8.28.15 Issue #703 info@mckenziemgmt.com 1-877-777-6151 Forward This Newsletter

Belle DuCharme, CDPMA
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Three Keys to Medical Claim Filing for the Dental Practice
By Belle DuCharme, CDPMA

In recent years, new scientific/clinical evidence has linked conditions of the mouth with disease systems of the body, resulting in insurance billing complexities. This mostly affects oral surgeons, but with more combination policies flooding the insurance market, general dental practices are more frequently finding themselves having to send claims to patients’ medical insurance first, prior to submitting to their dental insurance.

Dental offices that are not accustomed to billing medical insurance are caught in the confusion of more than one coding system. It is necessary to now have a CDT (ADA) yearly manual, but also information on CPT (AMA) codes and medical diagnostic codes found in the ICD-9 system and in October 2015, the ICD-10 medical diagnostic code system. This is a strict rule-driven system, especially if the dental office is in-network with Medicaid or Medicare patients or other government sponsored health care plans.

Follow these keys steps to simplify the process:

1. Obtain the patient’s medical insurance information when you obtain the dental insurance information. Your current updated software system may have this on the patient registration form. Take a copy of the cards, front and back. Emphasize in writing that while some procedures may be filed with the patient’s medical plan, the patient is responsible for the entire fee.

2. Contact the medical carrier prior to treatment to determine eligibility, benefits and the type of medical plan you are billing. HMO’s or PPO’s may decline benefits, pay the subscriber, or pay a lower percentage to non-participating providers. Find out 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 the plan that dental must be filed first if the procedure is performed by a dentist.

3. Trauma claims require special handling. It is a good idea to request that trauma patients provide you with a copy of the emergency room report or the police report if either applies. These should be attached to the claim along with the narrative. Also, liability carriers (e.g. homeowners insurance, automobile insurance, etc.) will typically be primary to medical carriers.

What is similar between dental and medical insurance claim filing is that procedure codes are required. Medical procedure codes are called CPT Codes. Similar to the dental procedure code set, the codes are divided into categories. These categories are evaluation and management; anesthesia; surgery; radiology; pathology and laboratory; and medicine. The evaluation and management codes are not like the dental exam codes. Dental practices need to cautiously choose codes from this section, as most of the mid-level to high-level codes require a time factor and the evaluation of multiple body systems. Part of the difficulty in cross-coding is that very few CPT codes exactly parallel dental procedures. There are some insurance carriers that will accept CDT codes on the medical claim form (ask them).
Within the CPT code set is a subset of codes called Modifiers. Say a procedure was altered by a specific circumstance and that is demonstrated with modifiers. Examples include; the need to report that a procedure is less involved than the code normally used, or the need to explain that more than one type of procedure was performed on the same date by the same provider. Modifiers would also be used to explain that an exam and x-ray were performed on the same date of service and should be paid as separate entities. There are many more modifiers and it is important to know when and how to use them.

The dental record must be complete and legible, with all entries dated and signed. Every patient appointment must include the date, the reason or complaint, appropriate history and physical/oral exam, review of radiograph results and other ancillary services where appropriate, an assessment and a treatment plan or release plan. Past and present diagnoses should be available to the treating or consulting health care professional. The reason for and results of radiographs, tests and other services should be documented to the dental record including referrals. Patients’ progress reports such as response to treatment change in treatment or diagnoses, treatment plan or plans.

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