What’s that Code? The Importance of Chart Notes in Cross-Coding.

In dentistry we are familiar with a cut and dry approach to coding. Generally there is only one or two, maybe three, procedure codes on the CDT listing that apply to any given treatment. So when a practice decides to begin submissions to medical carriers it can be a daunting task. There are over 10,000 CPT codes that apply to medical procedures and even more ICD-10 codes to specify diagnosis. So how do you determine which code best fits your dental procedure?
The answer seems so simple and yet can have an enormous impact not only on choosing the appropriate code but also choosing supporting diagnosis coding. Chart notes can make or break a successful medical claim. Chart notes should read like a map to the location that the procedure was performed as well as the steps taken to get there. Chart notes should specify the location of the procedure, the nature of the site before treatment was administered and the outcome of the treatment (successful, guarded, problematic, failure, etc.). All of these will help the coder to determine the correct medical cross code to use for maximum success and reimbursement. In cases where a biopsy or other excision is being done the appearance of the tissue should be noted closely. Any pain the patient is feeling before the procedure should be noted and detailed thoroughly (jaw pain, headache, grinding/clenching teeth, etc.). The chart notes combined with the patient’s health history will lend the material for determining the correct diagnosis codes which are the claims front line of support when being processed.
Many providers undervalue the importance of chart notes, especially accurate ones. While everyone has moments they are rushed or short on time the provider should find the best process for them making efficient and detailed notes. This may be writing them while the patient is numbing or the assistance is cleaning the room immediately following the procedure. Maybe it is beneficial to the provider to write the notes with their assistant at the end of the day. Or perhaps you would like your assistant to fill out the notes as the procedure is being performed. Providers should find which method works best for them and establish a protocol. Being detailed in your notes and providing plenty of supporting documentation will lead to very successful medical claims filings.