An emergency patient arrives at your office in pain, having fallen and fractured a tooth. She's taken to the treatment room, where you determine that she needs a root canal and crown. Your insurance coordinator says the patient does not have dental insurance coverage. Due to the nature of this case, you begin treatment. Later, the patient tells your financial coordinator that she will only be able to pay $50 today and a maximum of $50 per month after that.

These production dollars could sit uncollected in A/R for years. Collection costs alone will significantly erode the value of those fees.

A solution to this common problem is filing dental/medical cross-coded insurance claims. Cross-coding is an effective and relatively easy way to increase practice revenue and reduce the costs associated with A/R collections.

Why use it?

Medical insurance has significant advantages over dental insurance.

Most medical plans do not have yearly maximums, so when claims are filed with medical insurance, the dental yearly maximum is not depleted.

Also, most dental plans follow the guidelines of allowing benefits for full-mouth x-ray series once every three to five years. The American Medical Association (AMA) allows this service every two years.

When medical insurance can be filed in addition to dental, it can greatly reduce co-pays for patients, as well as attract new patients who do not have dental plans.

When to use it

You may file dental procedures under a patient's medical plan in any of the following four categories:

• Infection that is beyond the tooth apex and not treatable by entry through the tooth.

• Pathology that involves soft or hard tissue.

• Procedures related to dysfunction.

• Emergency trauma procedures.

How to use it

The implementation of a dental/medical cross-coding system in your office involves several steps.

Redesign your patient registration form to add a section for medical insurance information. The requested information should include the patient's name, date of birth and Social Security number. You also will need the name of his or her employer, as well as the patient's marital status, group number, insurance ID number, claim filing address and the insurance carrier's phone number. If the patient is a child and a full-time student, you will need the name of the school.

Indicate that some procedures may be filed on the patient's medical plan as a courtesy, but the final responsibility of payment of fees is theirs. HMO and PPO plans may decline benefits, pay the subscriber or pay a lower percentage. The subscriber has the right to file with the medical insurer as the primary payer, as long as it is not stated in the plan that dental insurance must be filed first for dental procedures.

You also will need to become familiar with CPT-2005, ICD-9, V and E codes and modifiers.

CPT-2005. Dental insurance companies require CDT-5 codes along with their word descriptions. HCFA 1500 forms (see "How To…" page 10) require CPT-2005 codes as the description of service with no word descriptions.

ICD-9. These are the diagnostic and surgical codes used to establish a medical necessity. More than one code can apply to a procedure and decisions as to the diagnoses must be made on every claim.

V and E codes. These codes are used to classify factors affecting health and the seeking of medical services. V codes are used when situations other than a disease or injury are entered as diagnoses. E codes are used as the classification of the external cause of the injury. An example of this would be the patient who fell and broke a tooth. You will need to find out how and where she fell to determine the E code.

Modifiers. Located in the appendices of CPT-2005, modifiers are attached to a procedure code when the circumstances of the code have changed, but not the definition. For example, you'd use a modifier if you provided only one component of a procedure; i.e., you read an x-ray taken by another professional. Modifier 26, "Professional Component," identifies that you provided a professional, not technical, contribution to this procedure.

A modifier also may be used when several doctors perform a service. Other modifiers provide for partial and adjunctive procedures, as well as services performed multiple times.

Not all third-party payers recognize modifiers. But if you are permitted to attach modifiers, they can help with claim acceptance.

Troubleshooting

Cross-coding isn't difficult, but problems occasionally arise. Here are some tips to resolve some of these nettlesome issues.

No check. If three to four weeks have passed since submitting your claim, and you have not received a benefits check, call the insurance company. If the claim is denied, insist that they give you the reasons for denial.

If a phone call does not produce the desired results, send a letter requesting an explanation of the denial so that you may make any necessary corrections and ask for a reconsideration of the claim. By law, the insurance company cannot discriminate against you because you are a dentist. If the policy states "no dental claims," advise them that it is a medical claim. Your last resort will be to have your patient contact the state's insurance commissioner.

The right codes. The biggest obstacle is choosing the correct codes, because incorrect coding will cause the greatest delay in payment.

Prepare a list of the most common appropriate procedures and assign the corresponding CPT-2005 and ICD-9 codes. This can be a handy reference tool for the actual preparation of the claims. Dental/medical cross-coding manuals can be of great assistance with this.

You can purchase coding manuals from the AMA (www.ama.org). "Maximizing Medical Reimbursement in the Periodontal Practice" by The Z Group LLC (www.thezgroupusa.netscape.net) is a resource that can help with dental/medical cross-coding. HCFA 1500 forms can be purchased from any medical-office supply store.

Practices should collect payment-in-full at the time of service. Patients should be told that the medical claims are being processed as a courtesy; any benefits received will promptly be refunded to the patient.

It is certainly worth the time and effort to implement a dental-medical cross-coding system. You will be able to add a valued service for your patients that should reap financial rewards for you.

Posted by dentalproducts.net. Originally published in the March 2005 Dental Practice Report. Copyright 1999-2005 Advanstar Dental Communications