What you need to know about medical-dental necessity

November 1, 2013

Dental practitioners have been hearing stories of paperless requirements in place by 2014 or 2015. Minnesota policymakers recently upped the ante when they voted to require dentists, oral surgeons, and orthodontists to adopt a certified, interoperable electronic health record (EHR) system, like their medical counterparts, by 2015.

Change is not coming. Change is here.

Dr. Charles Mayo nearly 100 years ago said dentistry is a branch of medicine. Interoperable EHR will join medicine to dentistry in ways we have never experienced. Routine determination and documentation of medical-dental necessity now can only bring benefit to our patients and our practice.

To quote Yoda from Star Wars, “Ready are you? What know you of ready? You must unlearn what you have learned.” The time is now.

Dentistry continues to evolve as the crossover evidence between medicine and dentistry emerges. Dentistry is no longer fixing teeth. It is dental medicine. To medically manage oral disease in our EHR world means determining medical-dental necessity, which is the responsibiliy of clinicians. Clinicians may find that EHR provides valuable data from patients medical conditions, history of prescription medicines, and potential drug interactions that had previously depended on patient self reporting.

In medicine, both procedural and diagnostic codes are used. Current Procedural Terminology (CPT) describes medical, surgical, and diagnostic services equivalent in dentistry to Current Dental Terminology (CDT) codes, except that dentistry does not yet have codes for diagnoses. In medicine, International Classification of Diseases (ICD) is used to code signs, symptoms, injuries, diseases, and conditions.

The critical relationship between an ICD code and a CPT code is that the diagnosis supports the medical necessity of the procedure. This is where dentistry is going with EHR interoperability. In dentistry, the ICD equivalent has not yet been decided but does not limit the determination of medical-dental necessity.

Medical-dental necessity isn’t as complicated as it might first appear. It is defined as:

  • Service provided is the most appropriate

  • Diagnosis is consistent with the symptoms

  • Treatment is consistent with the diagnosis

  • Treatment is not primarily for the convenience of the patient or provider

  • Treatment is good medical/dental practice

The idea of medical-dental necessity shouldn’t be foreign to dental clinicians. It simply requires documenting the reason a procedure is needed. For example, in the general description for the radiographic imaging section of CDT 2013, it states that radiographs, “should only be taken for clinical reasons determined by the dentist...”

A list that works in concert with this description is provided in the updated 2012 ADA/FDA work The Selection of Patients for Dental Radiographic Examinations guidelines. Currently, radiographs are often taken as part of a routine office visit. This is not a medical-dentally necessity (Yoda’s: You must unlearn what you have learned). A medical-dental necessity for a dental radiographic image can be as simple as previous periodontal or endodontic treatment. The reason the radiograph was taken must be documented.

Benefit carriers can request the reason for radiographs. An excerpt from a 2013 Delta Dental letter to a Rhode Island dental practice illustrates this point, “The number of X-rays your practice takes per patient is not only well above that of your peers but also contrary to ADA/FDA recommendations for radiographic examinations.” A documented medical-dental reason is all that is needed.

Dental clinicians must provide consistent methodical documentation of medical-dental necessity for coding. Coding is not limited to codes for insurance. Codes are the language of EHR. The time is now.