When you first begin learning the ropes for cross-coding (billing medical insurance in dentistry), you’re focused on navigating the medical claim form boxes and connecting ICD-10 codes (diagnosis) to the appropriate and corresponding CPT codes (procedures). A new cross-coder might get all of the ICD, CPT, and claim form fields correct, but then neglect the one thing that could make all the difference – documentation.  Specifically, S.O.A.P. reports related to the patient’s case. S.O.A.P. reports are your secret weapon when dealing with medical insurance reimbursement.

So what is a S.O.A.P. report? No, it isn’t an evaluation of your last bath!

It is actually the ideal method to communicating patient encounters in the medical community, detailing the:

S. – Subjective Complaints of the Patient

O. – Objective Findings of the Provider

A. – Assessment of the Provider

P. – Plan of the Provider

In layman’s terms, this translates to:

S. – Patient Questionnaire (such as a TMJ disorder or obstructive sleep apnea screening form)

O. – Your Exam Findings

A. The Diagnosis Related to the Encounter (this is where ICD-10 diagnosis codes come in)

P. The Procedures Performed and Billed for During the Visit (this is where CPT procedure codes come in)

These reports are typically 1-3 pages long and provide the exact documentation that medical insurance and the patient’s other providers are looking for.

If you’ve billed medical before and did not see the results that you expected, dental sleep apnea, TMJ treatment and oral surgeries can be considered medical necessity.

And taking a little extra time to show the SOAP elements will help ensure that you don’t take a bath with medical insurance and physician communications.

By Rose Nierman