Coding when dental procedures fall under medical guidelines

Sept. 28, 2009
Within the varied procedure mix of a dental practice there are many procedures that actually have a medical necessity. Without medical necessity, a dental procedure should never be submitted to a medical insurance plan, says author Marianne Harper.

By Marianne Harper

Did it ever occur to you that no one routinely asks you “why”? The “why” that I mention refers to insurance claims and whether you need to explain why you performed the procedures on a dental claim. Yes, you sometimes have to submit a narrative to explain this, but on a routine basis it is not required. Aren’t you lucky? Well, maybe I should say, “Aren’t you lucky … for now.”

The “why” of which I speak is answered with diagnosis codes. Physicians, medical examiners, and coroners have used a diagnosis coding system called the International Classification of Diseases (ICD) since the early 1900s. It was developed originally as a means to compile statistics on mortality.1 For many years, ICD was used by hospitals and was periodically updated to meet their needs. It was not until 1989 that physicians were required by law to submit diagnosis codes for Medicare reimbursement of outpatient procedures.2 Since that time, physicians have been using ICD codes routinely for all services and use the version ICD-9-CM (clinical modification). Today, diagnosis codes are used to describe the medical necessity of procedures and, in doing so, provide the following:
• Facilitation of payment of health-care services
• Evaluation of patients’ use of health-care facilities
• A way to study health-care costs
• Research on the quality of health care
• Prediction of health-care trends
• Planning for future health-care needs3

Obviously, ICD-9-CM is very beneficial to the medical community and provides much data through the use of its codes. Does it seem strange that dentistry has not been requiring similar information? After all, with the growing research into the oral/systemic link, dentistry is experiencing a paradigm shift and becoming, more accurately, the field of dental medicine. With this shift comes the need for dental practices to code medical claims for those procedures that are medically necessary now and, in the not-too-distant future, the need to report diagnosis codes for all procedures. So let’s explore both.

Within the varied procedure mix of a dental practice there are many procedures that actually have a medical necessity. Without medical necessity, a dental procedure should never be submitted to a medical insurance plan.

So let’s define medical necessity. The American Medical Association’s definition is threefold:
1. In accordance with generally accepted standards of medical practice
2. Clinically appropriate in terms of type, frequency, extent, site, and duration
3. Not primarily for the convenience of the patient, physician, or other health-care provider.4

There are actually many different definitions of medical necessity, and there is no single one that is accepted by all. One that I prefer to use and that I believe is very useful in helping us to determine whether we can submit a dental procedure to medical insurance is: “Medical necessity is defined as accepted health-care services and supplies provided by health-care entities, appropriate to the evaluation and treatment of a disease, condition, illness, or injury and consistent with the applicable standard of care.”5 In other words, these procedures must comply with recognized medical standards and be appropriate and necessary for:
• Diagnosis or treatment
• Prevention of a medical condition
• Improvement of a condition
• Rehabilitation of lost skills

Currently, there are many dental procedures that fall under these medical guidelines and that can and should be filed medically, and among them are:
• Examinations and consultations for orofacial medical conditions
• Many oral surgical procedures
• Medically necessary periodontal procedures
• Medically necessary implant procedures
• Procedures relating to oral dysfunction
• TMD procedures
• Procedures for myofascial pain conditions
• Medically necessary radiographs
• Trauma-related dental procedures
• Oral cancer screenings
• Sleep apnea procedures

In order to complete a medical insurance claim form for any of these procedures, you will need to use a CMS-1500 (08-05) claim form. This article is not meant as a step-by-step guide to completing that claim form but rather a teaching tool as to the “why” of diagnosis coding. I consider entry of diagnosis codes on the medical claim to be as important as the procedure coding (CPT codes) section because it answers for the insurance carrier all of the questions as to why the procedures were performed. Without a strong diagnosis code to support the procedure, a claim will not be paid. It is as simple as that!

The ICD-9-CM manual is huge. It is broken down into different classifications that are then designated by alpha-numeric codes that represent any known disease, condition, or circumstance that can result in mortality. These codes can be used for definitive diagnoses; secondary diagnoses; and signs, symptoms and ill-defined conditions. When choosing diagnosis codes for a dental procedure, one must first determine the primary diagnosis. The primary diagnosis is the “most significant condition for which services and/or procedures were provided.”5 Primary diagnosis codes can be followed by secondary codes if they apply, and then by signs, symptoms, and ill-defined conditions. A secondary code represents a condition that coexists with the primary condition, can affect the primary condition, and for which the patient is being treated. Signs, symptoms, and ill-defined conditions codes are used to designate exacerbating conditions pertaining to the primary diagnosis. The medical claim form provides space for up to four diagnosis codes.

Over the course of years, there have been multiple revisions to the ICD in addition to the yearly updating of the codes that involves addition, deletion, and changes to the code set. It is not a static code set.
At present, dental claims do not require any diagnosis codes on the claim form. We have been fortunate to be able to continue to file more simplified claim forms. That is not to say that we haven’t been diagnosing our patients, as we have had to form a diagnosis in order to treat a patient; but we just have not had to report that to anyone except when narratives have been requested. The diagnosis information should be readily available in the patient’s record. Let me quote Dr. Paul Bornstein, a retired dentist and former insurance company consultant: “If it ain’t written, it didn’t happen.” He states that this is the philosophy of insurance carriers and can cause many problems upon audit if a diagnosis is not recorded in the patients’ records. Therefore, make sure that you have a written or electronic diagnosis documentation for each patient.

You may ask if there is a diagnosis code set for dentistry. At present, this code set is in the process of being developed. It is called SNODENT (Systemized Nomenclature of Dentistry). SNODENT is a set of diagnostic codes that was specifically designed to serve the field of dentistry. It is “a comprehensive taxonomy that contains codes for identifying not only diseases and diagnoses but also anatomy, conditions, morphology, and social factors that may affect health or treatment. An examination of a partial listing of the codes provided by the ADA . . . shows that dentists can code not only the dental conditions but also concurrent medical conditions and risk behaviors (e.g., diabetes, smoking behavior) which might be expected to affect patients’ oral health and to influence treatment decisions.6 It is hoped that SNODENT will become an effective tool in enhancing the clinical practice of dentistry. It is also hoped that SNODENT will become a resource for both basic and clinical research into issues that involve oral health and the interaction of orofacial systems with other systems in the body. ”7

Just as ICD is not a static code set, I am sure the same will apply to SNODENT. Many sources have indicated that there are deficiencies in SNODENT at present that will require time to fix. Once it is put into use, I am sure that revisions will be necessary till any potential problems are resolved and, as conditions, diagnoses, and treatments change, so will SNODENT.

A further indicator that points to this change in dentistry is that our CDT evaluation codes state that the evaluations must include diagnosis and treatment planning, and these are the responsibility of the dentist. As you can see, it is mandatory that a diagnosis be determined and, at least, documented for now.

If you are wondering how diagnosis codes can benefit your practice, I have good news. First of all, diagnosis codes provide an easy way to accurately communicate your diagnoses with patients. Patients can be provided with a list of their diagnosis codes that will give them accurate detail. Diagnosis codes prevent miscommunication on diagnoses. Treatment plan acceptance can only increase when patients have an understanding of why they need to have recommended procedures performed. Secondly, once diagnosis codes have been used consistently in a practice over the course of time, dentists will be able to compare the outcomes of treatment to patients with similar diagnoses. And for dentistry in general, diagnosis codes can provide a means of accumulating data for studies that can lead to improvements in our patients’ dental health care.

Marianne Harper is the owner of The Art of Practice Management. Her areas of expertise are revenue and collection systems, front-desk systems, and dental-medical cross-coding. She is a well-respected speaker nationally, has been published in dental journals, and is the author of "CrossWalking -- A Guide Through the CrossWalk of Dental to Medical Coding." Harper is a member of The Academy of Dental Management Consultants and the Speaking Consulting Network. Her Web site is

1Colorado Dept. of Public Health, Brief Health Statistics Section, New International Classification of Diseases (ICD-10): March 2001, #41, 3/15/09
2ICD-9-CM, Ingenix, p.ii
3Step by Step Medical Coding, p. 396, 3-15-09, 3-15-09, 3-15-09
5Understanding Health Insurance – A Guide to Professional Billing”
6, 3-19-09, 3-15-09