What Every Dentist Must Know about Medical Billing and Coding

Although most dental procedures are filed with a patient’s dental insurer, some are medically necessary and must therefore be submitted to a health plan. For many dentists this can create a problem, since dental claims normally do not require a diagnosis code. Here are some things you should know in case you are ever faced with this situation.

What is Medical Necessity?

Before filing a claim with a medical insurance company, you should first ensure that it meets the definition of medical necessity as defined by the American Medical Association (AMA). According to this agency, three things are required:

  • The procedure should be in accordance with “generally accepted standards” of medical practice.
  • Treatment should be clinically appropriate in terms of frequency, type, extent, duration and site.
  • The primary purpose of treatment should not be the convenience of the patient, physician, or health care provider.

Common Procedures

A number of dental procedures are commonly performed due to medical necessity, including:

  • TMD procedures
  • Treatment for myofascial pain conditions
  • Oral cancer screenings
  • Procedures related to sleep apnea
  • Surgery to correct oral trauma

Many other procedures can be classified as medically necessary if they are required for diagnosing or preventing a medical condition, improving a condition, or rehabilitating lost skills.

CMS-1500

When submitting a medical insurance claim for a dental procedure, you will need to fill out the CMS-1500 form. When completing this form, you will want to become familiar with a subset of medical codes known as the “V” and “E” codes. V codes are often used in medical billing and coding to explain conditions that affect treatment-for example, heart disease, diabetes, etc. E codes on the other hand are most often needed to pinpoint the external cause of trauma as well as its location in the body.

You must also pay attention to modifiers within the CPT code set. Modifiers could be needed to provide more specific information, such as when more than one procedure is performed on the same date. A common example is when x-rays and exams are performed during the same visit but are billed separately.

Diagnosis and Treatment Planning

When cross-coding dental treatments as medical procedures, keep in mind that the current CDT codes require that diagnosis and treatment planning be performed by the dentist. Diagnosis codes must be prioritized on the CMS-1500 claim form. When there is more than one diagnosis, use the primary diagnosis code to explain the major reason for care as well as the problem being treated. You may use up to three additional codes (to include V and E codes) to provide further information.

The concept of medical coding is foreign to many dentists. In addition, dental billing software programs do not typically produce the CMS-1500 form, which cannot be printed using plain white paper. Each health insurance company also has its own unique requirements that are unfamiliar to many dentists. If your practice regularly performs medically necessary procedures, partnering with a firm such as Leeward Medical can help you eliminate frustration and ensure that all of your claims are paid in a timely manner.