By Marianne Harper
It used to be so simple – your practice is dental and you filed dental claims for dental patients. You only thought about medical claims when you had medical procedures performed by your doctor. Well, times have changed. If your practice is not up-to-date on the latest in insurance filing systems, then you could be losing money and/or delaying reimbursement.
From many dental practices, the following is what I hear when they first discuss filing cross coded medical claims:
• It’s not worth the trouble
• It’s too difficult
• It’s too costly to implement
• It never pays
• There’s not much that it will cover
…and on and on!
As a dental-medical cross coding specialist and trainer, these are the type of comments that I deal with much too frequently prior to training. Sadly, this represents the negativity associated with implementing cross coding in dental practices. Let me dispel those myths and show you how you can create a win-win situation for your patients and your practice by implementing cross coding.
Over the last decade, there has been ongoing research into the systemic link and, as a result, dentistry can now be seen more as the field of dental medicine. The medical community has embraced this model by incorporating many more dentally related conditions in their coding systems, thereby recognizing the medical nature of certain dental procedures.1 Within the dental community, many of the oral and maxillofacial surgeons have been successfully filing with their patients’ medical plans but very few general practices or other specialty practices have taken advantage of this opportunity. Some have tried to give it a go by attempting to figure it out on their own, but with poor results. To successfully cross code, one must understand what can be filed medically and how it should be done correctly.
So let’s look at those negative comments by starting with “it’s not worth the trouble.” If we consider the “trouble” to be learning and implementing cross coding, we need to take a big step back to when we all had no knowledge of how to create a dental claim. What did we have to do? We had to learn how to do it by some or all of the following methods: learning from fellow coders, reading manuals and articles, and taking courses. Then, through experience, we excelled at the process. Our patients are grateful that we do this for them. As individuals, we too are grateful when our medical practices file claims for us. We must realize that those medical staff members had to do the same thing as we did with regard to learning the process. So, basically, if they can do it why can’t we? Yes, it means learning a second insurance filing system but it can definitely be worth the “trouble”.
“It’s too difficult” is our next myth to dissect. Granted, medical insurance is more complicated than dental insurance. One major difference between the two at present is that medical carriers always require the use of at least one diagnosis code to explain why a procedure was performed. Hence, more than one coding system is required. Be aware that dental insurance requirements will be changing in the coming years by also requiring the use of diagnosis codes.2 The answer to eliminating the difficulty in cross coding is to learn how to do it correctly. Cross coding manuals, lectures, webinars, and on-site training are the methods that I use to help dental practices excel in medical coding. Taking advantage of one or more of these options is your answer to eliminating “difficult” from the implementation.
In these economic hard times, we appreciate being able to make improvements to our practices that are not costly. Implementing cross coding is one of those that won’t incur much added cost with regard to the software that will be needed. Most of the practice management software that is available today has a medical cross coding component that is already part of the package or can be obtained as an additional component that must be purchased. From what I have heard, those that charge for the extra component bill a nominal fee. If your practice management software does not have such a component, there are other sources of software that can be used for medical claim form completion such as www.ub-92software.com/hcfa.php (must be purchased but not high priced) or www.availity.com (free). Aside from the software, additional costs will include the purchase of the annual code updates and the purchase of medical claim forms.
Have you heard individuals from dental practices state that they never get paid for their medical claims? I, too, have heard that statement but I want you to know that it’s not the case. Dental practices that have learned how to cross code correctly are receiving successfully paid EOB’s. We must be aware though that not all procedures are going to be covered by all insurance plans. My recommendation is to always call the carrier to determine if benefits are available for the procedure(s) and if a pre-authorization is needed. By preparing in this manner and by submitting accurate claims, your chances for successfully paid medical claims is greatly improved.
Keep in mind that only medically necessary dental procedures are those that should be submitted to medical carriers. Medically necessary basically means that the procedures must be appropriate and necessary for diagnosis or treatment, prevention of a medical condition, improvement of a condition, or for rehabilitation of lost skills.3 The medical history form that you use in your practice should be a great tool to show which patients have diseases or conditions whose dental procedures could be considered medically necessary. These forms should be completed again every three years to keep your patients’ records up to date4. Such procedures could be any of the following:
• Trauma procedures
• Medically necessary oral surgical procedures
• Medically necessary periodontal procedures (and this should only continue to grow with continuing research into the oral systemic link)
• Medically necessary implant procedures (trauma, loss of teeth due to a medical condition, or patients with bone atrophy that results in dentures that won’t seat correctly, resulting in difficulties with chewing and nutrition)
• Medically necessary endodontic procedures (trauma or a medical condition that caused the need for the endodontic treatment)
• Medically necessary prosthodontic procedures
• TMD procedures
• Sleep apnea appliances
• Oral cancer screening
• Any medically necessary exams and X-rays that are associated with the above procedures
In addition, patients who are medically compromised by diseases or medical conditions may need dental treatment such as follows:
• Patients needing radiation treatment
• Patients with medical conditions such as diabetes, heart disease, pregnancy, hormonal conditions, Parkinson’s disease, Alzheimer’s disease, dry mouth, etc.
• Patients taking medications such as Dilantin or insulin
• Patients needing dental clearance prior to certain surgeries
The whole practice can participate in determining which patients might be candidates for medical claims by asking the right questions and reading the responses to the medical history forms. You should be able to see that there can be a good number of your patients and procedures that fall under these categories. You can significantly help your patients afford their medically necessary dental procedures and this results in patients who will speak very highly of your practice to their family and friends – thus it becomes a great marketing tool.
Some dental carriers are now requiring dental practices to file certain dental procedures (e.g. third molar extractions) with the patient’s medical plan prior to the dental plan considering the claim. If you receive one of these letters and don’t know how to complete a medical claim form, how will you obtain any insurance benefits for the patient at all? This makes for some unhappy patients!
So I ask you: “What’s holding you back?” The myths have now been dispelled and replaced with good reasons to implement cross coding. There is also one significant plus to filing with medical plans that should be considered and that is the fact that there rarely are any annual maximums. In addition, you may consider adding some additional procedures to your practice’s procedure mix such as non-surgical sleep apnea procedures. With a diagnosis of obstructive sleep apnea established by a sleep study, many medical insurance plans have been covering oral appliances for mild to moderate cases of sleep apnea, including Medicare5. Medical cross coding can definitely help the practice’s bottom line.
Consider this quote by Winston Churchill, “A pessimist sees the difficulty in every opportunity; an optimist sees the opportunity in every difficulty.” So let’s add some optimism to our practices by embracing medical coding as an opportunity to help our patients afford their medically necessary dental procedures which in turn will help them achieve greater levels of health and will also help our practices achieve greater levels of financial health.
1. ICD-9-CM, (Los Angeles, CA: PMIC, 2011), PP 453–464
2. Goldberg LJ, Ceusters W, Eisner J, Smith B, The Significance of SNODENT, http://www.ncbi.nlm.nih.gov/pubmed/16160346 , (September 25, 2011)
3. Physician’s News Digest, What is Medical Necessity, http://www.physiciansnews.com/law/802.miller.html, (September 11, 2011)
4. Dianne Glasscoe-Watterson, RDH, BS, Medical History Update Dilemma,
www.professionaldentalmgmt.com/pages/documents, (September 25, 2011)
5. Medicare Coverage for Oral Appliances for Patients with Obstructive Sleep Apnea, http://www.aasmnet.org/articles.aspx?id=1066, (September 25, 2011)
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].
By Marianne Harper