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
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