Has the following happened to you yet? The mail has arrived and is being opened. One of the envelopes is from an insurance carrier and appears to be a benefits check. But as you open it you are disappointed to see that there is no check. Instead, you are surprised as you read “This dental policy will consider reimbursement after the claim is submitted to the medical carrier for payment or denial”. Would those words give you a sinking feeling because you know nothing about filing a medical claim and you don’t know what you will tell this patient? What you realize is that you will have a very disappointed patient because no benefits will be paid at all without a medical claim and it may take a long time to be paid by that patient. Well, if this hasn’t happened yet, it soon will.

With the growing documentation on the link between oral health and overall body health1, more and more dental carriers are recognizing the medical nature of certain dental procedures. This increases the need to file those dental procedures with medical carriers while also requiring 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 prosthodontic procedures
• TMD procedures
• Sleep apnea appliances
• Oral cancer screening
• Any medically necessary exams and X-rays that are associated with the above procedures

There are some similarities between preparing a dental claim and 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 simply 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 and it can be said that 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 out-dated codes.

The medical claim form also has some major differences in relation 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 pre-printed, 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, you 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 and will be able 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.

You have now been given an overview of the medical coding system as it applies to dentistry. Look for my future articles in “The Observer” that will detail this process in more depth and will help you learn how to implement a dental-medical cross coding system in your practice.

¹ Oral-Systemic Health (Your Oral Health and Overall Health), Oral Health Topics A–Z, http://www.ada.org/public/topics/oralsystemic_gumdisease.asp, accessed March 5, 2008