Jaycee Brown

Jaycee Brown

Director of Communications

To Bill or not to Bill for Evaluations, Exams and Consultations?

By Stefanie Fario
We’ve seen it many times in our medical billing department. Claims are sent to us for submission of procedures. Chart notes document several visits with exams before the procedures are performed but this is the first claim we’ve ever seen for this patient. Where are the billings for exams, evaluations and consultations that are office visits?
We have a list of restorative procedures to submit that seemingly come out of the blue. Even worse is the knowledge that many of our providers are giving away their valuable time for free when patients come for consultation but do not move forward with treatment.
It is a familiar problem with dental insurance, the patient gets two exams a year and if the doctor is lucky they get to bill an extra problem-focused exam when they see the patient. Doctors are reluctant to bill patients for exams because they don’t want to lose the patient over what they see as “frivolous over-billing”. They simply code these additional visits as zero-charge exams or observational visits and move on with their days.
Medical carriers have no such limits. You will rarely see a specialist office visit denied because the patient has “met their maximum” for office visits. And doctors are losing valuable revenue, time and credibility when they don’t bill for their consultations.
A prime example is the sleep apnea appliance. Providers will see the patient for an initial consultation which can include impressions, pharyngometer/rhinometer testing, radiographs (pano or CBCT) and easily 30 minutes of face-to-face conversation between the provider and the patient.
TMJ appliances can take the same course for an initial consultation. Full mouth reconstruction due to disease or illness – a 30 minute consult, xrays and impressions for study models. You can see the trend here. Hour after hour of unreimbursed chair time. However, it doesn’t have to be unreimbursed.
Any encounter with a patient should be billed as an appropriately coded office visit. Other services such as study models, xrays and testing should also be billed in conjunction with the office visit. Bill for what you do.
Important documentation and considerations for coding an office visit include whether the patient was a new or established patient, how much time was spent face-to-face with the patient and what was discussed (follow up, reviewing records, establishing a future treatment plan, etc.). The office should collect the patient’s specialist visit copay at this time as well. For intents and purposes of medically billed care the dental provider is a specialist and should assert and bill as such.
Your time as a provider is valuable. We strive every day in this industry to assert our value to our patients and place worth on the amazing services performed. If you are filing medical claims for reimbursement make sure you are filing for ALL of your time and not just that spent performing procedures.
Dental Billing Tips and News for Pros; Edition #126


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Dental Billing