the medical necessity of your procedures. Lastly, accident codes are a must if the treatment is necessary due to trauma. There are thousands of codes to help you properly code the type of accident or trauma that has occurred.
While carriers can always request clinical documents and you may choose to forward them on your own it will be the diagnosis codes that are the first window into the “why” of the procedures you are submitting. Review chart notes thoroughly, ensure you are choosing codes with care and always use every applicable diagnostic code.
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