Are We Doing Enough? The “How To” of Medical Coding for Screening Performed in Dental Practices.
Marianne has a great manual that walks you through cross coding. It is our go to reference guide that we use when doing medical billing for our clients.
Medical billing is an art and is time consuming. We offer different training packages for our clients who want to do their own medical billing in house.
Written By: Jill Coon
What is the Primary Diagnosis?
A potential obstacle in dentistry is the success to billing medical insurance is in our field of view. To be successful at medical billing and having dental procedures covered under medical insurance, It’s time realize how powerful the oral systemic link is and their connection. Dentistry has mastered the art of detecting even the smallest problem in most cases. This isn’t even something medical professionals do very well. The problem with focusing on the micro is that when you magnify something too big, you can easily lose track of the bigger picture. Dentistry has been so focused on early detection that we have lost our view of prevention. Virtually everyone who has teeth has the same bacteria that causes periodontal disease. Why is it that some people can prevent the bacteria from destroying bone and others, despite good home care and more frequent trips to the dentist for maintenance cannot? In the dental profession the definitive diagnosis would be periodontal disease and go no further. Periodontal disease is, in many cases can be linked to an underlying medical condition.
Medical insurance pays for treatment of symptoms as a result of a medical condition. We see diseases present in the mouth every day such as diabetes, G.E.R.D., osteoporosis, and heart disease. There are also many other contributing factors to oral dysfunction. When a patient informs us that they have cancer and are going to undergo treatment, dentists recommend fluoride because we know that we consistently see chemotherapy and radiation treatments causing problems in the mouth. The good news is that medical insurance knows this too. Most procedures linked to the treatment of cancer are almost always covered under medical plans.
When I first started billing medical insurance in the dental practice where I worked, we saw a patient on short notice because she felt like a crown was loose. After clinical examination, it was revealed that this tooth had 8 and 9mm pockets and removal of the tooth was required. Most dental professionals would agree that periodontal disease is to blame in this case but looking through her previous treatment notes, I discovered that this was the third tooth that required removal from this disease in the past few years. Looking over her medical history, I found a side note stating she had a mastectomy. The only reason I could come up with for a mastectomy was cancer. I asked the patient if she had underdone chemo or radiation and she said yes to both. She had been a patient since 2006 and was diligent about keeping up with her cleaning appointments. Her history showed that although she did show signs of inflammation, there was no bone loss reported. After her treatment of cancer, her inflammation went from controlled to progressive. Using cancer treatment as the proper primary diagnosis, I was able to obtain an approval for the replacement of all three teeth with dental implants in determining the medical necessity . The total paid by medical was more than $15,000!
Once we are able to expand your field of view to start thinking outside of the mouth and thinking about the body as a whole, a door will unlock. Not only will we be rewarded with staggeringly higher reimbursements, we will also be able to provide a whole new level of patient care to our patients. Medical thinking will not only allow us to provide the clinical expertise our patients have come to expect but we will also be reimbursed appropriately for the services we provide.
Danielle and Jill
Written By: Jill Coon
Time to Make the Paradigm Shift
Just recently, I had the pleasure of speaking and attending the ACE (Academy of Comprehensive Esthetics) meeting in Las Vegas. The first day, I listened to other speakers who talked about dentistry and the body as a whole. Speakers were saying that we need to change our thinking about the way we practice dentistry and begin thinking about the patient’s total health not just focus on drilling and filling or scaling teeth right away. The way we have been doing or looking at things over the years is now changing dramatically.
Dr. Bradley Bale M.D. caught everyone’s attention. Dr. Bale is a cardiologist who definitely understands the link between cardiac disease and periodontal disease. Did you know that endodontic disease and caries also trigger a significant percentage of heart attacks? The American Heart Association has research showing the direct connection between oral pathogens (associated with periodontal disease, endodontic lesions, and caries) and acute heart attacks! Almost half of heart attacks are being triggered by oral pathogens. Oral bacteria were found in every thrombus, and 30% had live oral pathogens in the clot. Dental infection and oral bacteria are associated with development of acute coronary thrombosis. Oral health and dental care should be part of heart attack prevention and more. We need to encourage greater collaboration between the medical and dental professions. In doing this paradigm shift, our dental procedures become medically necessary thus making some of our procedures now billable to our patient’s medical insurance. The use of cross coding in your dental software makes billing medical insurances much easier.
Dr. Sam Low D.D.S., a periodontist and a professor at the University of Florida, College of Dentistry, spoke abut achieving restorative/periodontal success by controlling inflammation. Dental infection and oral bacteria are associated with inflammation. We all have the bacteria in our mouth but some people are more susceptible to inflammation than others. Why is this? This is what we need to find out when reviewing our patient’s medical history rather than smoothing root surfaces because of calculus and plaque or just filling teeth. Are your patients taking medications that cause dry mouth, making them more susceptible to bacteria and decay or do they have certain diseases or conditions that cause breakdown of teeth or bone?
During my presentation, I spoke about The Missing Link to The Insurance Puzzle and tied together the use of medical and dental billing in relation to your patient’s total health. I explained how and why cross coding is needed in the dental practice and how it is beneficial to both the patient and the practice. Below are several images (images modified and courtesy of Marianne Harper-The Art of Practice Management) from my presentation at ACE this past weekend of medically billable procedures in your dental practice:
Of course before you start billing anything to medical insurance, you will need to check on your patient’s insurance eligibility and coverage. For information on cross coding and medical billing, please don’t hesitate to contact us.
Written By: Jill Coon
Virtually Everything is Possible.
Have you considered hiring a virtual assistant for your practice or business? Virtual assistants can defintiely simplify your life. In my article for the Progressive Orthodontist Magazine, I have explained all of the things that virtual assistants can do for your practice: Virtually Everything is Possible
Written By: Jill Coon
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Dental Medical Cross Coding via Health Claims Unlimited
In the interest of resolving some confusion with regard to Dental to Medical Cross Coding, we have created a list of the guidelines that the insurance plans normally will pay for, as always it’s a good idea to get a prior authorization before you treat the patient.
Preventive Dental Services:
Space maintainers are allowed for: Accidental dental Cancer Cleft palate (congenital abnormalities) TMJ Preventive dental services are never covered Diagnostic, Restorative, Endodontic, Periodontics, and Prosthodontics Services.
Certain diagnostic, restorative (basic and major restorative), endodontic, periodontics, and Prosthodontics services are eligible for:
1. Accidental dental.
3. Cleft palate
4. Transplant preparation (does not include prosthodontics)
5. Initiation of immunosuppresses (does not include prosthodontics) Dental Implants: The following applies to CPT codes 21248 and 21249, and dental implant CDT codes: Dental Implants are rarely covered. See your patient individual Coverage Limitations and exclusions. Dental Implants are allowed for certain accidental dental situations.
Medical Oral Excisions: Certain oral excisions are allowed under the medical plan the same as any other illness. This includes biopsies of oral tissue (soft and/or hard tissue), surgical excisions of lesions, tumors, Neoplasms, and non-per apical cysts. Clinical Guidelines for Medical Oral Excisions: 21030 – Excision of benign tumor or cyst of maxilla or zygoma by enucleation and curettage. 21040 – Excision of benign tumor or cyst of mandible by enucleation and/or curettage. 21046 – Excision of benign tumor or cyst of mandible; requiring intra-oral osteotomy (e.g., locally Aggressive or destructive lesion(s)) 21047– Excision of benign tumor or cyst of mandible; requiring extra-oral osteotomy and partial mandibulectomy (eg, locally aggressive or destructive lesion(s)) 21048 – Excision of benign tumor or cyst of maxilla; requiring intra-oral osteotomy (eg, locally Aggressive or destructive lesion(s)) 21049 – Excision of benign tumor or cyst of maxilla; requiring extra-oral osteotomy and partial maxillectomy (eg, locally aggressive or destructive lesion(s)) Guidelines: 21030, 21040, and 21046 – 21049 are covered if not dental related. These codes are not covered if done in conjunction with third molar removal or with endodontic surgery. 40810 – Excision of lesion of mucosa and submucosa, vestibule of mouth; without repair. 40812 – Excision of lesion of mucosa and submucosa, vestibule of mouth; with simple repair. 40814 – Excision of lesion of mucosa and submucosa, vestibule of mouth; with complex repair 40816 – Excision of lesion of mucosa and submucosa, vestibule of mouth; complex, with excision of underlying muscle.
Accidental dental benefits are available when:
1. Treatment is necessary because of accidental damage; and
2. Dental services are received from a Doctor of Dental Surgery, “D.D.S.”, or a Doctor of Medical Dentistry, “D.M.D.”; and
3. When the following criteria is met for Notification, Types of Covered Injured Teeth, Initial Contact Timeline and Treatment Timeline. Notification/Prior-Authorization: Except for the initial visit, notification/prior-authorization by the enrollee is required. Without Notification/prior-authorization benefits may be reduced or denied depending on plan design. Refer to the patient’s specific plan document for details.
Types of Covered Injured Teeth: The types of injured teeth covered depend on:
a. Benefits are available only for treatment of sound, natural teeth. The Physician or Dentist must certify that the injured tooth was: A virgin or unrestored tooth or a tooth that has no decay and no filling on more than two surfaces, no gum disease associated with bone loss, no root canal therapy, is not a dental implant and functions, normally in chewing and speech. Benefits are available for sound natural teeth OR restored teeth.
Initial Contact Timeline: Accidental dental coverage requires that the dental damage is severe enough that initial contact with a Physician or dentist occurred within 72 hours of the accident.
Note the following:
1. An extension of this time period is normally not allowed.
2. An extension of this time period may be granted if the request for an extension is made within 60 days of the Injury and if extenuating circumstances exist due to the severity of the injury. Treatment Timeline:
Final treatment to repair the damage must be both of the following:
1. Treatment is started within 3 months of the accident. Note the following: An extension of this time period is not allowed.
2. An extension of this time period may be granted if extenuating circumstances exist (such as prolonged hospitalization or the presence of fixation wires from fracture care). And 2. Final treatment is completed within 12 months of the accident. There are no exceptions Allowed to the 12 month completion date. Dental services are generally not covered.
The dental exclusion includes but is not limited to:
1. Diagnostic – including, but not limited to, oral evaluations, examinations, x-rays/films, lab tests, and casts.
2. Preventive – including, but not limited to, dental prophylaxis (dental cleanings), topical fluoride treatments, nutritional counseling for dental disease, tobacco counseling for oral disease, oral hygiene instructions, sealants, and space maintainers.
3. Restorative (basic or major) – including, but not limited to, amalgam restorations (silver fillings), resin restorations (white fillings), gold foil restorations, inlay/onlay restorations, crowns, core buildups, and posts.
4. Endodontic – including, but not limited to, pulp capping, pulpotomy, pulpal therapy, root canals, and apicoectomy.
5. Periodontic – including, but not limited to, gingivectomy, gingivoplasty, crown lengthening, osseous surgery, grafting procedures, provisional splinting, scaling and root planing, full mouth debridement, and periodontal maintenance.
6. Prosthodontic (removable or fixed) – including, but not limited to, complete dentures, partial dentures, interim dentures, denture repairs, denture rebase, denture reline, denture pontics, denture inlays/onlays, denture crowns, and other removable or fixed denture services.
7. Dental Implants – including, but not limited to, dental implants, dental implant surgical base, post, crown, abutments, retainers and denture
8. Oral and Maxillofacial Surgery – including, but not limited to, extractions, surgical extractions, alveoloplasty (surgical preparation for dentures), and vestibuloplasty (surgery to increase alveolar ridge height)
9. Orthodontics – including, but not limited to, limited, interceptive and comprehensive orthodontic treatments including appliance therapy, orthodontic braces, and retainers. Except for certain state mandates, orthodontic treatments are never covered. 10. Adjunctive Dental Services – including, but not limited to, anesthesia, other dental examinations, visits, consultations, occlusal guards (bite plates/guards), athletic mouth guards, occlusal adjustments to teeth, and teeth bleaching.
For exceptions to the dental exclusion please see the Indications for Coverage section above Accidental Dental: For plans that cover accidental dental the following may not be covered under Accidental Dental:
1. Otherwise eligible accidental dental services that exceed the accidental dental dollar limitations on the plan.
2. Services that do not meet the criteria listed in the Indications portion of the patients plan.
3. Damage to teeth as a result of activities of daily living such as chewing and/or biting.
4. Skeletal damage (covered under medical).
5. Dental implants. (See Indications for Coverage section or call the plan)
6. Orthodontia (i.e. dental braces). Except for certain state mandates there are no exceptions to this exclusion.
7. Repair to bridges.
8. Repair to crowns. Some plans do not cover accidental dental services. For these plans accidental dental services are not covered regardless of the situation.
Please see state mandates for state mandated dental benefits. We hope this clears up any questions you might have, of course if we can be of any help please do not hesitate to contact us at 1-877-428-6606 or via email firstname.lastname@example.org.Visit www.healthclaimsunlimited.com for more information.
Written By: Jill Coon
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