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Dental Claims vs. Medical Claims

There are some similarities between preparing dental claims and medical claims. For example, patient and insurance demographics and insurance information that must be provided to medical carriers are similar.

However, there are some very significant differences between the two. While dental carriers typically require a procedure code. Medical carriers not only require procedure code(s) but also the reason why the procedure(s) were performed or the patient’s diagnosis.

Diagnoses are classified in code form in the ICD-9-CM “International Classification of Disease, Ninth Revision – Clinical Modification” manual. Without at least one diagnosis code that supports the procedure(s), the medical claim will not be paid. There must be an appropriate diagnosis to establish the medical necessity of the procedure. This is probably the most important part of successful dental-medical cross coding.

Another very significant difference between dental and medical coding systems is the time period and frequency between updates, deletions and revisions. All medical code sets update yearly and medical carriers generally offer no grace periods on using outdated codes.


The medical claim form also has some major differences compared to the dental claim form. Most medical carriers require the CMS-1500 (08-05) claim form. Medical carriers require these preprinted, red-inked forms because these forms are the only ones that scan correctly. Hand-written claims and comments or copies are not accepted.

Apex EDI can provide the best medical electronic billing for all of your medical claims and dental claims. The main benefit to implementing a dental-medical cross-coding system is satisfied patients who recognize your willingness to help them save their dental plan allowance and access medical benefits. Grateful patients can become your most valuable marketing asset.

Articles with this disclaimer may not represent the beliefs or core values of Apex EDI. The above is simply a summary taken from the industry’s general community to help readers stay up-to-date on what people are talking about.

Posted in: Dental, Dental Claims, Medical Claims

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How to Reduce Podiatry Claim Denials

Denial of a podiatry claim is at best, upsetting for the doctor and staff. At worst, it’s an unexpected cost, which if ignored and continually repeated over time can reduce the value of your business. Taking the time to correct these errors and educate staff will lead to proper payments in the future. Long term will reduce the stress associated with billing corrections, increase revenue and decrease one’s audit exposure. There are 8 common billing mistakes, which corrected can improve the growth of your business.

1. Incorrect CPT-ICD-9 Codes

It’s essential that each individual CPT code correctly aligns with a proper ICD-9 code. If a patient has more than one condition, several ICD-9 codes may be required. Be sure to check with the carrier about which codes are allowed.

2. Physical Therapy

Always check with the carrier for benefits, deductibles and policy limitations before proceeding with providing physical therapy treatments. The order should list the diagnosis, treatment modalities, frequency of treatments, goals, and the expected duration. Never submit claims for modalities that patients can apply or use themselves.

spooky foot

3. X-Ray Reimbursement

Only take the number of x-ray views medically necessary and reasonable. Also, ensure thorough documentation of all x-ray views taken. Be sure to use appropriate diagnosis codes for an x-ray service.  

4. Durable Medical Equipment (DME) Documentation

Generally, home is the proper place of service (POS).  To ensure accurate reimbursement this must be submitted correctly on the claim form. Always verify the HCPCS code with the DME carrier and be sure to explain the various options for obtaining DME to patients along with the financial implications.

5. Surgery

It’s important to verify prior to surgery whether or not prior authorization is required. Check with each carrier about the software it employs to bill properly for the services performed. The proper use of modifiers is also very important.   

just feet

6. Routine Foot Care

Due to the multiple Medicare carriers, coding for routine foot care that raised blood pressure can be very confusing. Be careful to clearly list and align at-risk conditions and painful conditions with the appropriate ICD-9 codes on the claim form.  

7. Evaluation and Management (E/M) Coding

Use of the 25 modifier is a common area of confusion. Make sure to use this modifier only when indicated.

8. Casting Reimbursement

When a cast is applied at the time of surgery, it is included in the surgical allowance and is not payable separately. Supplies are only payable with a diagnosis of a fracture or a dislocation.

It is important to continually monitor one’s billing practices. Being aware of new changes in policies and learning from errors can go a long way toward avoiding repeat claim denials.

Articles with this disclaimer may not represent the beliefs or core values of Apex EDI. The above is simply a summary taken from the industry’s general community to help readers stay up-to-date on what people are talking about.

Posted in: Podiatry Claims

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The Benefits of Partnering with Apex EDI

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We at Apex EDI are the leader in private label claims delivery. We created a One Touch Solution to offer you a secure, easy, and inexpensive way to process your private insurance claims electronically.

Within two weeks, we will improve your bottom line by lowering the cost of claims processing, providing faster reimbursement to your clients, and increasing your access to healthcare payers. You’ll never have to worry again about client satisfaction with our state of the art service.  You’ll have the ongoing support of our friendly and knowledgeable staff always standing by 24/7 to answer questions and solve problems.

Partnering with APEX EDI is completely stress-free. We provide a generous revenue sharing program, free training and ongoing, automatic compliance updates. Our experienced team will handle once expensive and time-consuming upgrades for you. You will be able to load and send claims directly from the APEX One Touch or your own practice management software. You will have instant access to your account from any computer with Internet access. Through our secure partner portal, you’ll find co-branded marketing materials, customized client reports and the expertise of our support team.


We’re confident that we can add value for your business and increase your customer satisfaction. There simply isn’t another claims clearinghouse partner that can match our level of support. You won’t regret adding the most powerful set of practice tools available to your business. Contact us today to tell us about your business needs and schedule a free demonstration.  

Articles with this disclaimer were not written by Apex EDI.

Posted in: EDI, Medical Claims, News, Resources

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Why Choose Apex EDI

With electronic data integration (EDI) reaching the forefront of electronic data transfer, more and more services seem to offer this option for medical and wellness practitioners. How do you know which service to choose?


Apex EDI offers a host of positive features that will allow your practice to run smoothly, but here are a few reasons why we think you should choose our software for your business.


Not only does Apex EDI offer a user friendly interface, it integrates seamlessly with dozens of existing practice management softwares. Click here to see a list of practice management softwares that Apex EDI currently integrates with; and the list is still growing.

This integration allows for your staff to focus on providing exceptional care to your patients. Instead of fighting with complicated softwares and difficult transitory processes, Apex EDI allows your staff to process insurance claims quickly and cohesively with plug and play efficiency.

Fool Proof Submissions

Another great benefit of Apex EDI is the ability of the software to read and recognize potential errors within insurance claims. Before a claim can be properly submitted, the software scans the claims and checks for errors or misapplied information. When Apex finds the error, it notifies the billing professional of submission errors to correct before the claim can be sent to the payer.

Error identifying technology allows for your staff to catch these mistakes before they can be denied by a patient’s insurance company. Not only does this speed up the process of claims processing, it also allows your practice to get paid faster to maintain a profitable and well managed business.

Compliance & Privacy Driven

You might be thinking, “This is all fine and good, but what about industry standards regarding HIPPA and patient privacy?”

That’s a valid concern, and we’re glad you asked. Apex EDI is fully compliant with HIPPA and state and federal patient privacy practices. We don’t share any patient information with outside parties. Apex EDI is committed to the highest possible service of our clients and their customers. Your privacy and security is of the utmost importance, which is why we have a detailed privacy statement for your review here.

If you have any other questions or concerns about privacy practices at Apex EDI please feel free to reach out to us here.

Commitment to Excellence

At Apex EDI, we live and breathe customer service. We are committed to providing an exceptional experience with our products for your practice, regardless of your specialty.

If you would like to learn more about how Apex EDI can assist your practice, please do not hesitate to reach out to our support team with your questions or concerns.

Articles with this disclaimer may not represent the beliefs or core values of Apex EDI. The following is simply a summary taken from the industry’s general community to help readers stay up-to-date on what people are talking about. 

Posted in: EDI, Resources

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What is the Role of a Medical Clearinghouse?

In the world of medical billing, there are a few concepts that can get a bit confusing. One of these concepts is that of a medical clearinghouse. What exactly does a clearinghouse do, and why is it important?  Let’s discuss the role of the medical clearinghouse, its benefits, and how to choose one.


What They Do

A medical claims clearinghouse acts as a middleman between the provider (doctor, dentist, chiropractor, etc.) and the payer (insurance company). The practice management software on a billing professional’s computer creates an electronic file (the claim) also known as the ANSI-X12 837 file. This file is then uploaded to your medical billing clearinghouse account.

From here, the clearinghouse then checks the claim for errors, ensuring that the claim can be properly submitted to the payer. Once the claim passes inspection, the clearinghouse securely transmits the electronic claim to the payer with which it has already established a secure connection that meets the strict standards laid down by a HIPAA.  The claim is then either approved or denied by the payer, in which an approved claim generates a payment of services to the provider, and a denied claim may require additional information to procure processing.

Benefits of Clearinghouses

The main benefit of the clearinghouse is efficiency. Clearinghouses scrub medical claims to ensure correct data entry for properly processed claims. Without this error checking, incorrect claims would be submitted to payers on a more regular basis. Incorrect claims cause inefficiency in the workplace, more work for your staff and the payer, and often result in denied claims due to incorrect filing or coding.

Another benefit of using a clearinghouse is the integration between the payer’s software and the provider’s software. Each payer and provider are likely to use different softwares, but these softwares are not necessarily compatible with each other. When using a clearinghouse that integrates with each software separately, the payer and provider are able to allow each software system to communicate through electronic data integration (EDI).

How To Choose One

When choosing a clearinghouse, it is important to keep the following aspects in mind:

  • User-friendly Interface
  • Integration with Existing Practice Management Software
  • Customer Service & Support
  • Privacy Practices & Compliance

With a friendly user interface that integrates with dozens of existing practice management softwares, Apex EDI is the premier choice for medical claims processing. Our clearinghouse is dedicated to upholding exceptional practices with regards to customer service, as well as compliance with federal privacy practices such as HIPPA.

For more information, be sure to reach out to us on our Contact Us page.

Articles with this disclaimer may not represent the beliefs or core values of Apex EDI. The following is simply a summary taken from the industry’s general community to help readers stay up-to-date on what people are talking about. 

Posted in: EDI, Medical Claims

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