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Medical coding in the dental world.

Just when you think you have it figured out how to file dental insurance--the insurance companies will come up with something different that providers have to do in order to get a simple claim processed. A new trend with insurance companies these days is requiring the dental provider to file certain procedures with a patient's medical insurance policy, such as extractions and occlusal guards to name a few. Medical coding and filing claims to a medical policy is becoming more prevalent in the dental field.

The days when everyone had the same basic dental coverage with insurance paying 100% on preventive services, 80% on basic services and 50% on major services are over! Insurance is a beast that changes every year creating new hoops for the provider to jump through. This can be very frustrating especially when the insurance companies dictate what a provider has to do in order to get the insurance claim paid.

Most dental staff know how to code dental procedures by using the current version of the CDT (Current Dental Terminology) code book. The CPT (Current Procedural Terminology) code book has to be used when filing medical claims for professional services. There is a considerable difference in these codes versus the CDT codes. The CPT coding manual also consists of modifiers and place-of-service codes for professional claims.

The ICD-9-CM (International Classification of Diseases) is used to identify the diagnosis of the patient. As you know, a diagnosis code is not required when filing a dental claim, but it is required when filing a medical claim. You can have up to four diagnosis codes. You do not code conditions that are referred to as "rule out," "suspected," "probable" or "questionable." Only use codes that are determined to be the patient's actual diagnosis. Keep in mind when medical coding, it is like telling a story. You are trying to tell the insurance company what exactly is physically wrong with the patient to justify the procedures the provider is performing on the patient. Make sure the diagnosis codes are listed in order of relevance. For example, if a patient comes in with teeth missing because of an automobile accident that he or she was involved in while driving a vehicle, the primary code would be 525.11 (loss of teeth due to trauma) and the secondary code would be E810.0 (motor vehicle traffic accident/driver).

You can't use these codes on a regular ADA dental claim form. You have to use the CMS-1500 form. This form used to be called the HCFA 1500. It has since been revised. The claim forms must be red in color. Downloaded forms are not acceptable. You can purchase these red forms from most dental and medical vendors selling front office products. The main issue that will have to be addressed is if the dental software system that is currently being used in the practice is compatible with the medical claim forms. If not, you can always type out the claim form.

When filing medical insurance, the claim must be a "clean claim" in order for the insurance companies to process it. In other words all required blocks must be filled out and correct coding must be used.

Check with your vendors to purchase books or cross coding manuals to help staff properly code medical claims. You can also go to the following websites to get additional information on how to file a medical claim:

Patients will ask if Medicare will pay for any dental services. Medicare has a statutory exclusion for dental care. It will not cover routine dental care and most other dental procedures. In rare cases, Medicare will pay some on certain procedures. An example of this includes extraction of teeth to prepare the jaw for radiation treatment secondary to cancer, and a dental examination prior to a kidney transplant. An additional requirement to those exceptions is that the dentist must also be a Medicare-approved provider.

Go to for additional information regarding dental coverage for Medicare patients.

In best case scenarios, most medical insurances will pay around 50% of a claim, if at all. Be leery of the "repricing" companies that are contracted by the insurance companies to call the provider trying to get them to agree to decrease his or her fees in order for the insurance company to consider the claim. Repricing companies are not necessarily your friend. They are there to save the insurance company money, not to help the provider.

If a patient is being seen due to trauma or some type of medical condition that has directly affected the mouth and teeth area, then file medical insurance first. File dental insurance as secondary. Remember to attach documents such as clinical notes and x-rays when sending medical insurance claims. If your practice is capable of sending electronic attachments along with the electronic claim, then your claim will be processed much faster.

This is an exciting time in the field of dentistry! Staff should always stay on top of the new insurance trends in order to keep the dental practice profitable without jeopardizing patient care.

By Terri Rollins, CDA, RDA, CDPMA, FADAA

Terri Rollins, CDA, CDPMA, RDA, FADAA, of Nashville, Tenn., is employed by Doral Dental of Tennessee, LLC as the Provider Relations Representative for the State of Tennessee. She serves as President of the Nashville Dental Assistants Association and is Past Secretary of the Tennessee Dental Assistants Association. Ms. Rollins is also a Consultant with sharing her extensive knowledge in medical/dental cross coding.
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Author:Rollins, Terri
Publication:The Dental Assistant
Date:Sep 1, 2007
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