There has been an upsurge in interest in medical billing by dentists and many have eagerly jumped on the bandwagon, only to find it's nothing like they imagined and they're receiving only denials and rejections, with maybe a bone thrown to them once in a while by the medical insurance companies, just as a tease. This article is meant to share the pros and cons—unfiltered, as Dr. Howard Farran would say—of commercial medical billing, so you can decide if it's a service that you'd like to incorporate into your practice's business armamentarium. (This advice refers to commercial plans only, not Medicare; the covered procedures and "medical necessity" criteria are markedly different between the two.)
For starters, let's address the misconceptions.
Myth #1: The codes and claim forms for medical billing are different, but otherwise it's
just like dental billing.
Nothing could be further from the truth! Medical billing is nothing like dental billing. Not only are the codes different, so also are the documentation requirements and the format in which information is presented. The language used must also be one that a registered nurse or medical doctor can understand.
There are two code "sets"—one for the diagnoses, another for procedures and treatment. There is no "cross-coding" (a term I'm opposed to using, because there is no one-to-one coding relationship between medical and dental codes). Rarely are dental codes acceptable on a medical claim form. If they are used, the claims will routinely be denied, despite what you may have heard.
The medical claim form also is different and it's critical that it be completed correctly for claims to be processed quickly and payments made promptly. How hard can it be to complete? Check out the CMS website: There are more than 60 pages of instructions and they change yearly, every July.
Myth #2: A biller who is good at dental billing will automatically be good at medical billing.
Not necessarily. To be successful at medical billing, the biller must be aggressive, assertive, focused, and religious about following up with precertification and claim submissions. The biller must also be familiar with the procedures being billed, and not just have the terms and/or codes memorized. Visual learning is the best—it then makes sense to them as to which procedure precedes or follows another, and why certain codes are selected and appropriate for a given procedure or surgery.
The biller cannot back down when dealing with medical insurance company representatives and must not take "no" for an answer from them, especially those in customer service. The more you push back, the more successful you will be.
Myth #3: My chart notes
are excellent and should be
acceptable for medical billing.
Sorry, but probably not. None of the dental schools that I have taught at, or taught graduates from, teaches medical reporting protocols and the kind of detail required in a patient's clinical notes. Patient examination and consultation appointments require reporting in the SOAP format. "SOAP" refers to:
S = Subjective. A patient's presenting problem(s) or condition(s), in his own words—meaning that this is reported in quotation marks.
O = Objective. Clinical evaluation of the patient, including a complete medical history and radiographs—all from a medical standpoint first, then zeroing in on the head and neck, then the jaws and oral cavity. Add to this any study models, blood tests, additional medical radiographs, etc.
A = Assessment. A summary of the patient's oral and dental condition, including contributing or exacerbating medical factors such as diabetes, a history of chemotherapy, or late effects of therapeutic medical or surgical treatment.
P = Plan. Treatment plan, typically staged or phased, starting with emergency procedures (therapeutic or surgical) to address pain, swelling or infection, then progressing to treatment of any other presenting oral or dental issues that compromise your patients' ability to function or diminish their quality of life.
Myth #4: The medical history taken in a dental office
is adequate for medical
Rarely have I found this to be the case. To satisfy medical billing requirements, the medical history must address all systems, then zero in on the dentist's area of expertise. Thus, a history taken in your office must address questions related to cardiology, neurology, endocrinology, dermatology, the musculoskeletal system, digestive/GI disorders, etc., then zero in on specifics as they relate to the upper face and maxilla (facial symmetry, eyes, ears, sinuses), the TMJ, the lower face and mandible, including lymph nodes, thyroid, salivary glands, and finally the intraoral structures, including soft and hard tissues and the dentition.
Myth #5: As a dentist, I don't need to be involved in the medical coding or billing process if I have a sharp biller.
Medical billing involves a close cooperation between the clinical and business teams. To be successful at it, the doctor must present the diagnosis and treatment information to the billers in a format they can then translate onto the medical claim, in code form. When the documentation is submitted for precertification or with a claim for payment, it must be presented in such a way as to be easily understood by an R.N. or M.D., who will be reading it and determining the "medical necessity" of the procedures. "Dental speak" won't cut it.
Myth #6: Submitting an
FMX, periapicals and photos,
together with my clinical notes,
will suffice in proving the medical necessity of the procedure.
Documentation that is acceptable to dental reviewers is rarely, if ever, acceptable to medical reviewers in determining the "medical necessity" of the treatment. Dental radiographs and photos are not part of the standard reporting protocol for documentation, as required by medical reviewers. Claims submitted with this documentation will routinely be denied, even though the procedures requested may actually be billable and covered benefits.
OK, so give it to me straight. Knowing that it will probably
be a steep learning curve,
what else do I need to know?
You've read this far, so you're ahead of the eight-ball already and have determined that you're willing to consider accepting the challenges associated with negotiating the medical billing process. First, check out this list of the top medically billable procedures and see how many you perform, and whether it would be worth it to your patients and your practice to learn the process. Remember, whether they're "high end" or not, most patients are paying hefty premiums for medical insurance but aren't utilizing the benefits from their medical plans in dental offices, for procedures they need, because they (and often their dental health care providers) have no idea what's billable or covered.
1. Any traumatic injury to the mouth, whether dental or oral treatment thereof. This includes all oral and dental procedures.
2. Exams for soft and hard tissue pathology:
- Exams and consults
in preparation for surgery.
- Exams and consults also include visual screening exams for oral cancer.
3. Emergency treatment of oral inflammation or infection, such as pericoronitis, "pizza burn," floss stuck between teeth causing perio abscess or draining fistula.
4. Diagnostic, radiographic or surgical stents.
5. Medical radiographs—those in which most of the film shows structures other than teeth. Medical radiographs are of two types.
- Screening (2-D) X-rays: orthopantograms, lateral jaw X-rays, occlusal films, cephs, Waters' view.
If there are suspicious lesions or positive findings on the screening X-rays, then diagnostic (3-D) X-rays or CT scans are taken.
Dental radiographs (periapicals and FMX) are billable to medical plans only in cases of traumatic injury.
6. Biopsies (brush, smears or removal of part of a suspicious area) and excisions (removal of the whole lesion).
7. Extraction of teeth: wisdom teeth, supernumeraries, mesiodens, ankylosed teeth, exposure of impacted teeth. Any teeth, if traumatic injury is the cause. Extractions may be covered when performed at the request of an M.D. before specific surgeries (open heart, transplants, hip and knee replacements, tumor removal).
8. Any surgical procedure needed to:
- rebuild or reconstruct alveolar or jawbone because of bone loss/destruction.
- treat an infection.
- Interim prosthetics are covered when any elective or emergency surgery is performed.
Both interim and definitive (final) prosthetics are covered:
- When treatment is for a traumatic injury.
If there is a medical condition that involves the teeth (such as ectodermal dysplasia, methamphetamine addiction, bulimia, etc.)
- When previous or current medical treatment—for example, medication-induced, chemotherapy or radiation—has affected the teeth.
10. Removable or fixed appliances used to treat dysfunction—nightguards, TMD orthotics, palatal expansion, habit breaking, sleep apnea, etc.
What do I need to do to prepare myself? Give me the lowdown
on the approach to take!
1. Attending a comprehensive medical billing course is essential. You cannot learn medical billing from the internet or just by reading a book. Trial and error will not get you paid.
2. Arm yourself with the necessary reference materials that explain the process, the different insurance carriers and how easy or difficult it is to access benefits; that have templates for the necessary documentation required; and that have dozens of claim examples for you to follow.
3. Get properly credentialed with CAQH, NPPES and NPI. Medical insurers rely on these entities to verify your status, so they're critical to medical billing and payment because the information they provide determines your legitimacy. A reputable company that teaches medical billing will be able to assist you in this (or will do it for you at a nominal fee).
4. Sign up with a clearinghouse that correctly and accurately verifies, "sweeps" and submits medical claims by dentists, and has years of experience doing so successfully. Ask around, check its track record; rely on the recommendation of dentists who are already successfully billing their procedures to medical plans. Medical claims must be submitted electronically.
5. Download and subscribe to software that accurately completes medical claims. In my experience, no dental practice management software accurately does this.
6. Take advantage of follow-up support to the courses. Check the credentials of the support staff and consultants—ask about their years of experience; ask for proof of steady and continued success and outstanding results. Yes, that matters. They should not just teach it, they should still be doing it!
I'm not going to lie: Medical billing is not for every dental office. There is a steep learning curve. However, every office can learn to bill the simplest of procedures—exams, consultations, radiographs, TMJ and OSA appliances, procedures that do not require precertification—even if it doesn't try for the bigger (surgical) ones.
And no, you don't have to be a participating provider with a medical plan to get paid by one. It just requires you to learn what's actually necessary in terms of documentation, to tweak your existing reporting protocols, and to put basic systems into place to set yourself up for medical billing success. And, yes, having (or hiring) the right person for the job of medical biller is of paramount importance also. Are you ready to tackle this in your practice? You can, if it makes sense and your practice is up to the challenge.