There is an ongoing trend within health care toward integration and consolidation of health care delivery systems. This trend is reflected in provisions of the federal Affordable Care Act, such as the envisioned coordination of care provided under a single entity, the "Accountable Care Organization." The objective of such integration and consolidation is to provide better management of care, create greater efficiencies in the provision of care and improve patient outcomes.
How this trend will affect dentistry largely remains to be seen. But one area that is apparent is in an overlap between medical and dental services and how care is paid. What this means is that, increasingly, dental offices are being required to bill a patient's medical plan for treatment that is essentially dental in nature. These types of treatment situations can include trauma from an accident, sleep apnea, oral or periodontal surgery procedures, or dental disease that is secondary to cancer treatment. In those cases, an option exists for billing a patient's medical insurance. These are procedures that medical plans not only pay for, but increasingly dental plans are deferring to as the primary payers.
There are advantages to billing patients' medical benefits plan, including easing the financial burden on patients and conserving their annual dental insurance benefits. The disadvantage is the dental office must have the knowledge and business systems in place to file and manage medical claims. The learning curve can be considerable. It makes sense for practices that treat a reasonable volume of medically related issues to create and implement such systems.
What medical plans will cover
Medical insurance typically pays for treatment provided by dentists, but not as dental procedures. Dental services that have corresponding medical codes will be reimbursed by medical insurers. For example, Medicare Part B, which covers provider services, considers dentists "physicians" to be reimbursed for performing procedures that are Medicare benefits. The services provided, of course, must be within the scope of practice of the Dental Practice Act.
Similarly, commercial medical plans will pay for procedures performed by a dentist, provided they are properly coded as medical procedures. Medical plans pay for procedures that are medically necessary, that is, when the patient is medically compromised by a problem that the dentist treats.
For example, medical plans will pay for:
- 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.
Medical and dental benefit designs are determined by the insurance company and the plan sponsor, which is usually an employer purchasing coverage for employees. Many plan sponsors want specific oral surgical procedures paid under their medical benefit plan. Coverage by the medical policy allows the preservation of dental plan benefits, which generally have a low annual maximum compared to medical plans. Under a medical plan's coverage, dental care can be accessed without exhausting the dental plan's annual maximum in one surgical appointment.
The key to successful claim filing is the correct use of codes to identify what treatment was provided, and in the case of medical claims, the reason the treatment was provided. Current Dental Terminology (CDT) are the code sets established by the ADA for identifying procedures provided to patients for oral treatment. The CDT codes are used when submitting claims to dental plans. Medical plans do not pay for treatment claimed as CDT procedures.
Current Procedural Terminology (CPT) is a listing of procedure codes used to describe medical treatment, and used when submitting claims to medical plans. CPT codes are developed and maintained by the American Medical Association. The medical claim form is designated as CMS-Form 1500.
International Classification of Diseases (ICD) is the diagnostic coding system used with medical claims to describe the condition presented by a patient for which treatment was rendered. The current iteration of diagnostic codes is ICD-10. There are two types of ICD codes – ICD-10CM (Clinical Modification) and ICD-10PCS (Procedure Coding System). The CM codes are used for all health care settings, particularly outpatient care, while the PCS codes are used in hospital inpatient settings. ICD-10 codes are required as part of the 1500 medical claim form. ICD-10 codes are not required as part of the dental claim form, although the ADA claim form contains a field for placing diagnostic codes. This field is provided in anticipation of diagnostic coding used with dental procedures, but is not widely required by dental plans. ICD-10 is an alphanumeric coding system. Codes in the ICD-10 categories K00 to K95 describe diseases of the digestive system. This includes diseases of the mouth, including conditions treated by dentists.
A complete set of the ICD-10 codes are available on icd10data.com. ICD-10 codes associated with oral health conditions are also part of the appendix to the CDT Companion book published and updated annually by the ADA.
Obtaining medical claim forms
Medical claim forms may be ordered from the AMA bookstore at AMAbookstore.com under "insurance products." Some practice management software vendors provide the CMS-1500 form. Many commercial medical plans provide copies of the CMS-1500 form on their websites. Also, paper forms can be purchased at major office supply stores as well. Information on the CMS-1500 Health Insurance Claim Form, including instructions on completing the form, is available from the National Uniform Claim Committee at nucc.org.
This information is simply a brief introduction to billing medical plans. Beyond understanding dental/medical cross-coding, specific CPT coding, using diagnostic codes and navigating the CMS-1500 claim form, it is important to also become proficient at the use of "asterisk" codes, evaluation and management (E/M) codes, and modifiers to both procedure and diagnostic codes. These codes tell the insurer not only the nature of an injury, but how the patient got the injury.
In climbing the learning curve of medical billing, finding a training course that discusses all aspects of the process should be considered.
As the need for dental office staff to become proficient in medical billing increases, CDA will be providing new resources to help. For more information, contact CDA Practice Support at 800.232.7645.
Resources on the medical billing process
For now, the following resources will help to develop an understanding of the medical billing process. (Note: CDA does not endorse these resources, but provides this list as helpful resources for medical billing):