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Billing Patient Medical Plans:
There's Nothing Illegal About It!
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OVERVIEW Dr. Olya Zahrebelny tackles the common misconception that dentists can only access benefits from patient dental plans. Listen to this video lecture as she outlines how dentists can learn the ins and outs of billing patient medical plans.
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Olya Zahrebelny, DDS
Principal, The Z Group LLC
thezgroupllc@gmail.com |
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| Dr. Olya Zahrebelny graduated from the University of Toronto Faculty of Dentistry and completed a general practice residency. She has practiced in hospital and private-practice settings. A former insurance plan consultant, she has taught at three dental schools and was an attending physician at the University of Illinois Medical Center. Repeatedly named a leader in continuing education and dental consulting by Dentistry Today, she has lectured nationally and internationally. |
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Billing Patient Medical Plans: There's Nothing Illegal About It!Dentists have always wondered whether they could legally bill their services to medical plans. Traditionally, this has been an area of great concern. 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 could be further from the truth. A large number of routine procedures performed in general and specialty dental 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 billed simultaneously to the medical carrier, with no fear of legal ramifications. However, some basic premises and rules must be followed.
Medically Billable Procedures
Procedures can be divided into "oral" and "dental" procedures. "Oral" procedures are those performed on the bone and soft tissue. "Dental" procedures are those performed on or in the tooth itself. Procedures that are covered under medical contracts fall into these four categories:
- Inflammation and infections – problems not treatable by entry through the tooth
- Pathology – hard and soft tissue
- Dysfunction – skeletal dysplasias, sleep apnea,
oral dysfunction
- Trauma –
anything and everything related to traumatic injury
Let's take a look at individual treatment categories and the procedures that are medically billable in each.
Diagnostic: This includes examinations, consultations, radiographs (orthopantographs, cephalometric X-rays, occlusal films, lateral jaw projections) and other diagnostic procedures
PAGE 2 OF 5 such as photos, models and diagnostic/surgical/healing stents that are required for surgery and/or fall into any of the aforementioned four categories. This also includes impacted teeth (including wisdom teeth, supernumeraries, congenitally missing teeth). Injections that are needed to determine the cause and origin of pain, as well as bacterial testing, are also covered under this category.
Medical (i.e., Non-Surgical) Treatment: All non-trauma-related emergency procedures, such as incision and drainage (I&D), curettage of periodontal abscesses and irrigation of tissue overlying wisdom teeth, are typically covered under the medical contracts. Also included in this category are nightguards, TMD orthotics and sleep apnea appliances. Fluoride trays for at-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 non-traumatic and non-emergency situations, including any type of 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 billable to medical plans. The surgical placement of implants and periodontal hard- and soft-tissue (non-cosmetic) procedures, such as osseous contouring, gingivectomy, alveolectomy, removal of tori/ exostoses and frenectomy, are included in this category.
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. None of these procedures are restricted
PAGE 3 OF 5 to a specific specialty, and may be performed by any dentist that is licensed and properly trained to perform the procedure in question.
Procedures Billable by All Dental Providers
- Exams
- Consults
- Orthopantograms, CT scans, jaw X-rays
- Appliances – TMD/sleep apnea/habit breaking
- Cancer screenings and biopsies
Procedures Performed Mainly by Specialists
General dentists and specialists can bill the previously mentioned procedures. There is also a wide array of procedures performed by specialists that are medically billable and should be routinely submitted to a patient's medical plan for reimbursement. These include, but are not limited to, the following:
1. Periodontal
- Osseous surgery to correct defects
- Soft- and hard-tissue grafting (non-cosmetic)
- Soft- and hard-tissue augmentation (non-cosmetic)
- Implants
2. OMFS
- Sinus elevation
- LeFort procedures
- Implants and related procedures
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- Treatment of anomalies affecting function
- TMD surgery
- LAUP
- Laser procedures
- Dermatologic/plastic surgery procedures
3. Endodontic
- Apicoectomies
- Hemi-sections
- Endodontic therapy related to traumatic injury
4. Orthodontic
- Nightguards
- Palatal expanders for skeletal anomalies
- Habit-breaking appliances (including those for tongue thrusting and thumb sucking)
5. Pedodontic
- Emergency procedures
- Analgesia/anesthesia for the control of behavior problems in the office
NOW WHAT?
The various aforementioned procedures 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 (procedures on or in the tooth, not involving traumatic injury) and then to bill all other procedures to the medical plans.
PAGE 5 OF 5 Not only will this leave the paltry 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 implant services.
CONCLUSION
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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