Using the correct dental codes to appropriately report various procedures to insurance companies is a major concern for dental practices. For certain procedures, dental offices are required to bill a patient’s medical plan for dental procedures that are typically considered “medical” in nature. The submission of dental treatments to medical payers – referred to as dental to medical cross-coding – can seem complex. The good news is that dentists can ensure accurate submission of dental procedures to patients’ medical plans with the help of a company with expertise in providing both medical and dental billing services.

Dental Procedures that can be Billed to Medical Insurance

Oral health impacts general health. By billing medical procedures, dentists are treating the patient’s overall health, while also improving reimbursement. Medical insurance reimbursement is available for common procedures that dentists perform when the services meet medical necessity considerations. Dental procedures that can be billed to medical insurance include:

  • Dental repair of teeth due to injury
  • Treatment related to inflammation and infection
  • 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
  • Dental implants, bone grafts, and CT scans
  • Clearance exams before chemotherapy or surgery

Dental and Medical Cross Coding: Requirements for Successful Claim Filing

  • Use the Right Codes: There are standard codes sets for reporting medical and dental procedures in the HIPAA transaction sets. All HIPAA-covered entities are required by law to accept CDT, CPT and ICD-10 codes. Knowledge of CDT, CPT, HCPCS, and ICD-10 coding is crucial for successful dental and medical cross coding and billing. Dental practitioners need to report the correct codes to describe the treatment provided and why it was medically necessary in the medical claims. The clinical documentation should support all the diagnoses and procedures reported.

    Key points to note when using CDT, CPT, HCPCS, and ICD-10 to submit dental procedures to medical insurance:

    • CDT Codes: These codes are maintained by the American Dental Association. CDT codes identify oral procedures and are used to submit claims to dental plans. Many medical insurance companies accept the CDT code or HCPCS code if no appropriate medical cross code (CPT) is available or when the CDT is the most accurate code to describe the dental procedure performed. Most medical payers who allow submission of CDT codes require that only one dental or medical code be reported on each claim form.
    • CPT Codes: Referred to as Level I codes, CPT codes are used to report medical procedures to medical insurance. CPT codes are maintained by the American Medical Association.
    • HCPCS Codes: Referred to as Level II codes, HCPCS codes are basically used to report medical services, equipment, or supplies. Dentists use HCPCS codes to report durable medical equipment (DME) such as oral sleep apnea and temporomandibular joint disorder appliances. This code set is maintained by the Centers for Medicaid and Medicare Services (CMS). HCPCS codes are updated throughout the year.
    • ICD-10 Codes: These codes are used to identify diagnoses, symptoms, and procedures in claims. ICD codes inform the payer why the procedure may be medically necessary. Every medical claim requires at least one ICD-10 code be reported and not including one will result in claim rejection. ICD-10-PCS (procedure coding system) codes are used only by hospitals in an inpatient setting. Dentists report only ICD-10-CM codes and not ICD-10-PCS codes.
  • Verify Patient Coverage: Performing dental insurance verification is necessary to determine the type of coverage the patient has. If the patient has received dental care that is “related” to a medical condition(s), it may be possible to bill medical insurance. Before submitting the claim, the dentist needs to verify if the payer will accept CDT codes and other specifics of the insurance policy coverage.
  • Know Which Plan (dental or medical) to Bill First: Many dental policies require the dentist to file claims for procedures that are considered medical in nature to the medical insurance first, before billing the dental insurance. An article in Dental Economics recommends holding the dental claim until the medical insurance evaluates it for payment of benefits. “At that time, the claim may be submitted to the dental payer with the medical explanation of benefits (EOB). Filing both medical and dental claims simultaneously may result in an overpayment requiring refunds to the payer(s) and/or patient”, notes the report.
  • Use the Appropriate and Current Claim Form: Dental claims are reported using the 2012 ADA Dental Claim Form. Medical claims are reported using the CMS-1500 Health Insurance Claim Form (02/12). Whether submitting a medical or dental claim, it is critical to use the appropriate and most current version of the claim form. Tips to ensure clean claim submission:

    • Use the correct codes
    • Ensure the highest degree of specificity in clinical documentation
    • Follow claim submission instruction precisely when submitting a medical claim
    • Complete all the fields and ensure proper placement of required information
    • Claims can be submitted in print format, electronic format or by mail depending on payer requirements. The most important thing is to ensure legibility
    • Take care to avoid errors. An AGD Impact article reports that the most common claim errors are related to the use of punctuation (i.e., a decimal point in the ICD code), lack of a description when reporting an unlisted CPT code, and not using the appropriate modifier or qualifier, when required

Navigating the dental and medical cross coding process is much easier with the support of a medical billing company for dentists. Reliable companies will contact each patient’s medical carrier to determine their medical coverage. Their professional coding teams would be knowledgeable about the various code sets, which is crucial for proper cross coding. Billing expertise is also important for dental practices to stay up to date on new code changes and revisions that occur annually.