The focus on integrated care delivery based on the Accountable Care Organization concept is well reflected in the emerging integrated dental-medical care models. The goal of such integration and consolidation is to improve care management, increase efficiencies in care delivery, and enhance patient outcomes. Such integration has led to a convergence in the provision of medical and dental care and how these services are paid. Today, dental medical billing involves not only submitting dental procedures to dental payers, but also submitting dental procedures to a patient’s medical plan. Dentists now need to cross over via dental-medical cross coded claims. Billing dental to medical can be complex and dental offices must have the knowledgeable teams and business systems in place to file and manage medical claims. Here are the top considerations involved in billing dental procedures to medical plans.

Billing Dental Procedures

Dental Services – What Medical Plans Pay

Dental insurance is available in two ways: separate, stand-alone dental plans and health plans that include dental coverage. Dental payers are increasingly requiring dentists to bill a patient’s medical plan for specific dental procedures. According to the California Dental Association (CDA), some of the dental treatments that medical plans will pay include:

  • Treatment related to inflammation and infection
  • Dental repair of teeth due to injury
  • Exams for orofacial medical problems
  • Extraction of wisdom teeth, under certain conditions
  • Extraction of multiple teeth at one time
  • Certain periodontal surgery procedures
  • Consultation for and excisional biopsy of oral lesions
  • Consultation and treatment for temporomandibular joint problems
  • Infection that is beyond the tooth apex and not treatable by entry through the tooth
  • Pathology that involves soft or hard tissue
  • Procedures to correct dysfunction
  • Emergency trauma procedures
  • Appliances for mandibular repositioning and/or sleep apnea
  • Congenital defects

An article in Dental Economics points out that some plans may provide coverage for dental implants provided for reconstruction following trauma or cancer surgery. Oral surgeons also report exams, consultations, diagnostic, physical therapy, equilibration, and splint therapy to medical insurance using CPT codes.

Medical Coding for Dental Claims

The key to successful claim submission is the using the correct code to report the treatment provided. To report dental procedures to dental plans, providers generally use the CDT procedure code set. However, some medical payers will not pay for treatments that come under the category of CDT procedures. On the other hand, many medical payers will allow dental codes to be reported on the medical claim form when there is no applicable CPT code or when the CDT is the most accurate code to describe the dental procedure performed.

The appropriate CPT codes should be used to report medically billable dental procedures. The specific reason the treatment was provided should also be specified using ICD-10 codes. Medical claims should be submitted in CMS-Form 1500.

When it comes to dental to medical cross-coding, the most important consideration is the medical necessity to do so. Medical necessity requires that the services and procedures be in compliance with recognized medical standards and be appropriate and necessary for: diagnosis or treatment, prevention of a medical condition, improvement of a condition, or rehabilitation of lost skills.

Dental insurance verification is important to verify benefits and coverage prior to initiating treatment. Outsourcing companies that offer dental billing services have eligibility verification built into the process. Benefits verification requires diagnosis and procedure codes, which are determined after the comprehensive exam and radiographs are done. In dental to medical cross-coding, benefits and eligibility verification involves determining whether the procedure to be done is medically billable under the patient’s plan. This must be done before filing a patient’s medical claim. A reliable insurance verification specialist will verify benefits online as well as by phone.

Dental to Medical Cross Coding – Many Advantages for Providers and Patients

Billing medical plans offers distinct advantages for both dentists and patients:

  • It eases the financial burden on patients as when the procedure is paid by medical it will conserve their annual dental insurance benefits.
  • Medical plans may pay more for certain procedures.
  • Medical plans will pay for services such as tobacco and nutritional counseling, which practices usually cannot bill to dental.

Medical-dental cross-coding offers new opportunities to treat patients and improve care, but to take advantage of these opportunities, dental offices should have the knowledge and business systems in place to file and manage medical claims. Moreover, dental team members feel weighed down when submitting medical claims for dental procedures such as surgical extractions, trauma-related procedures and biopsies. Outsourcing dental medical billing to an experienced service provider is a practical option for providers that treat a reasonable volume of medically related issues. Established companies have expert coders and billing specialists who have the knowledge necessary to bill dental claims as well as to bill dental procedures to medical. Their comprehensive revenue cycle management solutions would cover everything from patient enrollment, scheduling, and insurance verification and authorizations to billing and reconciling of accounts, AR collections & management, and follow-up on denials and submit appeals.