Christine Taxin is the founder and president of Links2Success, a practice management consulting company to the dental and medical fields. Prior to starting her own consulting company, Taxin served as an administrator of a critical care department at Mt. Sinai Hospital in New York City and managed an extensive multi-specialty dental practice in New York. With over 25 years of experience as a practice management professional, she now provides private practice consulting services, delivers continuing education seminars for dental and medical professionals and serves as an adjunct professor at the New York University (NYU) Dental School and Resident Programs for Maimonides Hospital. She can be reached through www.links2success.biz.

Christine Taxin

	If you want to serve your patients and help them afford the treatments they need, it’s time to start using ICD-10-CM diagnostic coding in your dental office.

	Proper coding means that medical insurers may pay for your patients’ treatments. If you’re used to CDT codes and have never dealt with medical insurers before, using 

 may seem like an intimidating change for you and your staff. Here are a few simple steps you can take to jumpstart diagnostic coding in your dental office.

Related article: 4 benefits of using gingival inflammation code D4346

	1. Get training for a least one member of your billing team

	Changing from the CDT to the ICD-10-CM is a major shift in terms of thinking, and your billing staff is the group most affected by the transformation. Schedule training for the people most likely to be dealing with medical insurers. While some practices do try to self-teach, you’ll have a smoother transition and more effective billing if you begin the process with training for your team.

	2. Explain coding to the rest of your staff

Diagnostic coding is the language of medical insurers and medical doctors. By adopting it, your staff makes it possible to explain their work to a larger audience. This, in turn, will help your patients receive better care.

	3. Emphasize the oral-systemic health link

	The reason medical insurance pays for some dental procedures is because 

there’s a link between oral health and whole-body health

. If you teach your staff about this link, they’ll be more willing to take on the new tasks associated with medical diagnostic coding.

	If patients have medical conditions like pregnancy, diabetes, high blood pressure, heart disease or cancer, then their dental health can have an outsized impact on their whole-body health. Take time at intake to get a complete medical history, since these conditions affect how you use diagnostic codes.

	5. Talk to your patients about their health and listen to them

	Diagnostic coding is a way to tell a story to insurers. To bill medical insurers, you need to be able to show that a condition has real, negative effects on your patient’s life and health.

Related article: What 2018 means for insurance coding

	For instance, if a patient’s dental problems are making it difficult or impossible to eat appropriately, that’s an important piece of the story. If a dental infection is also causing pain, or if there seem to be related sinus issues, those parts of a patient’s experience are important. Part of documenting medical necessity is documenting the suffering caused by a condition, and the only way you can get a sense of suffering is to ask questions and listen to what your patients have to say.

	6. Train your hygiene team to spot and flag possible medical issues

	Your hygienists can be valuable partners in using diagnostic coding in your practice. Certain infections, bleeding gums and sensitivities may be signs that a patient might be better served by ICD-10-CM coding than by CDT codes, especially if the patient has other medical conditions. A good hygienist will spot these issues and draw your attention to them so that you can address them during your portion of the exam.

Related article: Medical billing for dental surgery: What you need to know

	7. Use ICD-10-CM codes whenever possible

	Learn the ICD-10-CM codes most likely to show up in your practice and post a list in each patient bay. When you’re making notes on during examination, write in any codes that might apply. That will help your billing staff apply the codes and bill medical insurance.

	With these seven quick steps, you can quickly make the shift to ICD-10-CM coding and medical billing in your dental practice. The change will open new routes of treatments to your patients, since medical insurance will cover many treatment options in cases of infection, pain or impacted ability to live a normal life. By implementing ICD-10-CM diagnostic coding and medical billing in your practice, you can continue to serve patients as an independent dental practice in a challenging environment.

Articles

How you can navigate the sometimes intimidating world of medical billing.

7 simple steps to jumpstart diagnostic coding in your office

	Sometimes, one of the most difficult parts of performing dental surgery is helping your patients figure out how they’re going to pay for it.

	You see a deteriorating oral health situation that 

, but they’re focused on the cost of the procedure. Unless you can find a way to help them pay, you’re not going to be able to solve their problems.

	Medical billing for dental surgery can make it easier for your patients to afford treatment. Dental insurance often has very low benefit caps. Meanwhile, if a surgery is medically necessary, medical insurance may reimburse for nearly 70 percent of the cost. When you add medical billing capabilities to your office, life gets easier for your patients. However, making the switch means changing how you think about necessity.

	To receive reimbursement from medical insurers, you need to make a case that proves that dental surgery is necessary for the patient. To make your case, you need to explain your decision process in terms that a medical insurer can understand, using 

 codes and CPT codes. These codes may appear similar to the 

 codes that you’re familiar with, but they’re more detailed and take time to learn.

To succeed in your medical billing claims, you’ll need to document:

		The diagnostic code for the treatment you plan

		Medical Necessity, in the form of a letter of medical necessity

		Support from the patient’s Primary Care Physician, in the form of a supporting letter of medical necessity

		The procedures performed at each surgery location

	This information lets you give the medical insurance company a complete picture of the care you’ve provided. It makes a compelling case that the issue you treated was a medical issue, not simply a dental one, and that it should be eligible for reimbursement by the patient’s medical insurer.

	You’ve probably dealt with pre-authorization in your own life, with your own family. It’s usually fairly easy to contact the insurer by phone, explain the procedure and the date, and receive pre-authorization for treatment.

	While some insurers will provide retroactive pre-authorization after the fact, the surgeries you’re performing don’t happen on a moment’s notice. Have your office call for pre-authorization when the surgery is scheduled. Being proactive on pre-authorization will save you and your patients headaches later on and can make the difference between the acceptance and rejection of a medical claim for dental surgery.

	When you contact the insurer, you should also collect information on what coverage your patient has and how the insurer will reimburse for surgery. It’s essential that you get information on co-pays and deductibles upfront, so you can help your patients plan for their part of the cost.

	In the Letter of Medical Necessity (LMN) you have a chance to outline your case for surgery. You must use ICD-10 codes properly in this letter, or the insurer won’t accept your reasoning and will not pay for the surgery. In general, you should limit yourself to four diagnostic codes in the letter. List the codes in order, from the most important to the procedure to the least important. For instance, you might start with periodontal disease, but also mention the patient’s heart disease and Type II diabetes, since these conditions both complicate the surgery and make treatment more urgent.

	You can also expand, in writing, on other contributing factors from the patient’s medical history. For instance, a root canal may be related to an earlier auto accident, or tooth loss may be complicated because of a past history of cancer.

	The process of choosing codes can be confusing, but often it’s simply a matter of telling a clear, accurate story. For instance, consider implants. The insurer wants you to answer two main questions about medical necessity. First of all, you have to explain why they lost the tooth. In general, the cause is either going to be an accident or bone loss. Then you need to explain why the tooth must be replaced. Usually the reason is either that they’re suffering a loss of function or that tooth replacement is covered because of some other medical condition, such as cancer.

Related article: Are you overlooking your most valuable practice management asset?

	In addition to your LMN, it can be helpful to get a supporting letter signed by your patient’s PCP. This provides the insurance company with more evidence that your procedure is necessary. Remember, you’re trying to build an ironclad case for your treatment plan, so that the insurer understands that treatment is necessary and that your treatment addresses the patient’s problems.

	Filling out a claim form: tricks of the trade

	When you reach the Medical Claim form, there’s a right way and a wrong way to fill it out, and it’s not covered in the form’s instructions. Insurers pay claims for procedures at a given surgical site in the order they’re listed on the form. The first procedure listed may be paid at 100 percent, for instance, the second at 75 percent and additional procedures at 50 percent. 

If you list the procedures in the order they occurred, you may lose money.

	Instead, list the procedures for each surgical site in order from the most expensive to the least expensive procedure. This will help you maximize your reimbursement from the insurer.

	Always double check your codes before submitting a form. Take the time to read over the patient information as well. Typos and other errors can cause the insurer to reject your claim or delay your reimbursement.

	Include supporting documentation with your claim. Lab reports or diagnostic imaging can help prove your case. Send copies of your letter of medical necessity, any medical review results and pre-authorization. It doesn’t matter if the insurer already has these documents somewhere in the system. Submitting them with your claim can speed up processing.

	Finally, remember that medical billing is a both an art and science. Forms need to be filled out correctly, and you have to carefully follow each insurer’s rules and processes. On the other hand, within those rules, you need to learn how to paint a compelling picture of medical necessity.

Related article: 8 ways to make insurance less of a pain

	You and your office staff may benefit from training so that you can get the most from your medical billing efforts. A crash course in anatomy, medical terminology, and surgical modifiers and qualifiers will help you billing department prepare and proofread claims so that insurers accept them and reimburse in a timely manner.

	Your patients deserve to receive the treatment they need when they need it. Learning to work with medical insurers can be an important step as you strive to protect their health and improve their lives.

It’s not always easy to get medical insurance to pay for dental operations, but these tips will help make the process a lot smoother.

Medical billing for dental surgery: What you need to know

	Most dental practices assess the dental history of their patients at intake. Some go a step further and take a complete medical history for each patient. However, if your practice is truly concerned with the health and wellness of your patients, you should also be conducting dental risk assessments.

	A dental risk assessment goes beyond dental and medical history. It also provides your clinical staff with information on a patient’s lifestyle, habits, background and family history that could affect their risk for dental complications and other health issues.

	Some of the questions on a dental risk assessment might include:

		How often you brush, floss and use mouthwash?

		Did your home have fluoridated water as a child? If not, did you receive fluoride supplements?

		Have other members of your family experienced tooth loss?

		Do you drink bottled or filtered water? How often? From what source?

		Do you bite your nails or chew on other non-food items?

		How often do you drink carbonated beverages?

		What beverages do you drink with meals?

		How much calcium and vitamin D do you get as part of your diet?

	Each of these questions has some bearing on a patient’s risk for caries, tooth injury, gum disease or oral cancer, yet none of these are strictly medical questions. However, taken together, these and other questions can give you a more nuanced portrait of an individual patient's risks.

Trending article: Why educating the entire team in oral cancer detection protocol is critical

	You have a couple options for creating a dental risk assessment. Risk assessments for specific conditions, like caries or oral cancer, are available online. You can look them over and combine them into a single assessment for your practice. You can also hire a consultant to create a custom risk assessment for your practice. Or, if you have certain criteria that you’re interested in, you can create one on your own. Remember to keep questions short and use simple, non-technical language so that you patients can understand the questions and answer quickly.
	
	Once you’ve created your assessment, remember to revisit it periodically. As research indicates new oral health risk factors, include them on your assessment. Don’t be afraid to remove questions that don’t give you significant or useful information. Tweak your assessment until it fits your style and the needs of your practice.

Trending article: 7 ways to promote oral health during orthodontics

Giving a dental risk assessment                                                                                                 

	You can either have patients fill out the assessment on their own, or have them go over it with staff members. For the first time, it’s probably best to have a staff member go through the assessment with a patient. That way, they can record any extra information that comes out in conversation.

	After the initial assessment, have patients go over an assessment and check off any new information at each appointment. This will keep your records up to date and help you keep track of changing patient situations. For instance, a patient who drinks plain city water at one appointment may switch to a reverse osmosis filter before their next visit.

Trending article: 9 important tips for communicating with your patients

	Use the answers on the assessment to assign each patient to a low, moderate, or high category of dental risk.  For each patient, make a list of one-to-three behaviors they can change in the next six months to improve their risk profile.  For instance, a patient who has many family members with caries may want to chew gum with xylitol or drink milk with meals. A patient who drinks soft drinks daily may want to cut back, or cut soft drinks out altogether. A child who drinks water from an RO device may need to take fluoride supplements.

	Make sure that the suggestions you give patients are simple, carefully targeted to their risk profiles, and evidence-based. The key is to use your medical and dental knowledge to improve the health and overall well-being of your patients.

	In addition, these risk assessments can often be the first step in helping you document medical necessity for certain treatments and helping you plan future treatments for patients. You can give your patients concrete reasons why they may need scaling in the future, or why you think a sleep apnea appliance could improve their overall health and wellbeing. Risk assessments help patients understand why you’re making certain recommendations for their treatment plans.

	Over time, track your patients as they move between categories. When they eliminate risky behaviors and add healthy ones, congratulate them. Let them know that you care about their oral health and notice when they take steps to improve it. This sort of personalized, supportive care will give your patients the motivation they need to stick to treatment plans, embrace healthier lifestyles and improve their oral health.  

Most dental practices assess the dental history of their patients at intake. Some go a step further and take a complete medical history for each patient. However, if your practice is truly concerned with the health and wellness of your patients, you should also be conducting dental risk assessments.

Why dental practices need to conduct risk assessments of patients

	Dental professionals are a patient’s primary source of screening within the oral cavity; thus attention must be paid to the most common oral malignancy: squamous cell carcinoma. Historically such malignancies were attributed only to patients with a history of extensive alcohol and tobacco use.

	However, other risk factors such as human papilloma virus and medication use are shifting the profession’s perception of who may be at risk for oral cancer.

	According to experts, “the dentist must consider all patients at risk and act accordingly in the history-taking and examination phases of the dental visit.“

 Due to the newfound understanding of oral cancer risk, the dental professional should take seriously the options for insurance coverage from both the dental and medical insurer for the patient’s exam.  

	Historically dental professionals relied solely on health history and visual exams to detect abnormalities in the oral cavity. While within acceptable limits, the variance in training and experience of the practitioner is enough to leave the patient questioning reliability. What is more, recent evidence suggests high rates of clinical misdiagnosis by general oral health practitioners

. Thus, studies suggest that augmenting the traditional approach with technology can in fact assist the practitioner in “One of the most difficult decisions a clinician may face…when to refer a lesion for further investigation and biopsy.”

	It would stand to reason that implementing the most comprehensive exam available be enough to garner the use of a targeted risk factor checklist including (but not limited to) information on the patient’s history of tobacco use, alcohol consumption, exposure to HPV, and recreational drug use; as well as the use of a chemiluminescent device to augment the risk assessment visual exam. However, many patients are bound financially to what will and will not be covered by their insurance plans. So to further the argument for use of oral cancer screening devices mentioned above, it is worth noting that both dental and medical insurance codes can and should be utilized during the process.

	Nearly 41,000 Americans will be diagnosed with oral cancer in 2014. The survival rate of this cancer, when found in late stages is at best grim. However, equipped with new evidence regarding risk factors for the disease as well as innovative tools to add to an office armament like oral cancer screening devices and comprehensive health history forms, patients can be confident their dental team can alert them in the case malignancies are suspected.

	If something is found, the patient’s dental insurance should be billed first, utilizing appropriate CDT codes.

	CDT D0480 for adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures.  A copy of the pathology report is needed for hard and soft tissue biopsies: D7285-D7286.

	If the patient’s dental plan does not cover the procedure, a medical claim can be used. The International Classification of Disease codes (ICD) are required each time a claim is submitted to describe what abnormalities have been detected.  The most common in the case of oral cancer screening are listed under the new ICD 10 codes. The encounter, follow up and “why” are found under these categories.  This is just a sample of the list, but the most common within the dental practice for oral cancer.

	Categories Z00-Z99 are provided for occasions when circumstances other than a disease, injury or external cause classifiable to categories A00-Y89 are recorded as 'diagnoses' or 'problems'. This can arise in two main ways:

	(a) When a person who may or may not be sick encounters the health services for some specific purpose, such as to receive limited care or service for a current condition, to donate an organ or tissue, to receive prophylactic vaccination (immunization), or to discuss a problem which is in itself not a disease or injury.

	(b) When some circumstance or problem is present which influences the person's health status but is not in itself a current illness or injury.

			Aftercare following medical care (Z43-Z49, Z51)

			Surveillance of contraception (Z30.4-)

			Surveillance of prosthetic and other medical devices (Z44-Z46)

	Nonspecific abnormal findings disclosed at the time of these examinations are classified to categories R70-R94.

	Malignant codes should only be used if the doctor is 100 percent sure of the diagnosis.

	The other set of medical codes used are called Current Procedural Terminology (CPT) codes. These codes can be used to cover things like the exam, screening devices, radiographs and other procedural tools. In this case the CPT code for the use of an oral cancer-testing device is:

	As a patient’s first line of defense dental screening for oral cancer is a necessary part of the dental practitioner’s job. With the advances in diagnostic and screening technology and the safe-guard of cross-billing, there is no reason patients should not be offered a comprehensive oral cancer screening utilizing the latest technology as part of their regular dental visit.

	There are complexities within both dental and medical billing. Classes, consulting and training are recommended for practitioners new to one or both systems. For a consult on all types of billing, including that discussed here, dental professionals should contact consultant Christine Taxin at Links2Success.biz.

Kondori I, Mottin RW, Laskin DM. (2011, Jul-Aug). Accuracy of dentists in the clinical diagnosis of oral lesions. Quintessence Int., 42(7):575-7.

 Denise M. Laronde, P. M. Williams, T. G. Hislop, Catherine Pohl, Samson Ng., Chris Bajdik, Lewei Zhang, Calum MacAulay, Miriam P. Rosin . (2013). Influence of f

luorescence on screening decisions for oral mucosal lesions in community 

dental practices. Journal of Oral Pathology & Medicine.

 ADA, CDT 2014: Dental Prodedure Codes, 2013

Dental professionals are a patient’s primary source of screening within the oral cavity; thus attention must be paid to the most common oral malignancy: squamous cell carcinoma. Historically such malignancies were attributed only to patients with a history of extensive alcohol and tobacco use. However, other risk factors such as human papilloma virus and medication use are shifting the profession’s perception of who may be at risk for oral cancer.

A dental guide to cross-coding for oral cancer screening

Unless billing departments understand the new forms of insurance available under the law, dental practices risk losing income due to incorrectly billed claims, delinquent patient accounts and other issues.

rollout approaches, many dental practices still struggle to adjust to the changes that 

 has made to dental insurance in the United States.

	Unless billing departments understand the new forms of insurance available under the law, dental practices risk losing income due to incorrectly billed claims, delinquent patient accounts and other issues. Many Americans are embracing embedded dental plans, especially for pediatric dental care. These plans represent a change from more traditional, stand-alone dental insurance plans. Savvy providers must update their billing and insurance practices in order to cope with these new plans.

Related reading: The Ultimate Guide to the Affordable Care Act for Dental Practices

	Before the ACA, most dental customers carried stand-alone dental and vision plans or paid out of pocket. These plans usually offered the same benefits to all members of a family. Under the ACA, plans sold on the exchanges may offer embedded pediatric dental care or the option to purchase a separate, stand-alone dental plan. The new dental plan options can be confusing to both patients and office staff who are used to traditional stand-alone plans. Because ACA-compliant plans may differ from the plans they had in the past, patients depend on office staff to explain their benefits, networks and financial obligations.

	In an embedded pediatric dental plan, a medical insurance company includes some dental benefits as part of a health insurance plan. The covered dental benefits are described in the same publication that lists covered pharmaceuticals, orthopedic treatments and other kinds of medical care. The covered dental procedures vary from state exchange to state exchange. On the exchanges run by the federal government, benefits are usually benchmarked to the FEDVIP plans available to government employees.

More on pediatric dentistry: 75 percent of parents miss key milestone of bringing children to dentisty by age 1

	Some embedded dental plans are administered directly by the health insurance company. Others are contracted out to companies that also provide stand-alone dental insurance. Embedded plans often view dental procedures through a medical lens. For instance, “medically necessary” orthodontia may be covered, but orthodontic treatments to correct more common issues with bite may not be.

	Because insurers on the health care exchanges use narrow networks to control costs, embedded dental insurance plans may have narrower networks than stand-alone plans. Many consumers can’t find reliable information on their dental plan’s network until after they’ve already purchased a plan. Dentists may be unsure whether they’re included in an embedded plan. Some insurers contract with stand-alone plans to manage their networks, so it’s possible for a dentist to be in-network for an unfamiliar embedded plan. Office staff must take extra care when dealing with embedded plans because they’re unfamiliar and the procedures for medical insurance companies frequently differ from the procedures for dental insurers.

Related reading: 5 products making pediatric dentistry easier while delivering better results

	While the ACA mandated first dollar coverage for preventive care, Congress did not include routine dental cleanings and checkups as preventive medical care. This means that if a child has embedded pediatric dental coverage, his or her parents may be responsible for the full cost of cleanings until they have met their medical deductible. They may also have copays for dental visits. These new terms of coverage may come as a shock to parents who are used to stand-alone dental plans that cover two cleanings a year.

	Since parents of patients don’t always understand the new billing procedures, office staff will have to verify insurance information and payment terms before the children arrive for their cleanings. Practices that treat children may need to update their pre-appointment procedures to include a phone call discussing expected expenses with parents. By explaining costs and bills before the child enters the office, dental practices can save time and money later on.

Video: What does the future hold for dental insurance?

	Family practices can no longer assume that all members of a family have the same dental plan. However, even the family members themselves may not understand the details of their new plans. According to the 

Health Policy Institute of the American Dental Association

, 35.7 percent of insurance plans offered on the health care exchanges now include embedded pediatric dental benefits. Yet parents often buy stand-alone whole family plans to cover the entire family.

	This creates a situation where certain family members may have double coverage. However, traditional rules for determining primary and secondary insurance don’t apply to dental insurance obtained through the health care exchanges. The American Dental Association warns members that when a child has double coverage as a result of a plan purchased on the exchanges, costs must be shared equally between the two plans.

More on insurance: How to save time on dental insurance verifications

	Billing and office staff must evaluate each member of a family group individually to determine whether any of the children carry insurance plans purchased on the health care exchanges, and whether those plans include embedded pediatric dental care. In many cases, billing staff will have to contact health insurance plans directly to determine what coverage members have. Since they’ll also have to contact the stand-alone dental plans that cover these pediatric patients, billing staff may have to adjust their checklists and procedures for dealing with insurance.

	It’s not immediately clear if a given dental office is part of the network for an embedded dental plan. Many health insurance companies contract with dental insurance companies to administer embedded plans. This gives the embedded plans access to the dental insurance company’s provider network. However, a patient’s insurance card will often list only the health insurance company, not the dental insurance subcontractor. Office staff cannot determine whether a patient with embedded insurance is in-network based on the insurance card alone.

The Dental and Optometric Care Access Act: New bill before Congress targets dental insurance plans

	Networks can also cause trouble for family dentists. With stand-alone insurance, parents and children share a network. Entire families often visit the same dental practice. With pediatric embedded insurance, parents and children may have two totally different dental networks. Families who have an established relationship with a specific practice may show up for an appointment only to find that they can no longer share a dental care provider. Until patients become used to the changing nature of dental insurance, office staff will have to deal with these issues.

	One final pitfall of embedded dental plans concerns Medicaid. The health care exchanges have resulted in a larger number of children being covered under Medicaid. All of these children receive embedded dental care.

Related article: Why insurance coordinators need to be flexible in today's dental world

	Congress offset the expansion of Medicaid by increasing payments to physicians. This was done to increase the number of appointments available to Medicaid patients. However, while the law raises payments to medical practices, it does not increase payments to dental offices. Dentists face an economy where more of their patients have transitioned from traditional dental insurance to Medicaid, and where payments do not keep pace with increasing expenses.

	In 2016, the next phase of the ACA goes into effect. Businesses with up to 100 employees will be required to carry ACA-compliant insurance and may purchase plans with embedded pediatric dental care. American dentists can expect to see more pediatric patients with embedded insurance than ever before.

	How can practices adjust to the challenge of embedded dental plans purchased on the health care exchanges? A well-trained staff will be able to adjust existing policies to meet new demands and create new routines for dealing with complex situations. Practices should offer their billing staffs opportunities to learn about embedded pediatric dental plans and the options for dealing with new plans. 

 can offer training and education on billing issues including embedded pediatric plans. With education, training and experience, dental practices can weather the difficulties posed by embedded pediatric dental plans.

More on pediatric dentistry: America's pediatric dentists ask parents to 'Fight the Mouth Monsters'

Christine Taxin is the founder and president of Links2Success, a practice management consulting company to the dental and medical fields. Prior to starting her own consulting company, Ms. Taxin served as an administrator of a critical care department at Mt. Sinai Hospital in New York City and managed an extensive multi-specialty dental practice in New York. With over 25 years’ experience as a practice management professional, she now provides private practice consulting services, delivers continuing education seminars for dental and medical professionals and serves as an adjunct professor at the New York University Dental School and Resident Programs for Maimonides Hospital in New York.

Ms. Taxin is passionate about helping dental practices reach their highest potential and increase their profitability. In her consulting work she focuses on helping practices strengthen their communication skills, their ability to work as a team and their capacity to set goals. She helps team members develop their latent strengths and improve their effectiveness and job performance. Ms. Taxin’s specialties are creating highly efficient administrative systems, consulting on valuable internal and external marketing efforts, providing strategies for successful financial planning and educating practices on advanced dental and medical billing techniques.

More from Christine Taxin: Understanding medical billing and its relationship with 3D scanning technology

Understanding embedded pediatric dental plans: What your practice needs to know

Most practices are seeking ways to get patients to accept treatment, to be paid in a complete and timely manner, get more patient referrals of friends and family, have improved collegial relationships with physicians, and receive compliments from patients and the feeling of a job well-done. This requires ongoing training for the entire team. Spending any money when the schedule is slow can seem just plain stupid, yet how can your practice stay relevant in a changing world without essential learning? Learning is much more than fanny time it has to be practical and applicable.

Taking the necessary steps to provide your entire team the needed tools that will move you into the wellness model is the basis of success and, more importantly, profitability. Courses, webinars, seminars, academies, books, articles, and videos abound with costs ranging from free to thousands of dollars. What is the return on investment (ROI)? The answer is often unfortunately not what is hoped. The difference is the delivery of data versus creating useable information. Data is raw, unorganized facts that need to be processed by the individual. Data can be random and useless until the individual knows how to organize it. When the individual processes, organizes, and structures data for the needs and direction of your wellness practice, it becomes “information.”

Many procedures performed in the dental office may qualify for wellness benefits through medical insurance. Medical may reimburse for oral disease complications or causes of other medical problems. Dentists can and should bill for all services performed with the understanding that each state has a statute specifying that medical insurers cannot deny a claim based solely on a provider’s degree and license if the care is within the scope of practice and the treatment is a medical necessary. In other words, the oral cavity is our scope of practice. For example, the ADA Council on Dental Care does not define implants as routine, therefore you should file implants to medical first if the diagnosis is medical in nature. Both TMD and implants have previously put us into the “no insurance coverage zone.” However, many states have added laws that do not allow jawbone and/or jaw joint treatment to be excluded if bones and joints in other parts of the body are covered.

Coding involves the entire team because the answer to nearly every benefit coding question is diagnosis and dental-medical necessity. 

No one in the practice can be hands-off with coding. 

Christine has been consulting on medical cross-coding for many years. The biggest problem she finds is that information is 

. A whole team system for data collection and documentation is needed for determining dental-medical necessity.

Medical-dental necessity isn’t as complicated as it might first appear. Our weapons for identifying the clues to the most accurate dental-medical necessity are:

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 dental-medical practice

The idea of dental-medical necessity shouldn’t be foreign to dental professionals. It’s simply requires documenting the reason a procedure is needed.

, have watched the Sherlock Holmes movies, or seen the recent TV show 

. The object is to bring together different ways of thinking to provide the answer. Every case is different just as every patient is different.

Which one of the several suspects did it?

In the insurance game, we need to answer these questions:

What condition is putting them this patient at risk?

Where in overall system are there conditions and diseases affecting oral health?

What weapons are needed to assess risk, perform the right tests, and gather all the clues to make the diagnosis?

In real criminal cases, we treat everyone as if they are guilty until we prove they are not. In a wellness practice, we also treat everyone as if they qualify for medical coverage until we prove they do not.

We have created books and courses that are going to rock the dental world with the simple steps. We play a detective game starting with why and the detective role each team member (including the dentist) plays on billing. We end up with how-to dental-medical billing for TMD, sleep apnea, implants, periodontal risk patients, pediatric, trauma, and more. Learning the practical, applicable steps to fill out the forms leads to making life easier and more profitable with a team excited about the future. That’s ROI on every level.

Editor's Note: For more information on these authors, check out their book, 

DentalCodeology: Jump Start Diagnostic Coding

Changing data into profitable information for the dental practice

Dental professionals are a patient’s primary source of screening within the oral cavity, thus attention must be paid to the most common oral malignancy: squamous cell carcinoma. Historically such malignancies were attributed only to patients with a history of extensive alcohol and tobacco use. However, other risk factors such as human papilloma virus and medication use are shifting the profession’s perception of who may be at risk for oral cancer. According to experts, "the dentist must consider all patients at risk and act accordingly in the history-taking and examination phases of the dental visit" (Kondori I, Mottin RW, Laskin DM, 2011). Due to the newfound understanding of oral cancer risk, the dental professional should take seriously the options for insurance coverage from both the dental and medical insurer for the patient’s exam.

Historically dental professionals relied solely on health history and visual exams to detect abnormalities in the oral cavity. While within acceptable limits, the variance in training and experience of the practitioner is enough to leave the patient questioning reliability. What is more, recent evidence suggests high rates of clinical misdiagnosis by general oral health practitioners (Kondori I, Mottin RW, Laskin DM, 2011). Thus, studies suggest that augmenting the traditional approach with technology can in fact assist the practitioner in “One of the most difficult decisions a clinician may faceâ¦when to refer a lesion for further investigation and biopsy” (Denise M. Laronde, P. M. Williams, T. G. Hislop, Catherine Pohl, Samson Ng., Chris Bajdik, Lewei Zhang, Calum MacAulay, Miriam P. Rosin , 2013).

It would stand to reason that implementing the most comprehensive exam available would provide the most accurate and timeliest detection of oral cancer. This should be enough to garner the use of a targeted risk factor checklist including (but not limited to) information on the patient’s history of tobacco use, alcohol consumption, exposure to HPV, and recreational drug use; as well as the use of a chemiluminescent device to augment the risk assessment visual exam. However, many patients are bound financially to what will and will not be covered by their insurance plans. So to further the argument for use of oral cancer screening devices mentioned above, it is worth noting that both dental and medical insurance codes can and should be utilized during the process.

Nearly 41,000 Americans will be diagnosed with oral cancer in 2014. The survival rate of this cancer, when found in late stages is at best grim. However, equipped with new evidence regarding risk factors for the disease as well as innovative tools to add to an office armament like oral

cancer screening devices and comprehensive health history forms, patients can be confident their dental team can alert them in the case malignancies are suspected.

If something is found, the patient’s dental insurance should be billed first, utilizing appropriate CDT codes.

CDT D0480 for adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures

CDT D7285: code for biopsy of oral tissue (hard)

CDT D7286: code for biopsy of oral tissue (soft)

CDT D7287: code for exfoliative cytological sample collection

CDT D7288: code for brush biopsy- transepithelial sample collection (ADA, 2013).

If the patient’s dental plan does not cover the procedure, a medical claim

can be used. The International Classification of Disease codes (ICD) are required each time a claim is submitted to describe what abnormalities have been detected.  The most common in the case of oral cancer screening would be:

ICD V76.42: Screening for malignant neoplasms; oral cavity.

The other set of medical codes used are called Current Procedural Terminology (CPT) codes. These codes can be used to cover things like the exam, screening devices, radiographs and other procedural tools. In this case the CPT code for the use of an oral cancer-testing device is:

There are complexities within both dental and medical billing.  Classes, consulting and training are recommended for practitioners new to one or both systems.

As a patient’s first line of defense dental screening for oral cancer is a necessary part of the dental practitioner’s job. With the advances in diagnostic and screening technology and the safe-guard of cross-billing, there is no reason patients should not be offered a comprehensive oral cancer screening utilizing the latest technology as part of their regular dental visit.

For a consult on all types of billing, including that discussed here, dental professionals should contact me at Links2Success.biz.