Coding, this is the part where you need to buckle in and get going. We're going to go through these. I'm going to try to explain to you how to code rather than what to code. So when you're looking at coding on the medical side, we're going to have a diagnosis and the service. Those always come together. You can't have one without the other. So your diagnosis right now, the current diagnosis set is called ICD-10, the International Classification of Diseases or Disorders, Volume 10. Your service code is what you did. We have different versions here. We have CPT. This is the medical version of CDT, if you will. This is the, I believe, current procedural technology or, well, I'm going to have to look that one up. Then you have HCPCS. This is also called HCPCS. This is going to be every code that does not start with five numbers. It's going to start with a letter. You have CDT. This is going to be your D codes. This is the fun part. D codes are HCPCS codes. So HCPCS codes, and I'll go into these a little bit more later, but these are codes set by CMS or the Centers for Medicare and Medicare Services. CPT codes are set by the AMA and the American Dental Association creates the CDT codes and then they license those to CMS to include in HCPCS. So again, you can see how this is all circular and a bit confusing, but if an intern says they don't accept D codes, ask them if they accept HCPCS codes. They'll say yes. That means they accept D codes. So don't let insurance tell you they don't accept D codes. And the last step is we have modifiers. What modifiers are, are explaining to insurance what you did or more specifics on what you did. Again, I'm going to give you examples of these in a little bit. The most specific code and the most appropriate code is what you're going to report. That's why we have a different code for, for example, an adjustable or custom oral appliance versus a non-custom oral appliance. Those are different codes and we need to be specific to what we use. So code every encounter, no exceptions, of course, exceptions apply, but in general code every single encounter. If the patient has a phone call, code it. If the patient, if you deliver a morning aligner, code that. Now there might not be an appropriate code. You might have to use a miscellaneous code. You might not submit that code to insurance, but you want to code the encounter. What did you do? Why did you do it? The next one is very important and that is a dentist equals a physician. Most states and the federal law basically states that if a dentist is acting within the scope of their license, they must be determined to be a physician by the insurance company. So again, if an insurance company says they don't accept a bill from the dentist, they can't do that. Again, you can appeal that. Now that does not mean they have to allow you a network. It just means that they can't tell you that you can't submit to them a claim. They must allow claims from dentists as long as what we're doing is appropriate for dentists to do. So of course I can't submit a claim for fixing their foot. I'm not, it's not what I'm saying when I say dentists as a physician, but you have the all of the authority and ability to act as a physician as it comes to dental realm. Now if the policy states MD or DO and they call out a degree, not just physician, very different and we'll see that in Medicare for example, states that only an MD or DO can order the sleeve study. So very different than only a physician and in the policy for Medicare, it'll actually specify what physician means and that it means an MD or DO. For coding, code what you did and why you did it. So again, we're looking at those pairs. What you did is the procedure, why you did it is the diagnosis. And the last thing, don't code just to get paid or just to get it covered. In other words, don't make up a code or don't guess at a code because you think that's the code or you've been told that's the code to use for that insurance. If it's not what you did, don't put it down. I want to compare and contrast dental versus medical. I am assuming most of us are familiar with dental coding and billing dental insurance. So in dental codes, often the diagnosis is optional. Now on the dental coding form or billing form, insurance form, you're going to see a spot to put a diagnosis. There are diagnoses available, but a lot of insurances don't require them or a lot of times they may be included in the service. So for example, if we're extracting a bony extraction, you know, bony tooth extraction, bony impacted kind of implies that it's a tooth that's impacted. Some of the coding on the dental side keeps the diagnosis right in it. As far as exams on the dental side, we're looking at a new versus established patient for some of our exams, right? When we have a comprehensive oral evaluation, but realistically, we're not really looking at that. So we look at it when we think about how we bill, okay, a new patient is comprehensive oral eval. If we've seen the patient before, it's periodic, but of course it's not that simple on the dental side because what if a patient comes in for emergency and we do a limited exam? So while we look at new versus established as shorthand in dental, it doesn't apply the same way it does as medical. And the other side on dental is we have specified criteria. So if I open my CDT book, I'm going to see, okay, a comprehensive exam has these elements. Does it fit that? The medical side, it's more guidelines and we'll get into those. Insurance caps. So on the dental, these are the exact opposite of medical. On the dental side, insurance, the cap is how much the insurance will pay. On the medical side, I'm sorry, it's how much the patient will have to pay maximum. So if a patient's hit their cap on the dental, patient's on the hook for every cost after that insurance says, thanks, but no thanks, we'll see you next year. On the medical side, when they've hit their cap, insurance says, all right, everything else you get that's necessary is covered, you owe nothing. So very important distinction. When you see that out-of-pocket or the patient's hit their cap on the medical side, know that they will owe nothing, again, if it's medically necessary. The last thing is covered treatment. Very similar. First of all, it must be necessary, right? That's why dental insurance is not going to cover a crown on a tooth that doesn't have a crack, doesn't have any caries, doesn't have any indication for a crown. Insurance isn't just going to go, sure, do a crown. But the difference is that on the dental side, it's a defined benefit plan. So just because it's necessary doesn't mean it's covered. So in other words, the patient, many patients aren't entitled to ortho, but on the dental side, you might be able to get a necessity and now they do. Or you could have a blatant, no, we don't cover fluoride for adults, period. In that case, again, it's not a covered benefit. On the medical side, they're just looking at the coding and then asking you, is the diagnosis appropriate? Most of the time, it's hard for medical insurance to argue that no procedure is allowed at all under any circumstance whatsoever. It's very rare you'll find that. So for example, oral splints to treat temporomandibular disorder, many insurances will say, okay, we don't cover TMD, but you can go back and say, okay, but do you cover arthritis in joints? And they'll say, yes. And do you cover arthritis in the temporomandibular joint? Oftentimes they'll say yes. Okay, now I have an argument to make it to my splint. So sometimes you have to stack these arguments together on the medical side, whereas the dental side, they might simply say, no, we don't cover fluoride. And there's no way getting around that. Diagnosing ICD-10. Again, this is one half of your coding pair. So ICD-10, it's set by an organization. That organization then defines, okay, here's what our codes want to be. Like most of these coding sets, they're going to submit those to a public review, let you comment, say, okay, I think this is a bad code. This is a good code. It's two or three years of this public comment period. And then they certify it as, okay, this will be the standard. And then it comes out. So the nice thing is it is a public standard. It's free to view. You don't need to pay to see ICD-10 codes and they follow a very specific formula. Now ICD-9 was our last one that ended in, I want to say 2015 or 14, I could be wrong, but it did end. They made this transition. The transition took about two years where we had cross-coding, insurances would allow you to do both. Then they put a hard date. Okay, now it's ICD-10. And so this is the current structure we follow. This is split into categories. So your first three digits of this code, now it's typically a seven digit code, but it can go longer. But, or I'm sorry, it's typically a five digit code, but it can go up to seven digits. Your first three are going to be, generally speaking, the category, where does this fit? The next set are going to be your kind of etiology, site severity. You're giving a little more clarity to your coding. And then number seven is kind of this extension. It's going to be extra information. Now they don't always have all of these levels of code. So it certainly gets variable. But generally speaking, you want to get the most specific you can. As far as where to draw that line, you'll see here, etiology is greater than NEC. And NEC is not elsewhere classified or categorized, meaning it's a code, but it isn't given a good answer anywhere. So here's our NEC code. If that doesn't exist, and you want to at least get to the site of the problem, that doesn't exist, at least get to the symptom. And the worst case, if there is no, you can't even get it as clear as the symptom, you can use an unspecified code. But generally, they're going to want you to code in that way or again, so if you can get down to exactly what's wrong, where it's wrong, and why it's wrong, that's going to be your best and most accurate code if that code exists. And then again, this is what we're doing to tell us why and or what is related to our service. So a good example might be a sleep study. We might code to say, okay, I know this patient now, we of course, usually don't code the sleep studies, but the sleep physician will, why are they doing the sleep study because the patient is snoring or because the patient has excessive daytime somnolescence or whatever code that they feel is appropriate to add the sleep study. However, after we do our testing, maybe our diagnosis changes. So we're going to code as to what we did for the service, and then the test might change the future coding. So these are some little hacks, I'll call them their tips, if you will. You'll have billable and non billable coding. Again, generalizations here apply, but generally speaking, a three digit code is usually a parent code, meaning it gives you an idea of some idea, but it's not specific enough to bill. Again, exceptions to this rule are going to be snoring is a great example. That's a three digit code, and I'll show you that in a minute. And then most of the time, you're going to want at least a four digit code. If there are more specific codes available, use them. Unspecified or NOS codes, you'll see these listed in ICD-10. Unspecified NOS means similar things. NOS stands for not otherwise specified, and another way to say that is unspecified, so you'll see both types of writing on there. Basically, there's not enough information to code it. So this might be happening if I have to code that the patient has a joint problem, but I don't know what the joint problem is yet. I might use an NOS or unspecified code. NEC is now not elsewhere classified or other coding. So this might be for, for example, arthritis. And again, we're going to get into these specifics, but arthritis of the joint doesn't have a code. However, it is a specific diagnosis. So I'm not guessing at what's going on in the joint. It's arthritis. I know that. So then I'll use an NEC or other code to say, okay, it is a diagnosis. I know what it is. It's specific in the diagnosis form, but you didn't create the code for it. So I'll use an other code. Again, common trends. The final three digits are oftentimes going to be where it's going to give you a site or source, especially when we're looking at the jaw. Usually the number one is right. The number two means left, and number three means bilateral. Again, these are common. This is not universal. Always look up your code. And then mystery nines, this is going to be that last digit of the code. We might get into that a little bit. Some can go very far out. But also the other side of mystery nines, what I mean by that is that sometimes if the code ends in a nine, it can be a sort of miscellaneous or mystery code. So anytime you see something ending in a nine, just kind of trick your head to that. But also if you see a code that can be up to nine digits long, again, now we're very specific and I'll be honest, you're probably not going to run into those in sleep medicine, but they're there. Again, use the most specific code available. And then they're always paired, a code and diagnosis never exists without the treatment that that diagnosis was used or that explains the treatment itself. So they must match. In other words, if I code that I'm treating the temporomandibular joint disorder, but my billing code is for orthotic for the foot, that doesn't make sense. So they must always be paired and that pairing must make sense. As far as categories, here's some common categories. You see how they're broken down. Thankfully with ICD-10, it's very systematic. So if you see a code that starts with a C or D, you know, we're dealing with a neoplasm. Conversely, if you're trying to code a neoplasm, you know, you're going to go to the C or D section. Again, generalizations, there are exceptions, which I'm going to get into my favorite exceptions soon. But kind of let you go through these to see, feel free to pause the video if you want to jot these down. These are all going to be available online. If you just Google ICD-10, you're going to get great websites that go through it. Again, do not pay for access to ICD-10 codes, they are free. Going back, sorry, I didn't have to head, but going back to this slide, I want to highlight Z codes specifically. Z codes are, you'll see here, factors influencing health status and contact with health services. A really wordy way to say miscellaneous reasons the patient's there. So you'll use these a lot when you want to code something for, you know, the patient had a miscellaneous encounter with a healthcare professional, that's in there. The other side are R codes. These are typically symptom codes. So you'll see these often, for example, when I'm treating a patient where I've never seen the patient, I don't know what's wrong with them, but they referred to me and I am asking for a gap for pain. Well, I know their pain is in their head, but I don't know, is it muscle pain? Is it nerve pain? I'll code with R51, which is headache. It's a broad term meaning pain in the head. So a code like that explains to insurance, hey, this is why it's appropriate to give me a gap to see this patient. I'm dealing with a head pain, but I don't know what yet. And so, so feel free to use symptom codes appropriately snoring is a great example of a symptom code so breaking this down a little further masseter pain this is what your patient comes in with we know you know it's not just pain on the right side of the face we know it's masseter so now I'm gonna break it down okay masters a muscle so we're gonna musculoskeletal our M section well breaking it down there we've got four different groupings for that could apply the dental facial anomaly or a disorder of the jaw is it a connective tissue disorder as a disorder the muscles or is it other tissue disorder now in this case this is where again it ICD-10 coding makes sense until it doesn't so for me I would think this would fall under disorders of muscles I would not expect this to be under other soft tissue disorders sadly I didn't write it I would I would disagree with that but that's where they put it is they put under m79 other and unspecified soft tissue disorders and again there's your NEC none else were classifiable or none else were classified so I'm 79.1 is myalgia so we're dealing with muscle pain and that's where the they make that distinction so they ICD-10 does not find pain in a muscle to be a disorder of the muscle so you'll see kind of that that break there but either way we're gonna go to m79.1 now in 2019 they issued an update to ICD-10 which again makes no sense why you would have an update to in addition but they did and it made m79.1 non-billable if you're not watching your coding and seeing these these show up or you're not using a good either third party to help you with your coding or software that will fact-check to you you can run into this where you bill it and insurance says no it's not an appropriate code and you go well wait you've paid me for three years with this code what's wrong and then you'll see oh well October 1 2019 this code became non-billable because they added another digit so now we have a more specific m79.1 one is myalgia of the mastication muscle so do pull up your coding periodically I'd say once a year if we want to add another hack typically October 1 is when new codes go active they're gonna be published typically three months ahead of time so July 1 is when they'll publish the updates to these codes when they're official in the final updates you'll then be able to prepare three months in ahead I'll also be honest that's the only time I've seen a code change in that way mid cycle again mid addition between ICD-10 starting and ICD-10 now they added that code so for the most part if you you won't have to worry about those but it's still good to know in case you get insurance that says hey you can't bill that code and you have been go back and look so let's look at right versus left and pain versus displacement so we're gonna go to m26 or dental facial anomalies we're gonna m26.6 our TMJ disorders m26.62 because it's pain and a joint that's an arthralgia so arthralgia of the TMJ now if you pull up your your ICD-10 website if you will and type in that code most of them are gonna be red and I'll tell you it's non billable again it's not specific enough because there's a more specific code which is m26.621 so now we're saying okay it's the right side that has the pain for me that makes perfect sense I understand that from a from insurance perspective no different than telling them which tooth right otherwise we're just saying a tooth hurts not which tooth hurts now if we're looking at a disc displacement for example it's me a different one still under dental facial anomalies still under TMJ disorders but now we're looking instead of m26.62 we're going to m26.63 which is articular disc disorder and now again we need to give it that last bit of specificity of left TMJ that's the billable code so again when you're billing these a lot of these you can look up yourself by simply going through the coding they open up again that ICD-10 website they're all categorized fairly similar to how I've shown you here by going from system to parts of that system to to what's causing that system to have a problem or what's wrong with it being arthralgia to where is that arthralgia so it follows some logic usually but also Google's a good answer if you type into Google right TMJ pain or right TMJ arthralgia ICD-10 you're probably gonna get m26.621 is one of the first two answers so now we get into our NEC codes this is where it gets really fun and confusing so right TMJ osteoarthritis well would that fall into dental facial disorders anomalies I would think so the other two did we had pain that fell under there we had a disc displacement that fell under there but this is osteoarthritis okay that's a medical condition that's a little more specific so would it and we have an M code for our osteoarthritis well so we look under there we've got poly poly osteoarthritis or multiple joints affected and then we also have the this this osteoarthritis of unspecified site so in other words if you go through that section I don't want to list all of them there because you will run away from me very fast if I do but the TMJ isn't listed there while other joints are there's knee there's hip there's there's elbows so do I code it with m19.9 it's an osteoarthritis they just didn't give me a specified site well that says unspecified so that would imply I don't know where the arthritis is not other or or any C so then I go okay let's go look at the TMJ and see okay I knew TMJ was in m26 so let's look that up so I'm 26.62 great that's pain in the joint that doesn't mean there's arthritis it's just pain but there's a code for that so if the patient comes in and they have arthritis and pain maybe I'll use both codes but then I look m26.69 other specified disorders of TMJ this is generally regarded as to where this code should fall because it's the most specific right when we compare that m19.9 which is that osteoarthritis in an unspecified site it's not specific as much as this one where it's telling us okay it's an other disorder of the TMJ so that's where I put it and that's again where insurance is gonna expect it and that's where most policies are gonna write their expectation would you be if you put 19 point m19.9 I would argue yes because that is an unspecified site and you know the specific site all right what how about DSM coding give you the codes where do we do that gonna be honest I'm not gonna give you all the codes these change too rapidly but I'll give you some of the specific codes that that are gonna work at either your day-in day-out work courses but let's look at it where should obstructive sleep apnea fall well to me I would put under the diseases diseases of the respiratory system yes there might be neurologic component to it but generally speaking breathing is what we're dealing with apnea and breathing as part of the respiratory system that's where I put it disorders in the nervous system sure we can get there most of the time with apnea it's not a nervous system disorder unless we want to call loss of tone and the muscles affecting the respiratory system a nervous system disorder so it's it's difficult to get in there but but that's where they decide to put it and they put under episodic and paroxysmal disorders so in other words disorders that are not consistent or constant they happen every now and then or they might follow a pattern or they might be paroxysmal again kind of just hitting randomly so we follow it under g47 sleep disorders g47 dot 3 sleep apnea and then the specified and billable code is g47 dot 3 3 which is obstructive sleep apnea so note that that is obstructive there's a different code for mixed there's a different code for centrals snoring again this is where it gets interesting to me snoring in general is a symptom no different than sneezing or coughing something the patient does yet we also have primary snoring as a diagnosis where now it's not just a symptom it's it's a condition no different than hypertension where the patient's blood pressure is elevated as a symptom and essential hypertension where that's the diagnosis so it's it's a very interesting that they didn't add a separate code for primary snoring implying that okay now you've tested why are they snoring and it's just snoring but again I didn't write this and I don't think sleep physicians agree with it either they didn't write it sadly but snoring always falls under a symptom code so you're again you're gonna break this down somehow this falls under breathing as opposed to respiratory system earlier but this is where they broke it abnormal abnormalities of breathing other abnormalities of breathing and then r06 dot 8 3 snoring so if you have a patient that you're coding for snoring only r06 dot 8 3 if you want to code that you're treating their snoring and their apnea you can code both there's nothing wrong with that but list the most appropriate code first which in that case if we're doing sleep appliance for apnea the most appropriate code is apnea first but again snoring is certainly a symptom of apnea and it can be there bruxism this is my nemesis in life is this code every time I speak this is the question okay what do we code for bruxism not only that is pain specialist I have my own soapboxes here that I'll try and avoid today but remember that the diagnosis is paired with the service and that's important when it comes to bruxism so are we dealing with a disease of bruxism are we dealing with a sign and symptom of a separate disease so again think about that and then are we dealing with sleep versus awake because and I'm gonna say about night versus day right now everyone sleeps at night sometimes our schedules are shifted but in general we're looking at sleep versus day so it might be a pet peeve of me to say nighttime bruxism but it is it's a sleep bruxism or sleep related bruxism is our coding if the patient is doing it when they sleep so again that we're gonna go down sleep disorders other related movement disorders sleep related bruxism g47.63 what about daytime if I go to Google and type in bruxism ICD 10 generally you're gonna get sleep bruxism first but the other most popular one is f54.8 other somatoform disorders I really hate this diagnosis a somatoform disorder is not necessarily a made-up disorder but somatoform implies that it's it's a mental disorder that manifests as a physical symptom that implies an illness or injury but isn't explained by any other medical condition or by the direct effect of a substance so in other words you know they're drinking alcohol and that's causing it and it's not attributable to another mental disorder that's the definition if you look up what somatic somatoform disorder is so I don't love when we code it that way because that implies a that there's no other mental disorder which generally I think most of us can agree we aren't licensed to evaluate alone on that and it also implies essentially the patient is crazy now it's not what it's saying but that's what it's implying is that there's something wrong with the patients basically it's a mental disorder and if I was the interesting man so you know they should probably be seen by mental health to evaluate rule out and treat the somatoform disorder if that's what you're saying it is now let's look at another way we could say it's a dystonia or an involuntary muscle movement and movement disorder and it's idiopathic we don't know why and it's in the oral facial regions that's g24.4 that's also a very specific diagnosis and specific way to get there so I don't love that code either but that's the other one that shows up where I do like that code is when we've treated the general causes to bruxism or or bruxism in general and it's not relieved or I have other things that indicate a dystonia that's a fantastic code for those cases my opinion as to what it should be coded as is f59 and this is the most specific code even though it's only three digits which is unspecified behavioral syndrome syndromes associated with physiological disturbance and physical factors so in other words this is a behavior the patient is doing at the end of the day bruxism is voluntary if it's not a dystonia so it's a behavior that the patient is doing and then we have physiologic disturbances and physical factors with it so that's that's my favorite code for bruxism but here's why I don't think it matters why are you coding daytime bruxism if you're coding it for pain then go with a pain code if you're coding it at night use your nocturnal bruxism or your sleep bruxism code because it's been validated by their PSG and it showed bruxism so remember these could come together so there's very rarely do you actually need to code for bruxism because you're usually not actually treating bruxism what you're usually treating is the car the effect of bruxism and this is where I'm getting to bruxism versus attrition if you're coding or saying I hey I'm doing a night guard or a day guard for example because the teeth are worn down well you're not treating the bruxism you're treating the attrition so code the attrition and if we want to look for there how do you code attrition I'll be honest there's not a great answer initially when you think about it right where should this be should be under dental well we kind of looked in those dental disorders or earlier it doesn't fall into there so disease of digestive system the end of the day the mouth still part of the digestive system right it's the start of the alimentary canal so we're gonna go under there then we're gonna go under diseases of oral cavity and salivary glands other diseases of hard tissues of teeth and then right down there k03.0 excessive attrition of teeth that is where if you're treating the where that's what you're treating you're treating that so again why are you doing it is that the attrition what are you doing is the splint of the guard now if there's pain treat the pain and that's what you code for other side of the diagnosis is the procedure coding so what are we doing here we're looking at at CPT codes CDT codes and and hiccups codes so CPT again that's published and maintained by the American Medical Association those are five numbers CDT codes published and maintained by the ADA those are D codes if you will and hiccups again any for the most part any code that starts with a letter B through I shouldn't have even started that because I'm not sure it ends I think they have up to G codes they might go even even further than that those are published by CMS they are publicly available except the D codes so the ADA does license them but they license them in a way that CMS cannot give the specifics of the D codes so that is the one frustration I have with with that licensing but for example the E codes you can look those right up if you ever have a question what is BiPAP you can look that up pretty easily now modifiers this is where it's very different than CDT coding but also similar so you're gonna add this to the procedure code to give detail not all codes need a modifier some codes require a modifier and then oftentimes the modifiers are optional if you need to clarify further this is similar in CDT to if you think of tooth and surface coding right I don't just do a filling I don't just do a filling on tooth number you know 20 I don't just do a filling right I do a composite restoration that's our D code and then we're going to attach on to it to number 20. And then if it's a two surface code, we're going to put the two services we did. So think of it like that, where you're attaching it, it's just optional in many codes, but required in some, these are typically going to be alphanumeric, meaning you could have numbers, you could have letters, you could have a mix. And then next level coding, you can get into really fun issues here. I'm not going to go into there here into this here. But there are ways to code and explain it to insurance. At the end of the day, if I tell insurance what I did, and it's accurate, and insurance pays for it, it's not fraud. Now, if I lied about what I did, or I gave an inaccurate code, when a more accurate code is better, sure, then that's a problem. But if I tell them what I did, and they pay, and I didn't lie anywhere there, I didn't hide any facts, I didn't do anything wrong, you can actually get pretty good coding scenarios. A great example of this is last week, or I'm sorry, not last week, last month, I had a patient that refused Medicare patient that refused delivery of his oral appliance, but at delivery. So a patient has Alzheimer's, he was fine, the first appointment, but at the second one, he tried it in. And he said, No, I'm never touching that again, and didn't storm out angrily, but just forcefully said, No, don't don't bother me with it. I'm not taking it. So I go to Google, and I look up the policy, what is Medicare policy on patient, essentially refusing care of a DMV product after it was customized to the patient or custom design and fabricated. Medicare specifically says in their policy, you can bill it, you build the data services, the date that the patient either canceled their treatment or declined care. And then you put a line item in the claim that says that it you know, patient refused delivery, custom appliance, and that it's non salvageable, and you submit it to the insurance. Two weeks later, we got our check from Medicare with payment for it in full. And so again, that's fully legal coding, I didn't hide anything, I put a line item that said what happened, Medicare, if they would like, CGS, our local Medicare contractor could have asked for a letter could have asked for more explanation, they chose not to and paid. So as long as what you're doing is is written specific, it's up to the insurance if they pay it or not. So that's where you can get into some fun with coding. Again, those details are what I'd call next level or advanced, certainly not something that we we need to dive into today. Very, very, very, if you you take a picture of one slide this whole time, take a picture of this one. This is the the caution, this is what's gonna get you in trouble. So code what you did, and close does not count. So I should say close doesn't count unless there's no closer code. But code what you did. Don't code what's similar to what you did. And if a code doesn't exist for what you did, then you might want to use a miscellaneous code. And those codes are very similar to dental codes that end in a nine. Those are codes that you're saying, it doesn't exist, but I've got you close. So you know, I might get the first four digits to where some of what I did, and then there's a nine. And these codes are specified, you can look up these miscellaneous codes. Anytime you use a miscellaneous code, you're going to, the interns will require a report. In other words, you're going to send a letter with your claim stating that no better code existed. This is what I did. This is what I should get paid for it. So for example, and let's say I have a disorder in the mouth where I'm going to put the patient in a, in a stem, basically a bleaching tray, right to cover the area with with medication, there's no code for that. But there are surgical oral surgery codes for for oral surgical splints that are similar. So I'll bill out the miscellaneous of that. And I'll tell the insurance, this is why this is what it's necessary for. And not only that, tell them what your normal cost would be for the most similar code and explain why your cost should be less. So for example, I told them what an oral surgical splint costs for me. I said, I'll bill half of that because the patient's only wearing it for, you know, when they need their their medication applied, insurance paid me half my splint fee. Now normally, my splint fee gets me about a third of it. So I actually got paid better by using miscellaneous code for something not a splint. And it was cheaper for me to make. So I mean, but again, I told interns everything. So as long as you're telling them everything, you are generally safe. But don't skip and hide things that that's what gets you in trouble. Not only that, don't don't picket pennies. If the code is going to pay five to 10 bucks, don't code it if it's not perfect. It's not worth the risk. A great example is in my opinion, a morning aligner, we don't have an appropriate code for that. So I personally don't love the idea of sending that off to insurance with a defined code if you want to use a miscellaneous code and explain it and hope they get coverage great. But if you use a defined code, I would argue there is no defined code for a morning aligner that can come back to haunt you. So be careful with that. The other thing I've seen in billing is billing out for example, a tomograph of the joint because that is a code or billing out multiple views of the joint. When you do a CT, build a CT, the code exists, use the code that exists. As far as Medicare fee schedule, Medicare, this is published data, you can go to Google type in Medicare physician fee schedule, you're going to get a copy of it. It is impossible to search without ripping your hair off. You have to know which which code or I'm sorry, which region you fall under and which specific number that region is. It can even go down to the localities when that it is a pain to use. Best answer is Google CMAC rate CMA C. This is the champ VA, which is Veterans Affairs hospital rates. Now by law champ VA must follow Medicare rates. This is also the rate that Tricare pays in general. Again, it's directly tied to Medicare, and they have a utility that's 100 times easier to search. So go to Google type in CMAC rate if you're ever trying to find out what the general Medicare fee is. And now I will tell you these are for CPT codes, not not easier 486. Medicare doesn't publish a fee on that. But you can go to there. And then you can search you just type in your zip code, and which code you're billing. So you can type in your zip code type in 99203. And you're going to get exactly what that code will pay in your zip code, much better than using Medicare site. undercoding is still fraud. So if you do something to the patient, you need to code what you did. The reason for this is you can't downcode what you did to save the patient money. That is fraudulent. So if you generally speaking code a procedure, and then for one patient that, you know, is paying cash, and you go, well, wait a minute, I can't change it charge different cash rate, bigger than I do insurance rate, because that's insurance fraud. I'll just undercoat it. I'll say instead of doing a level four exam, I did a level two exam for that patient. That's equally fraudulent. So code what you did and do what you coded. And then the last thing is, always questions, can I code for x, y, or z? Yes, there's always a code, always, however, it just might not be specific. So again, that's why the miscellaneous codes exist. So I hate the question, can you code? Yes. Can you code easily? Not always. As far as what are we going to code on a general sleep patient, right? Let's go through through our usual sleep patient coding, evaluation management. This is the name of the exam on the medical side. This is what makes us a doctor. Only doctors can build these. And I want you to think of this, this is our doctor time, right? This is what's making us it's our thinking through evaluating the patient and managing their care. This is drastically and vastly different from dental exam coding, dental exam coding, you're not really your evaluation, the patient isn't in the code, as much as what did you do pretty wrote out, you know, I mean, a comprehensive eval has radio, you know, you're evaluating radiographs, you're doing a evaluation, the dentition, you're doing a periodontal exam, you know, it's written out what's done. EMS are a little more guidelines. And we're going to get into those radiographs on the medical side. Again, if there's another thing, it should set off alarm bells to you to pay attention to this. It's this. If you're using a medical code for your radiograph, follow the medical model, do what they do. So in the medical side, a radiograph code includes, you can build it three different ways, you can do global coding, meaning you just list the code. Or you can do the split it between technical and professional. So if you think about whenever you've had a medical x ray yourself, if you have, oftentimes, you might get it performed at one site, but read at another. And you might get two bills for it. One bill will be for the technical component that just exposing the x ray, creating the x ray, or the radiograph, and then the other is professional interpreting it. So if you build insurance, a panoramic, an ortho pantogram, if you're going to use the medical code, or as cone beam CT, using 70486, for example, just those five digits implies or tells insurance that you did it all you did the global, so you're going to have made the image, and you will have a study on file, or I'm sorry, a report on file interpretation on file. Now, as opposed to dental, the interpretations have to follow the medical side, too. So our, I'm not going to assume how you wrote it. But when I when I practiced general dentistry, my ortho pantogram report was maybe two words or two sentences, you know, adequate image and no obvious pathology, you know, or whatnot, you know, something similar, that will not fly in the medical world. Now, you don't need a professional, you don't have to go to a radiologist, but you do have to have everything a radiologist would have. And I'm not going to get into that coding, that's its own thing, or how to write radiology reports. But just know that as a risk. If you don't know how to do it, pay for a radiologist to read it, and have that report on file. If the radiologist bills you as the doctor, they say, Okay, I'll charge you $60 to read your image, then you can build a global fee. If the intern say, Hey, I give me the patient's info, and I'll build them the professional component, then you're just building a technical and their modifiers for that against specific coding things. Best is is go to Google, just look up radiology, technical modifier, radiology, professional modifier, and it will tell you what to put on there. Custom Sleep Appliance, E0486. I'm not going to get into every code. These are just the common ones we're going to build. I don't want to go into too many specifics because A, AADSM already has a great guide on it. And I don't want it to tell you the same thing five different ways and times because that guide is fantastic. But not only that, it changes every year. So the box that we're put in the steamy box is called our LCD or local coverage determination. That changes often, every year they review them. So you need to look that up. Again, Google's your friend, E0486 LCD, E0486 Medicare LCD is going to get it listed for you. But not only that, again, the AADSM guide already lists it, describes it. Now the numbers may change. So I wouldn't necessarily look up the number, but search it out, get the policy and check it every single year for updates. Updates. Typically, again, I love the government, they get to make their own rules. Updates typically start or are effective on January one of the calendar year. Many times they're not published until March or April of that calendar year. So they can actually retroactively apply. Now you usually won't be penalized if they changed it. But just know that if you look it up in the middle of January and go, okay, it's the same standards as last year, I would check again in March and April. The last three or four years, they've updated them in March and April, which is great. But not only that, we follow this DME box, Medicare defines DME very specifically. And one of the requirements of it is that it has to last five years. So if your appliance breaks in three years, Medicare will say, Ah, well, you must not have done easier for it six, you must have done coded it wrong, because easier for it six has to last. Now, if it breaks because of a dog chewing it, or the patient drops it different story. And if it breaks, that's why warranties exist. So you can't rebuild Medicare, you will rebuild your, you know, send it to your lab and use their warranty. If it takes 93 days to adjust it, Medicare will say, Oh, well, our requirement is that a an appliance that fits this code is adjustable and fittable in 90 days. So if you took, you know, 93 days to adjust it, you must have coded it wrong. And that's why you'll you'll often see and recommended not to bill out any exam during those 90 days, because the 90 global, but also not to bill any exam after, because the implication is that, well, if I'm working on it, or I'm billing out a change to it, I must have not done the right code, because it took me more than 90 days. I will tell you that there is a question on there, they're competing medical policies for Medicare on that, I'm not going to get into those arguments. But just know that that's the basis of that rule, is that Medicare says it's DME, it's got to be adjustable within 90 days. If it's not, then you code it wrong, is what they'll say. The other thing is easier for six, you're always going to include two two modifiers on this, if it's a brand new patient, that's kx, what kx is doing that is you saying legally, I certify I followed the Medicare policy. Medicare does not fact checked when you submit the claim, they will, I want to say universally, almost definitely never asked you for records when you submit an easier 486 claim with those codes attached. Because what you're saying is I followed the rules, what they will do is when they audit you ask for those. And if you don't have them, they're going to say, well, then you coded illegally because you said you follow the policy. So So again, Medicare gets very tricky in the way they do things, not intentionally, it's just the way it works. And then n u is typically added for a new patient, because that means a new appliance. There's coding if you're repairing an appliance, or if it's a rental, which you can't really rent a custom made appliance. But for CPAP, for example, you'll see our codes on there. So there are other coding there. But again, we're looking at the general new sleep patient, commercial policy specific, again, policy specific in your state, even. So get the plan documents easier for six almost always has a policy. If you accept an insurance, if you're in network, you need the policy no matter what habit, if you're out of network, still get the policy, put them in a binder, recheck them every year for all of the major insurances in your area. If you have an insurance you've never heard of the patient comes in and says, Hey, I've got, you know, this insurance, ask them you call the insurance when you eligibility check and ask for the policies, get them on file, that way, you know exactly what they are. You've got a peer to peer, you know what words to use. So when you that peer to peer call, they've got the policy in front of them. So that you know what words to use, you already know what you need to say. And again, I'm not saying make up things. What I'm saying is you know what you need to highlight, I guess is how I should phrase that. That policy determines your reimbursement, not the coding. So again, this is a big difference between Medicare, Medicare is going to say E0486 must fit in this box. If you don't fit it in that box, then it is not E0486. It's a miscellaneous code, or a non-covered service code. Commercial side, what you did is E0486. But it might not meet medical necessity. That doesn't mean you use the Medicare coding of the A code. You do what you code what you did, which was E0486, because they don't have the same policies as Medicare stating it has to fit in these boxes.

coding

medical field

diagnoses

services

ICD-10

CPT

HCPCS

accurate coding