Dentists perform many procedures. But which ones have possible medical coverage? Dr. Olya Zahrebelny shares what her years of experience have taught her about medically billable procedures with a comprehensive list. Continue below to find out more.
When used appropriately, medical billing can benefit both you and your patients.
I’ve learned a thing or two during my years as a practicing comprehensive dentist and on the inside as a consultant. As a result, I have compiled a list of procedures billable to medical plans, accordingly titled "Dr. Z’s Top 10 List of Medically Billable Procedures©". They are as follows:
1. ANY traumatic injury to the mouth, whether dental or oral and treatment thereof.
2. Exams for Soft and hard tissue PATHOLOGY
·Exams and consults in preparation for SURGERY
·Exams and Consults also include screening exams for oral/maxillo-facial cancer
3. Emergency treatment of oral inflammation or infection
4. Diagnostic, radiographic, or surgical stents
5. MEDICAL Radiographs
·MEDICAL radiographs are those in which most of the film shows structures other than teeth.
6. Biopsies and excisions
7. Extraction of teeth: wisdom teeth, supernumeraries, mesiodens, ankylosed teeth, exposure of impacted teeth. ANY teeth, if traumatic injury is the cause. Additionally, extractions may be covered when performed at the request of an MD prior to specific surgeries.
8. Any SURGICAL procedure needed to:
· rebuild or reconstruct alveolar or jaw bone due to bone loss/destruction or
· treat an infection
9. Prosthetics: interim prosthetics when ANY surgery (elective or emergency) is performed for both interim and defininitive prosthetics:
· when treatment is for a traumatic injury
· if there is a medical condition that involves the teeth, such as Ectodermal dysplasia, meth addiction, bulimia, etc., or
·when medical treatment has affected the teeth i.e. medication-induced, chemo and/or radiation;
10. Appliances: any removable or fixed appliances used to treat ANY dysfunction, i.e. nightguards, TMD orthotics, palatal expansion, habit breaking, sleep apnea, etc.
What are the advantages of accessing medical benefits for my patients?
Let me first clarify that, as far as oral/dental procedures are concerned, the biggest advantages are ones medical plans have over dental:
· No procedure limitations (with very few exceptions)
· No calendar year maximums
· No lifetime maximums
The benefits to your patients include:
· the ability to undergo “medically necessary” procedures that dental plans don’t cover
· increased coverage by accessing both dental and medical plan benefits
· lower or no out-of-pocket expense for necessary treatment.
Dental insurance calendar year maximums ($1000/$1200/$1500) have not increased since the introduction of dental benefit plans in the 1950s. In the meantime, premiums skyrocketed, our professional and lab fees increased and procedure limitations became more restrictive. Case in point: when I started practicing, the average fee for a prophy was $25, for a crown $200. Full mouth radiographs could be taken once a year, restorations replaced every 24 months, fixed and removable prosthetics every 5 years.
That is definitely not the case now. So what does dental insurance currently cover? A whole lot of nothing, as far as I’m concerned. And dental benefits are decreasing yearly — the “Deltas” now require that you first bill the patient’s medical plan for surgery, appliances and the removal of pathology. It is anticipated that these benefits will be excluded altogether from their dental plans, meaning higher premiums, fewer covered procedures and more restrictions.
Does dental insurance sound like a good plan to have? In this case, some insurance is not better than no insurance. I advise patients to buy better medical insurance, drop their dental coverage and set up an HSA instead.
What determines “medical necessity”?
“Medical necessity” requirements vary from one commercial insurer to another. What medical necessity means is not that the patient must have a greater medical issue (T2D, CA, etc.), but that the severity of the presenting oral or dental problem is the determining factor. For instance, the loss of one tooth may not be covered for replacement but the loss of several teeth in a jaw would.
Medicare “medical necessity” requirements are stricter and benefits more limited, which is true for any taxpayer-subsidized government program.
Must I be a participating medical provider in order to bill medical plans?
First of all, it is important to note that if you are a participating (Par-) or preferred provider for a dental plan, that does not automatically make you one for a medical plan, with few exceptions, such as Blue Cross/Blue Shield (BCBS). Becoming a Par- provider for any commercial insurance plan is neither encouraged nor recommended because not only are the benefits paid to Par- providers much less, but you must also write off the difference between the allowable benefit and your fee, which can range from 10 to 90 percent of the billed charge. This clearly is not good from a business standpoint.
How do I access medical benefits for my patients?
Medical billing requires familiarity with two code sets, ICD-10 for diagnosis coding (the presenting condition(s)/symptoms and reason for the procedure(s)) and CPT for treatment coding. Dental codes are not acceptable, except in rare circumstances, like billing extractions when traumatic injury is involved, and only by specific insurers.
In addition, the dental claim form cannot be used. All procedures requiring pre-certification must be submitted to Medical Review with a head and neck evaluation, LMN and other supporting documentation, when required (not on a claim form), and completed procedures must be submitted on a medical CMS-1500 (02/12) claim form with accompanying documentation.
Documentation requirements for all surgical and prosthetic procedures include the submission of a comprehensive head and neck evaluation and letter of medical necessity from the treating dentist. If the patient also has medical issues that contribute to, or exacerbate, the oral condition, then a copy of the treating physician’s progress notes is also recommended. For TMD or OSA appliances, the respective report is also required. Surgical procedures necessitate the inclusion of an operative report.
Medical billing by dental offices requires a different approach to the presenting oral and dental issues and problems. The dentist must approach the patient from a whole body perspective, then zero in on the head and neck and oral cavity. You cannot work with blinders on and only focus on the mouth and dentition. Yes, it takes a little longer for that first appointment or evaluation, but the results are very much worth it when you start receiving checks from medical plans for amounts that you have only dreamed.
You will never again hear, “let me think about it,” nor will you have patients who were just too embarrassed to admit they could not afford treatment but scheduled anyway. Your patients will be your best marketers, spreading the word to their family members, friends and co-workers. Just ask our Z Group clients about the difference it has made to their practices all over the U.S over the past 22 years!
Dr. Olya Zahrebelny (pronounced Zara-bell-knee) graduated from the Faculty of Dentistry at the University of Toronto, Canada, and completed a General Practice Residency, focusing on oral surgery, oral medicine, and oral pathology. She has practiced in both hospital and private practice environments for the past 39 years. Dr. "Z “is a former consultant to commercial and government insurance programs. She has also taught at three dental schools, as well as holding the position of Attending Physician at Swedish Covenant Hospital in Chicago, a Northwestern Memorial Hospital affiliate, for 19 years, and also an Attending Physician in the General Practice Residency program at the University of Illinois, Chicago Medical Center.
Dr. Zahrebelny has lectured extensively throughout the US and abroad at all the major dental meetings. Her book, "Accessing Medical Benefits in the Comprehensive and Surgical Dental Practice" has now been in print for 18 years, with yearly revisions, edits, and updates.
Dr. Z is a comprehensive general dentist and a Principal in The Z Group, a practice management consulting company. She provides group and in-house courses on medical billing to general dentists and specialists. She can be reached at thezgroupllc.com.