by Christine Taxin

Today I read an article on keeping healthy: “Experts now worry economic troubles can lead to serious health problems, and reveal plan to prevent them!”

You’ve probably been affected by the current economic news more than you realize. No, I’m not talking about your finances — I’m talking about your health.

Pick up the paper, watch the network news, check out your favorite blogs, and all you see is the same thing over and over again — stress-inducing bad news!

And now, study after study is actually documenting how stress is literally killing us. There is a cure, and it’s called “Medical Billing in Dental Practices.” If you are interested in learning the benefits of medical billing, this article is for you! You can also find more tips on keeping your practice healthy in the current market in the “Ultimate Office Manager” newsletter. Go to for more information.

I recently received a call from an office that was extremely happy with its new billing process. Nonsurgical periodontal treatment was performed on a patient, with the medical diagnosis attached. The office billed dental and medical insurance, and the entire treatment was covered. The patient’s only out-of-pocket expense was for home-care products.

After healing, she will have implants and crowns placed in Phase 2 of her treatment. She can afford to do this because the majority of her Phase 1 treatment was covered by insurance. One of the reasons for our success in filing medical claims for dental procedures is our knowledge of the mounting documentation about the link between oral health and overall body health. An increasing number of dental carriers are recognizing the medical nature of certain dental procedures. This leads to more opportunities to file claims with medical carriers, but it also requires dental practices to know how to do it. At present, the following procedures can and should be filed with medical carriers:

•Trauma procedures
•Medically necessary oral surgical, laser, and periodontal procedures (and this should only continue to grow with continuing research into the oral systemic link)
•Medically necessary implant, endodontic, and prosthodontist procedures
•TMD procedures
•Sleep apnea appliances
• Oral cancer screening
•Any medically necessary exams and X-rays (including CT Scans)that are associated with the above procedures

The office we discussed earlier in this article has also received insurance approval for a sleep apnea case. The increased profits from these two cases far exceed the time and expense to learn how to properly file medical claims. When we first began working with this office, the staff could not believe how many of their cases met the criteria for filing a medical claim. What does this mean to them? Their patients are accepting treatment, doctor is being paid & patients are referring friends and family. More importantly, MDs are referring and are as excited as we are to have partners in our patients’ health care. Your office can also reap the rewards that go along with happy patients, profit stability, and a team that will receive compliments daily

Remember, you don’t have to be sick to get help; prevention is always the best answer.

What’s the difference between medical and dental?

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. That reason is the patient’s diagnosis. Diagnoses are classified in code form in the ICD-9-CM (“International Classification of Disease, Ninth Revision — Clinical Modification”) manual. Without at least one diagnosis code that supports the procedure(s), medical claims will not be paid. An appropriate diagnosis is that which establishes the medical necessity of the procedure. Medical necessity is probably the most important part of successful dental-medical cross coding.

Just as the dental field has the CDT code set to report their procedures, the medical field has the CPT code set (“Current Procedural Terminology”). You may wonder if dental procedures can be reported using CPT codes. There actually are many CPT codes that can be used to report medically necessary dental procedures. There isn’t always a great degree of specificity with these codes, however. There is a Level II CPT code set that is called HCPCS (pronounced hick-picks).

What is fortunate for dental practices is that our CDT code set is part of HCPCS. Therefore, we can use our CDT codes on medical claim forms when a CPT code is not specific enough, as long as the medical carrier accepts HCPCS codes.

One very significant difference between dental and medical coding systems is the time period between updates. Medical codes go through the same process as dental in that they are evaluated for additions, deletions and revisions, and then all of these changes are published in their respective manuals. The main difference is in the frequency of the updates. All medical code sets update yearly and medical carriers generally offer no grace periods on using outdated codes.

The medical claim form also has some major differences compared to the ADA claim form. Most medical carriers require the CMS-1500 (08-05) claim form. At first glance, you will see one distinction and that is the color of the font and lines. It is red. Medical carriers require these preprinted, red-inked forms because these forms are the only ones that scan correctly. The carriers also do not accept copies of the forms for the same reason. One last thing to remember is that hand-written claims and hand-written comments are not accepted.

Should your practice take on the challenge to learn how to code dental procedures to medical claims, this will significantly impact your practice in a very positive way. The benefits to implementing a dental-medical cross-coding system are as follows:

•Patients who are compromised medically by oral conditions will be able to tap into their medical benefits to help pay for their procedures.
•Patients who have both medical and dental insurance plans can divert the medically-necessary procedures to their medical plan, allowing them to save their dental plan yearly allowances for their dental procedures.
•These situations will yield increased case acceptance and the resultant increased practice revenue.
•Patients who realize that your practice is willing to help them obtain medical benefits will be very grateful and will become excellent marketing tools for your practice.
One other piece of good news. All of the medical claims with their attachments can be sent using a special company called Apex. It will provide the best medical electronic billing for all your medical claims. It also has the ability to attach X-rays and letters of necessity.

Taken from

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36 Abington Avenue, Ardsley, NY 10502 USA
Christine Taxin Christine Taxin at Dental Medical Billing offers Medical Billing training and completion services (347)909-7068