By Marianne Harper
Have you watched Dr. Oz lately? Recently I decided to record some episodes of Dr. Oz so that I could catch some of his healthful tips and tricks. What I have noticed is that the majority of these episodes had a great concentration on ideas to aid weight loss. Today I was shopping at one of the many discount pharmacies in my hometown and I noticed that the book rack was full of weight loss books. So it appears that with all of this information we should all be slim. Yet, the statistics on obesity in America are astounding. Fox News reports that more than one-third of Americans are obese, not just overweight. Being overweight or obese raises the risk of heart disease, diabetes, some cancers, arthritis and other conditions. This is a very serious situation with little change occurring at present. However, dentistry at least can play a part in helping diabetic patients.
Dentistry over the last decade has become much more involved with overall body health and has the possibility of making a huge difference, especially where diabetes is concerned. Our patients who routinely stay on their recare schedules tend to see us more than they see their primary care physicians. This gives dentistry a greater opportunity to screen their patients for diabetes. “It’s been estimated that 5.7 million Americans with diabetes were undiagnosed in 2007 with the number expected to increase dramatically in coming years.”1 Add to that, the National Health and Nutrition Examination Survey (2003-2004) determined that 93 percent of subjects who had periodontal disease were considered to be at high risk for diabetes and should be screened for diabetes.2 These facts should be a wakeup call for dentistry. Dentists can be evaluating patients for risk factors of diabetes such as being overweight, having high blood pressure, having a history of high cholesterol, belonging to a high risk ethnic group, having a history of gestational diabetes mellitus, having a history of delivering a baby weighing greater than 9 pounds, patients who are age 65 or older, or having a family history of diabetes.3
Type II diabetes, the non-insulin dependent type, now accounts for 95 percent of all cases of diabetes. In addition, there has been quite an increase in cases of type II diabetes in children, as child obesity levels have risen dramatically. Pediatric dentists should be monitoring their patients closely for this.
There is another significant reason why dentists should be screening their patients for diabetes. We in the dental field have been treating our perio patients with the assumption that there is a cause and effect relationship between diabetes and periodontal disease, with diabetes being the cause. We don’t often consider the reverse, that periodontal disease might have an influence on the diabetic patient. Due to the fact that periodontal disease is a very common chronic bacterial infection that causes inflammation, it may be that periodontal disease can exacerbate diabetes. “The bacterial and inflammatory products from the diseased periodontal tissues can enter the bloodstream and induce greater insulin resistance in a variety of tissues in the body.”4 Therefore, our perio treatments may have a part to play in improving the diabetic patient’s condition.
Earlier diagnosis and secondary prevention efforts may help to prevent the long term complications of diabetes. You may ask what tools are available for dental practices to screen their patients for diabetes. After reviewing the patient’s health history with a consideration of the risk factors already mentioned, dentists can use a glucometer. The glucometer will provide a blood sample either from a finger stick or from a periodontal pocket. A study published in the Journal of Periodontology (June 2009) showed that there was very little difference in the results from either type of test. Our patients may actually be much more comfortable with a blood sample taken from the periodontal pocket as it is less invasive and they are used to dental staff working in their mouths. Healthy Heart Dentistry, Inc. is one company that offers a diabetes risk assessment kit that can be useful for diabetes testing.
We can also help our patients better afford diabetes testing by filing these tests with their medical plans. Practices that are familiar with dental-medical cross coding should easily be able to add the medical codes for this type of screening. For those practices that are not familiar with cross coding, now might be the time to jump on board. There actually are quite a few dental procedures that can be filed with a patient’s medical plan. The bottom line is that the procedure must always have a medical necessity. Examples of such procedures are:
- Many oral surgical procedures
- Reconstruction due to trauma or genetics
- Endodontics required due to trauma or a medical condition
- TMD procedures
- Sleep apnea treatment
- Implants due to loss of teeth as the result of trauma, a medical condition; or severe bone atrophy that results in difficulty with mastication and getting good nutrition
- Perio therapy for medically compromised patients (patients with medical conditions that affect oral health or who take medications that affect oral health)
- Exams, radiographs, diagnostics, and consultations that are needed for any of the above medically necessary treatments.
By implementing cross coding in our dental practices you can make a significant difference in helping your patients afford these types of procedures. Acceptance of treatment plans will increase with cross coding and, in addition, cross coding can become a good marketing tool for dental practices.
One of the major differences between medical and dental coding is that medical carriers always require proof of why any and all procedures were performed. The proof comes in the form of diagnosis codes (ICD-9-CM codes). When coding a diabetes screening test for a patient that has not been diagnosed yet, you will need to use the diagnosis code V77.1 (screening for diabetes mellitus) but if the patient has a history of diabetes, you would use the appropriate diabetes diagnosis code which will fall in the 250.** range of diagnosis codes. You can contact the patient’s primary care provider to obtain the correct code for the patient.
Other diagnosis codes may apply such as 278.00 (obesity, unspecified) or 278.01 (morbid obesity), or V12.50 (personal history of unspecified circulatory disease). By using appropriate diagnosis codes, the coder is describing the full condition of the patient.
Procedure coding is what you will do next. If you want to report the office visit, use an evaluation and management code. For a new patient you will probably want to use 99202 (new patient expanded problem focused) and if it’s an established patient you would need to choose from 99211 (problem focused evaluation and management) and 99212 (expanded problem focused evaluation and management) and your choice will depend upon the time spent with the patient and the complexity of the medical decision making. There are higher level evaluation and management codes available but the criteria established for using them is usually beyond the scope of practice for dentists. Next you will need to code the test. If the dental practice only draws the blood and sends the blood to a lab to be tested, the correct procedure code (CPT code) would be 36415 (blood draw) and the lab would submit a claim for the test analysis. However, if the dental practice processes the blood sample, check with the company that supplies the testing device to determine the correct CPT code to use.
There is no guarantee that diabetes testing will be covered by each patient’s medical plan. Calling the carrier may be the solution to determining whether there will be benefits available.
Resources are limited to help your practice learn to cross code. I can definitely help your practice make the transition to implement dental-medical cross coding by offering several great tools:
- An all inclusive cross coding manual, “CrossWalking – A Guide Through the CrossWalk of Dental to Medical Coding”
- My eBook series, “Abra-Code-Dabra,” which provides cross coding information for: sleep apnea procedures , TMD procedures, and dental trauma procedures
- I offer on-site training to meet your practices specific needs
- My lecture on cross coding, available on CD, is also available as an easy way to attend my seminar
- And a website full of helpful information is http://www.artofpracticemanagement.com
Many dental practice management software programs provide a cross coding component, so there doesn’t have to be a large investment in implementing cross coding. Out-sourcing of cross coded claims is also available to make the implementation even easier. Dental Medical Billing, Inc. offers this service (914-450-2906 or 252-637-6259) or you can email me at [email protected] or Mark Wilson at [email protected].
So let’s really make a difference in our patients’ lives. We need to re-evaluate our protocols in treating these patients to be sure that they include evaluations and testing for diabetes, thereby being proactive in helping our patients achieve a healthier state. Let’s also implement a cross coding system to help these patients better afford these tests and any other medically necessary dental procedures. Helping them will definitely help us.
1, 2. James, Christopher; Futurity, Diagnosing Diabetes in the Dental Chair, Retrieved May 21, 2012 from www.futurity.org/health-medicine/diagnosing-diabetes-in-the-dentist-chair
3. Medical Learning Network, retrieved on May 21, 2012 from www.cms.gov/mlnmattersarticles/downloads/SE0821.pdf
4. Dr. Mark Ryder, Diabetes and the Periodontal Patient, Retrieved May 21, 2012 from http://www.dentalproductsreport.com/dental/article/diabetes-and-periodontal-patient
For more information relating to this article, please contact Marianne Harper. Marianne is the owner of The Art of Practice Management, a dental practice management consulting company. Revenue and collection systems, business office systems, and dental-medical cross-coding are her specialties. Marianne is a member of The Academy of Dental Management Consultants, The Professional Management Consultants Association, Speaking Consulting Network (SCN), and CareerFusion. She is a published author and a well-respected speaker. You can reach her through www.artofpracticemanagement.com or through the SCN website, www.speakingconsultingnetwork.com or you can contact Marianne directly by phone at (252) 637-6259, (252) 670-0403, or by e-mail at [email protected].