Billing Implants and Related Services to Medical Plans

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CHOOSING THE APPROPRIATE DIAGNOSIS CODES (ICD-9)
The selection of diagnosis codes pertaining to the presenting symptoms and conditions is what sets the tone for billing of the procedure. The diagnosis codes should be selected from both the primary presenting situation(s), as well as from secondary, or supporting, diagnoses for the treatment to be provided. All surgical claims require pre-authorization from the medical plans, and this must be done before the procedure is performed. According to the American Medical Association (AMA), it is also recommended that a Letter of Medical Necessity be submitted via fax to obtain written verification of coverage and to confirm that the treatment has undergone medical review and was deemed "medically necessary."

The diagnosis codes must be listed in the correct order, both in the Letter of Medical Necessity and on the claim form. Start the list with the most important presenting condition and continue in descending order, followed by any V and/or E codes specifying contributing medical history factors, if present. The lack of a greater medical condition does not negate the medical necessity of the procedure. In deciding the order, keep in mind that the first diagnosis listed must relate to the most important or most expensive procedure to be performed and that only four diagnosis codes are allowed. All medical claims must contain diagnosis codes or they will not be considered for payment.

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When procedures are listed on the claim form, it is critical that they be ordered from the highest dollar amount down to the lowest dollar amount in each jaw or surgical site, not in the order in which they were performed. The reason for this is that the first procedure listed in each jaw/site is always reimbursed at the highest surgical benefits level and each subsequent procedure is paid at a lower percentage reimbursement. Thus, the first procedure may be paid at 100 percent, the second at 80 percent, the third at 70 percent, and the fourth and all others at 50 percent.

Pre-Authorization and Documentation Requirements
All surgical procedures must be pre-authorized by phone. As previously stated, the AMA also recommends that further verification and coverage determination be obtained by sub- mitting a Letter of Medical Necessity via fax to Medical Review for written authorization to perform the procedures and confirmation that they are cleared for "medical necessity" (Example 1). That being said, medical necessity does not mean that the patient has to have contributing health issues. It simply means that the anatomical situation and/or present- ing clinical and anatomical picture indicates the patient's condition necessitates that oral surgery be performed.

Submitting the Claim for Reimbursement
Once the procedure has been performed, the claim can be submitted to the medical plan for payment. Not only must the claim be completed correctly, but it also must include the appropriate documentation. In the case of Example 1, the Letter of Medical Necessity is for three implants and bone grafting. The actual claim (Example 2) requires that an operative report be included with the claim and indicated in Box 19 on the CMS-1500 (08/05) claim form. It also requires that the pre-authorization number be stated in Box 23 of the claim form. An interim prosthesis, although it cannot be pre-authorized, is also billed with the surgical claim. If the lab is billing your office, the lab charge would also be included on the claim form in Box 20. Any exam or radiographs (CT scan, orthopantogram and surgical stent) would have been billed following the diagnostic appointment.

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Conclusion
Successful medical billing not only requires knowledge of the codes, but also knowledge of the documentation requirements specific to the procedures performed. Not all procedures require the same supporting documentation. Examples of supporting documentation can include: a radiology report, operative report, Letter of Medical Necessity, pre-authorization, supporting Letter of Medical Necessity from the patient's physician, among others. In order to obtain successful reimbursement, it is absolutely mandatory that those who handle billing in the office, as well as the doctor and surgical assistant(s), take a comprehensive course in medical billing.

Medical billing is definitely not as simple as dental billing and requires not only a thorough knowledge of anatomy, medical terminology and procedures, but also familiarity with surgical modifiers and qualifiers, in order to correctly complete the claim form and facilitate medical reimbursement. The marketing opportunities this knowledge provides and the benefits it affords to your patients, who may be completely unaware they even have these benefits, are priceless!