You open the envelope fully expecting it to contain a payment for a patient. Instead, you notice that there is no insurance check. Quickly scanning the explanation of benefits, you see the dreaded words "Due to the emergency nature of this claim, file with medical insurance as the primary carrier". You suddenly get a sick feeling in the pit of your stomach because you have no idea how to file a medical claim, and you hate to disappoint your patient. Fear not. Although it is considerably different than filing a dental claim, medical billing is easy once you know the basics.

Medically-billable Procedures
While it is well known that trauma-related dental services can be billed to medical plans, there are other dental services that can also be billed to medical. In order for a dental service to be considered for payment under a medical plan, the service must be a medically necessary procedure that is based upon a medical diagnosis. Examples of such services are exams and consultations for oral-facial medical conditions, oral surgery procedures such as hard and soft tissue biopsies, periodontal procedures caused by or exacerbating a medical condition, procedures relating to oral dysfunction, TMD procedures, procedures for myofascial pain conditions, medically necessary radiographs, etc.

There are several advantages to filing medically-related dental services with medical plans. Dental plans typically have yearly maximums that medical plans seldom have¹. When medical or trauma-related services are covered under both a dental and medical plan, the patient’s out of pocket expense may be significantly reduced. You may see an increased case acceptance for those procedures that fall under the guidelines for filing medical, especially for patients who do not have a dental plan. Lastly, a willingness to file dental procedures that are medically-related will be seen as a value-added service by your patients.

Today’s dental practices need to become familiar with the medical billing process. Over the past decade, research has exposed a relationship between oral infection and systemic health conditions, causing dental professionals to look more closely at the link between a patient’s oral health and overall physical health². A carefully developed patient medical history form that includes entries for cardiovascular disease, high blood pressure, diabetes, and respiratory disease is essential on new patient registration forms and recare update forms. Periodontal pathogens are suspected to have an effect on these conditions. The information provided on the patient’s medical history form in combination with the dentist’s clinical findings and, on occasion, information obtained from the patient’s physician are used to determine the diagnosis codes that are needed to file medical claims.

Diagnosis Codes
Medical insurance is diagnosis driven. Medical carriers need to know why procedures are performed. Diagnosis codes provide the answer to this and are listed on a medical claim form following patient demographics. Medical benefits will not be paid without them. Providers currently use ICD-9 codes (International Classification of Diseases) to report the diagnoses and to establish medical necessity. Diagnosis codes are divided into primary codes, secondary codes, symptoms and ill-defined conditions, and V and E Codes.

The primary diagnosis is the most significant condition for which the procedure was performed and must be listed first. Secondary diagnosis codes are listed after the primary diagnosis and are used to report any additional medical factors, conditions, or symptoms. In addition, one may need to use V and E to other information about the diagnosis. V codes are used when situations other than a disease or injury are entered as diagnoses³. A V codes might be used when a patient has a personal history of neoplasm of the tongue that influences treatment (V10.01) or for a patient who is having difficulties with mastication (V41.6). E codes are used to classify the external cause of the injury, such as how and where it happened⁴. For example, E codes would be used if a child is injured when falling out of bed (E884.2) at his/her home (E849.0). E codes are also used to indicate an adverse effect of therapeutic doses of medication, such as an adverse effect from an anticonvulsant drug (E936.1). In addition, E codes also indicate late effects. Late effects are residual effects that are present one year or more after the original injury⁵. For example, E929.0 codifies late effects from a motor vehicle accident. V and E codes are rarely used as the primary diagnosis codes and should be listed after primary and secondary diagnosis codes. When a specific diagnosis cannot be determined clinically, codes can be found in ICD-9 for signs, symptoms, and ill-defined conditions (e.g. 780.51 for insomnia with sleep apnea)⁶.

Procedure Codes
While diagnosis codes are reported using ICD-9 codes, procedures are reported to medical plans using CPT codes (Current Procedural Terminology). Modifiers are sometimes used to clarify certain types of procedures, such as when a procedure is bilateral (-50). Modifiers are entered after the CPT code in box 24. When more than one surgical procedure is filed on the same claim, the most significant procedure should be listed first⁷.


The biggest challenge to filing a successful medical claim is selecting the correct codes. Dental offices need to become familiar with the CPT and ICD-9 medical code books, obtain a good dental-medical cross-coding book, or find a reliable resource to help with current medical coding. At best, incorrect coding will cause a delay or denial of payment. At worst, incorrect coding can result in serious legal consequences.

• Key Steps
  Filing medical claims involves several key steps. First, you will need to obtain the patient’s medical insurance information. This can be done by either re-designing your patient’s registration form to request the information needed or by using a separate medical information form or by using a separate medical information form. Emphasize in writing that while some procedures may be filed with the patient’s medical plan, the final responsibility for payment still lies with the patient. Keep in mind that it is always advisable to contact the medical carrier prior to treatment to determine eligibility, benefits and the following:
  
  
• The type of medical plan you are billing. Keep in mind that HMO’s or PPO’s may decline benefits, pay the subscriber, or pay a lower percentage to non-participating providers⁸.
• 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 his/her plan that dental must be filed first if the procedure is performed by a dentist.
• If a pre-authorization or referral is required for the procedures involved. (This is much more common in medical than it is in dental.)
  
  CMS-1500 Claim Forms Medical claims are billed using CMS 1500 claim forms (formerly HCFA-1500), which can be purchased from most medical or office supply companies. CMS-1500 forms are white with red print. As such, some medical carriers will only accept an original CMS-1500 claim form because duplicated claim forms may not scan correctly. Medical billing has become so common in dental practices, however, that many dental practice management systems have the CMS-1500 claim form and medical codes pre-loaded on their software.

Medical Pre-authorizations
Written medical pre-authorizations are generally discouraged. Unless the patient’s medical plan specifically requires one, offices rarely receive a reply. It is advisable, however, to take the time to inquire if procedures will be covered by a patient’s medical plan, but it is best to do so by phone. Some medical plans actually require a phone preauthorization before certain procedures are performed⁹.

Completing the Medical Claim Form
Completing the CMS-1500 form is relatively easy. The following overview highlights some of the basic elements of the medical form:

• Boxes 1 through 13 are similar to the patient information requested on dental forms. It is very important to spell all demographic information correctly. Spelling errors can increase the time it takes to get paid. Make sure to indicate in box 10 whether the procedures were related to employment or an accident. Box 13 determines where the payment will be sent. Be sure that you have the patient’s written authorization to have benefits assigned to you unless you have requested payment in full from the patient at the time of service.
• Boxes 14 and 15 are used to indicate when the symptoms first appeared.
• Box 16 is used for workers’ compensation claims and indicates days unable to work.
• Box 19 can be used to explain medical procedure codes (CPT) that end in 89 or 99. However, some explanations/narratives may require more space. If this is the case, a narrative letter can be attached to the claim form.
• Box 21 has four entries for indicating the diagnostic codes. These ICD-9 codes should be listed in order of priority with the primary diagnosis code listed first on line 1. Any secondary ICD-9 codes and/or V or E codes can be listed on the remaining lines.
• Box 24 has lettered boxes.
  a. Dates of service (If both the from and to dates are listed, then the number of days needs to be completed in field 24-G.)
  b. Place of service (the most common entry is 11 for office)
  c. Type of service (The most common for dental are "1" for medical care, "2" for surgery, "3" for consultation, "4" for diagnostic x-ray, or "7" for anesthesia.) Note: This field is not required by Medicare.
  d. List CPT Codes followed by any modifiers that might be necessary (or HCPCS "D" codes if the carrier recognizes them).
  e. List the line numbers (e.g. 1, 2, etc.) of the primary diagnosis code from box 21 that applies to each CPT code. Some procedures may have a different primary diagnosis code. For example, if a nightguard is delivered for bruxism on the same day that teeth are restored due to an accident, the primary diagnosis codes would be different.
  f. Enter the fee for each code
  g. Enter the number of days or number of services that were performed for a given procedure code, the number of anesthesia minutes, units of supplies, etc. If only one service is provided, the numeral "1" must be entered.
  h-k. These fields are rarely used.
• Box 25 – Enter the Tax ID number for the provider of service.
• Box 26 – The patient’s account number can be listed here.
• Box 27 – "Yes" is checked if you choose to have benefits assigned to you and for those plans with which you are contracted (e.g. Medicare). However, it is recommended that you have patients pay at the time of service unless your participating contract requires otherwise.
  • Box 28 – Enter the total of fees for this claim
  • Box 29 – Enter any payment received from a primary carrier
  • Box 30 – Enter the total of total of fees or the difference when the primary carrier payment is subtracted
  • Box 31 – Enter the provider’s signature and date
  • Box 32 – Enter the location of services if procedures were performed in a location other than the patient’s home.
  • Box 33 – Enter the practice billing address, phone number, and group number. If the insurance company has assigned the provider a personal identification number, place it in the PIN area of the box. Eventually, the NPI (National Provider Identifier) will be entered here.
  • It is advisable to attach a narrative to the medical claim form to explain the medical nature of the claim. Never write hand-written notes on the claim form because this can cause delays¹⁰. By the very nature of these claims, it is advisable to include a narrative with most claims. Remember to follow the K.I.S.S. principle (keep it short and simple). Staple the narrative to the right upper corner of the claim so as not to interfere with the barcode on the left.

Trauma Claims
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 carriers¹¹.

Always proofread the claim prior to submission to check for accuracy. It is a good idea to review the medical claim with the dentist to verify that you have selected the correct codes. After mailing a medical claim, it is important to promptly track it just as you track your dental claims. When benefits are received, review the explanation of benefits carefully. Payers may reduce payment levels or combine procedures. Denials may occur for no apparent reason or the carrier may indicate that the procedures submitted are dental, not medical. When submitting an appeal, it is crucial that you (or the patient) insist that the medical plan provide the exact contract language upon which its decision was based. Encourage your patients to handle their own appeals. Patients should be encouraged to contact their employer, plan administrator or insurance commissioner if they believe that their claim was denied unjustly.

As mentioned previously, it is always best to collect payment in full at the time of service when filing claims to medical. Kindly remind patients that you are processing their medical claims as a courtesy to them, and because it is a medical claim, benefits are being directed to the patient rather than the dental office. By requiring patients to pay in full at the time of service, they will take more responsibility to follow up on delayed or denied medical claims.

While you a short learning curve is to be expected when submitting your first few medical claims, it can be well worth the time and effort to submit claims involving trauma, oral surgery, periodontal disease exacerbating medical conditions, TMD, sleep apnea, and certain implant and laser procedures. Knowing how to bill medical-related dental services to medical insurance plans will ultimately benefit both your patients and your practice.

References:
1. Republic Data Information Systems: The Guide, Carrolton, TX, January 2000, p. 5
2. Rutledge RDH, C. and Landers, B.: Antimicrobial Delivery Systems, Contemporary
Oral Hygiene, May 2005, p 22
3. Rowell, J. and Green, M: Understanding Health Insurance, Delmar, 2002, p.101
4. Rowell, J. and Green, M: Understanding Health Insurance, Delmar, 2002, p.102
5. McGraw Hill: ICD 9 CM, New York, 1995, p.296
6. McGraw Hill: ICD 9 CM, New York, 1995, p.208
7. Rowell, J. and Green, M: Understanding Health Insurance, Delmar, 2002, p.169
8. Zahrebelny, O, Maximizing Medical Reimbursement in the Periodontal Practice, The
Z Group LLC, Lincolnwood, IL, 2004, p.1-3
9. Zahrebelny, O,: Maximizing Medical Reimbursement in the Periodontal Practice, The
Z Group LLC, Lincolnwood, IL, 2004, p. 1-5
10. Nierman, R: Medical Insurance Manual for Dentists, PenWell Publishing Company,
Tulsa, OK, 2005, p.137
11. Rowell, J. and Green, M.: Understanding Health Insurance, Delmar, 2005, p.278
12. Rowell, J. and Green, M.: Understanding Health Insurance, Delmar, 2005, p.13