Cross-Coding Dental and Medical Procedures

As more employers are offering embedded medical plans with family deductibles, and medical benefits are required for everyone under the age of 19, experts agree that dental practices will soon need to cross-code. Even though training staff to use a new coding system can be initially time consuming, practices that plan ahead and become proficient in billing medical insurance will be in demand.

Accepting medical insurance allows offices to serve their patients and increase their client base. Making procedures and appointments more affordable will encourage routine oral healthcare, ensuring that potential issues are diagnosed early. In addition, practices will receive more reimbursements for regular and preventive care.

“More and more practices are moving into the medical world of billing because dental insurances are informing them that certain procedures are medical services—and they need to be able to bill medical,” says Christine Taxin, president of Links2Success. For example, dental insurance policies are advising dental practices to bill to medical insurance for procedures such as extractions, TMD treatment, sleep apnea treatment, and patients needing collaborative treatment between a dentist and medical doctor. Currently, there are four medical billing code categories for dental procedures:

• Diagnostic procedures include any diagnostic procedures that are medically necessary to determine a cause of pain—whether an infection or some other dental disease is present or the patient has congenital dental deformities.
• Dental surgery includes tooth extractions due to injuries or underlying diseases. Additionally, biopsies and excisions of hard and soft tissues in the mouth are usually done for medical reasons and thus can be billed under surgical codes on medical insurance. Implant and other surgeries involving hard or soft mouth tissues are also medically billable.
• Nonsurgical medical treatment of dental issues incorporates treatment for abscesses and infections. Tooth restoration treatment for people with eating disorders can also be billed this way. And, while most dental policies will not cover them, appliances for TMJs, sleep apnea, and tooth grinding are considered medically necessary and can be billed through medical insurance plans.
• Treatment of oral injuries are covered when teeth and surrounding tissue are injured in any kind of accident. This billing code can also cover tooth restoration, implant placement, and tissue repair.

These codes may be billed to a medical insurance policy if the dental policy either does not cover the procedure or covers too little of the overall cost, depending on the patient’s circumstances. Most dental insurance plans have yearly caps on what they will pay, usually about $1,000 or $2,000 per year, which means that for many patients, especially those with severe dental issues, the amount will not be enough to cover their procedures in a given year. Accepting medical insurance may make it possible for these patients to get the dental treatments they need.

Cross-Coding Advantages

Medical-dental cross-coding can open up new opportunities to treat patients. “Technology has really been driving innovations in the dental field, allowing general dentists to provide life-changing treatment to patients,” Kaveh Ghaboussi, DDS, explains. “In turn, dentists have been looking for ways to help patients afford this life-changing dentistry. This has led many dentists toward billing medical insurance for certain procedures.” According to Ghaboussi, medical billing has several distinct advantages:

• Any procedure that can be paid by medical will leave more of the patient’s dental insurance for treatment of their dentistry.
• Medical insurance often pays differently than dental insurance, and may pay more for certain procedures.
• Procedures that practices typically cannot bill to dental can sometimes be submitted to medical insurance, such as tobacco and nutritional counseling.

What’s Stopping You?

Although the opportunities to bill insurances are available, lack of knowledge on what is covered is holding back practices. “In the dental world, without even going into medical billing, what they’re missing is the additional benefits patients have under their existing dental plans, or medical benefits of patients who are under the age of 20,” Taxin says. “Any patient with diabetes is entitled to two more dental visits, but unless the patients know that—and the office knows it—you can’t take advantage of that opportunity. You need to know the patient’s medical history, and the patient needs to think of us as oral physicians instead of dentists.”

As an example, Ghaboussi cites the growing interest in sleep apnea treatment. “A few years ago the general public was unaware of health risks of sleep apnea, but now it’s uncommon to find anyone who hasn’t heard of it,” he says. “The key point is that most of the people with sleep apnea do not have a clinical diagnosis and certainly are not being treated for it. This is one of those life-changing treatments that we, as general dentists, can do for our patients that can save lives. Most of the process of diagnosing and treating sleep apnea can be billed by a dental office, such as exams, diagnostic records (including cone beam), and even oral appliances.”

Becoming an office that accepts both medical and dental insurance offers an array of benefits for the practice, by helping patients get the most out of their insurance while minimizing out-of-pocket expenses. Ghaboussi admits that starting out in medical billing can be difficult, therefore he recommends hiring a company to help dental offices begin the process.

According to Taxin, practices need to learn the diagnostic codes for the treatment they provide. “Not every plan will require diagnostic codes, but every plan is going to require you to tell them the diagnostic tool, the reason, and the outcome—that’s the difference.”

“Patients who have systemic infections or autoimmune diseases are being told to go to their dental physician four times a year,” she adds. “Patients who have been diagnosed in the medical world become patients in the dental world. In fact, ICD-10 has specific, distinctive diagnostic codes for Diabetes and Perio, Diabetes I and Perio, and Diabetes II and Perio.”

Final Considerations

To ensure that appropriate billing codes are selected, procedures, medicines, diagnostics, and services should be carefully examined. In complex cases, some codes may be purely dental, while others are deemed medically necessary and submitted to the patient’s health insurance. When billing through health insurance, it’s important to demonstrate why and how the procedure will affect the patient’s overall health.

Clinicians planning to pursue medical billing for dental procedures should be sure they have all the resources necessary for successful reimbursement. The process can seem complicated at first, but any team can learn to navigate the process and start saving their patients significant amounts of money while providing comprehensive care.