Dental Coding-When to use CPT codes

Many dentists realize that trauma-related dental services are billable to medical plans, most dentists do not have medical coders in the office to understand the medical procedure codes or all the rules and regulations that change continually. Moreover, other dental services can also be billed to medical. For a dental service to be considered for payment under a medical plan, the service must be a medically necessary procedure that is based upon a medical diagnosis with supporting documentation

There are many advantages to filing medically-related dental services with medical plans. Dental plans typically have yearly maximums that medical plans rarely have to comply with. When medical or trauma-related services are covered under both a dental and medical plan, the patient’s out of pocket expense is typically significantly reduced to a small co-insurance or standard co-pay. You will likely see an increase in revenue for those procedures that fall under the guidelines for filing medical, especially for patients who do not have a dental plan. Lastly, a willingness to file dental procedures that are medically-related will be seen as a value-added service by your patients. Make sure you list this benefit on your website so patients are aware of your willingness to help them receive the care they need without the financial burden.

Over the past decade or so, research has exposed a relationship between oral infection and systemic health conditions, causing dental professionals to look more closely at the link between a patient’s oral health and overall physical health. A carefully developed patient medical history form that includes entries for cardiovascular disease, high blood pressure, diabetes, and respiratory disease is essential. Periodontal pathogens are suspected to affect these conditions. The information provided on the patient’s medical history form in combination with the dentist’s clinical findings and, on occasion, information obtained from the patient’s physician is used to determine the diagnosis codes that are needed to file medical claims. A little over a decade ago, the idea of billing medical claims was a huge topic with dentists and many jumped on the bandwagon, only to discover that medical coding is not as simple as dental and there are a lot of rules and regulations. Some dental practices hired certified medical coders to help decipher the codes or rely on their software to assist with code mapping.

Every payer/insurance carrier has their own guidelines as to how or if they will cover certain dental expenses. It is always a good idea to obtain a pre-authorization or pre-certification from the dental and/or medical carrier before proceeding with a procedure unless it falls under emergency care/trauma care.

Many carriers also have a coordination of benefits clause. This clause generally states; if the dental carrier pays any portion of the procedure the medical carrier will not be liable and vice versa. In instances where no coordination of benefits clause exists you can maximize reimbursement and minimize the patient’s out-of-pocket expense by billing both the medical and dental carrier for payment. Please note, you are not allowed to collect more than the allowed fee from both carriers combined.

Some similarities do exist between preparing a dental claim and preparing a medical claim. The patient demographics and insurance demographic sections are examples. As with dental, primary and secondary insurance information must be provided to medical carriers. There are, however, some very significant differences. As far as coding is concerned, medical carriers require more than just a procedure code as dental carriers do. Medical carriers not only require procedure code(s) but also the reason why the procedure(s) were performed.

Key Steps
Filing medical claims involve several key steps. First, you will need to obtain the patient’s medical insurance information. This can be done by either re-designing your patient’s registration form to request the information needed or by using a separate medical information form or by using a separate medical information form. Emphasize in writing that while some procedures may be filed with the patient’s medical plan, the final responsibility for payment still lies with the patient. Keep in mind that it is always advisable to contact the medical carrier before treatment to determine eligibility, benefits, and the following:

  • The type of medical plan you are billing. Keep in mind that HMO’s or PPO’s may decline benefits, pay the subscriber, or pay a lower percentage to non-participating providers
  • The medical plan’s special requirements for filing dental procedures with medical as primary. The subscriber normally has the right to file with the medical as primary as long as it is not written in his/her plan that dental must be filed first if the procedure is performed by a dentist.
  • If a pre-authorization or referral is required for the procedures involved. (This is much more common in medical than it is in dental.)

    CMS-1500 Claim Forms Medical claims are billed using CMS 1500 claim forms which can be purchased from most medical or office supply companies. CMS-1500 forms are white with red print. As such, some medical carriers will only accept an original CMS-1500 claim form because duplicated claim forms may not scan correctly. Medical billing has become so common in dental practices, however, that many dental practice management systems have the CMS-1500 claim form and medical codes pre-loaded on their software. If you can submit hard claims but are unsure how to complete them, there are detailed instructions available on the NUCC website: