Th 127080

Billing patient medical plans: There's nothing illegal about it!

June 1, 2003
Many of the services that dentists perform are covered by patient medical plans. You owe it to yourself — and to your patients — to utilize this important resource.

by Dr. Olya Zahrebelny

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Dentists have always been curious about whether they could legally bill their services to medical plans. It is a commonly held misconception that only physicians can obtain medical benefits for services provided, whereas dentists, with perhaps the exception of oral surgeons, can only access benefits from dental plans. Nothing can be further from the truth. A large number and variety of procedures that are performed routinely in both general and specialty practices are billable to, and, more importantly, are covered by, patient medical benefit plans. In addition, many procedures that are typically billed only to dental plans can also be simultaneously billed to the medical carrier, with no fear of legal ramifications. However, a few basic premises and rules must be followed.

Medically billable procedures

Oral procedures that are covered under medical contracts fall into four categories:

1 Inflammation and infections — Problems not treatable by entry through the tooth

2 Pathology — Hard and soft tissue

3 Dysfunction — Skeletal dysplasias, oral dysfunction, sleep apnea

4 Trauma— Anything and everything related to traumatic injury

Let's break these procedures down by category.

Diagnostic. This includes examinations, consultations, radiographs (orthopantographs, cephs, occlusal films, lateral jaw), and other diagnostic procedures such as photos, models, and surgical/healing stents that are required for surgery and/or fall into any of the above-mentioned categories. This also includes impacted teeth (including wisdom teeth, supernumeraries, or congenitally missing teeth related to a medical condition). Injections that are needed to determine the cause and origin of pain, as well as bacterial testing, are also covered under this category.

Nonsurgicap medical treatment. All emergency procedures, with the exception of those needed for the treatment of traumatic injury, such as I & D's, curettage of periodontal abscesses, and irrigation of tissue overlying wisdom teeth, are all covered under the medical contracts. Also included in this category are nightguards, TMD orthotics, and snoreguard appliances. Fluoride trays for home use are also billable when indicated for patients undergoing radiation/chemotherapy and for those with psychological/GI disorders such as anorexia and bulimia.

Surgical treatment. The removal of teeth in nontraumatic and nonemergency situations including impactions, as well as teeth requiring removal prior to radiation therapy, transplantation of organs, or other similar circumstances on the recommendation of the physician, are also covered benefits. In addition, the biopsy or excision of any hard- or-soft-tissue lesions is also billable to medical plans. The surgical placement of implants, periodontal hard- and-soft-tissue (noncosmetic) procedures, such as osseous contouring, gingivectomy, and frenectomy are included in this category. Treatment of soft-tissue lacerations related to traumatic injury is also a covered benefit.

Treatment for traumatic injury. Any and all treatment of the teeth, supporting structures, and surrounding tissues that are damaged during a traumatic incident is covered under the Comprehensive portion of the medical plan. This includes, but is not limited to, restorative, endodontic, surgical, implant replacement, removable and fixed prosthodontic treatment, as well as orthotics, stents, and the like. You get the picture!

Both specialists and general practitioners can bill for these procedures. There also are many procedures that specialists perform that are medically billable and should be routinely submitted to a patient's medical plan for reimbursement. These include, but are not limited to:

Periodontal osseous surgery to correct defects
Soft and hard tissue grafting (non-cosmetic)
Soft and hard tissue augmentation (non-cosmetic)
Sinus elevation
LeFort procedures
Treatment of anomalies affecting function
TMD surgery
Laser procedures
Dermatologic/plastic surgery procedures
Endodontic therapy related to traumatic injury
Orthodontic nightguards
Palatal expanders for skeletal anomalies
Habit-breaking appliances (including tongue thrusting and thumb-sucking)
Pedodontic emergency procedures
Analgesia/anesthesia for the control of behavior problems in the office

These specialty procedures are not restricted to the specific specialties and may be performed by any dentist that is licensed and properly trained to perform the procedure in question.

Now what?

The large variety of procedures mentioned are billable, for the most part, to both medical and dental plans, and can be billed simultaneously. It is prudent, however, to bill dental plans only for tooth-related procedures (not involving traumatic injury) and to then bill all other procedures to the medical plans. Not only will this leave the piddly annual dental benefits for strictly "dental" services, but will also allow the patient the luxury of having more necessary services performed with a decreased out-of-pocket expense. When a large comprehensive treatment is planned, the diagnostics can be billed to both plans in order to satisfy the medical deductible. This in turn allows for maximum coverage for the surgical portion of treatment, such as periodontal and implants services.

Don't be afraid to bill procedures to medical plans! Learn the codes and the language, the documentation and claim-filing requirements, and the billing protocol - and then go for it! Not only will the patient be able to undergo all the necessary treatment in a shorter time-frame, but the out-of-pocket costs will also be much more manageable, resulting in a happy and satisfied patient and a dentist thrilled with the ability to complete the total treatment in a shorter time period!

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