Medical Billing for the Dental Practice

Hello, my name is Dr Chris Farrugia, and I’m
a practicing restorative dentist in Pensacola, Florida. Dentistry is a wonderful profession, and I
love what I do, helping people achieve health. Over the course of 30 plus years of clinical
practice, I’ve learned many things and I look forward to sharing some of those things with
you through this series of courses. Over the next several courses, we’re going
to explore medical billing for the dental practice. The purpose of these courses is to give you
knowledge of medical billing core concepts. What this is all about, how medical billing
works, what type of services we render that are appropriate to bill the medical insurance,
and a basic understanding of medical billing codes. Let me be clear about one thing before we
begin. This is not a course on how do we get money
out of insurance companies. This is a course for health-centered dental
practices that view services they render in the context of treating the whole patient
and how can they be appropriately compensated for their services, especially the ones already
being provided on a daily basis. In this series, I will be presenting foundational
information on medical billing concepts so that you can make the determination, is this
appropriate for your practice? Because I will be presenting information in
broad strokes, please be aware that the medical insurance industry changes with time, and
you’ll need to investigate current rules and protocols as you evaluate medical billing
practices and procedures. In this first course, we will cover the dental
versus medical mindset, and the perspective that is critical and success with medical
billing. We’ll cover medical insurance, how does it
differ from dental benefit plans. I’ll introduce the important concept of medical
necessity, and we’ll go through some examples of medically billable services that are appropriate
for a dental office to bill. 02:13 S1: But let’s start at the very beginning. Are dentists allowed to bill medical insurance? Absolutely. The American Dental Association defines the
scope of our practice as the evaluation, diagnosis, prevention, treatment, blah, blah, blah, blah,
blah of the oral cavity, maxillofacial area, and/or the adjacent and associated structures. The word tooth does not even appear in the
definition of the scope of our practice. We are not defined by teeth, we are not limited
to teeth. Our practice goes beyond the teeth and that’s
very important for a medical billing perspective to understand that our practice is not limited
to teeth. And the truth is, that dentistry is a medical
specialty. It is one of the medical specialties, but
it is a medical specialty. And I know that this is probably very shocking
to the audience, but did you know that the mouth is actually part of the human body? There’s no separation that defines when you
cross this line, you’re now in dental land. You cannot separate the mouth from the body,
things that happen systemically manifest themselves in the mouth, and things that happen in the
mouth have systemic consequences. They’re all interrelated and connected. Also realize that just because a dentist performs
a procedure does not, does not, does not make it a dental procedure. I’m a dentist. My wife, Caroline, I love her to death, but
she does not believe that there is a plant in my yard that can’t be moved. So the shrubs that she had me dig up and move
six inches last weekend, I’m a dentist, that must be a dental procedure, therefore, I should
file a dental claim for it. Well, no, that’s silly. But that’s the thought process that needs
to be avoided. And the truth is, that dental benefit plans
are nothing more than supplements to medical insurance. And there’s an overlap between the two coverages. You have medical insurance that insures you
from the bottom of your feet to the top of your head, and you have dental insurance that
ensures this oral cavity and its contents. And because this is part of that, what do
you have? Overlapping coverage. You have two policies insuring the same thing. So how should you handle that? Well, no differently than how you’re handling
dental benefit plans in your practice right now. You determine which one is primary, you file
with the primary, then you go to the secondary number two policy, and you show number two
what number one paid. Basic insurance rules that apply whether you’re
involving medical insurance in the mix or not. And I wanna be very clear, there is a lot
of things covered by medical insurance that have nothing to do with our practice. There are a lot of things that we do in our
practice that involve only teeth. Those are not payable by medical insurance,
only the things that are in the overlap. And specifically, what is in the overlap? What can dental practices bill to medical? Well, let’s start with the basics: Examinations,
consultations that are probably being given away, two-dimensional radiographs you’re already
taking, and CT if you have it. Any trauma to the maxillofacial area should
be billed to medical insurance, including damage to the teeth. And doctors, if you operate on bones of the
face such as the maxilla or mandible, those surgical procedures are billable to medical
insurance. And the things that you need to perform the
surgery are also billable to medical insurance: CT to plan your surgeries, surgical guides,
and interim prosthesis like flippers as we call them on the island of dentistry, to manage
the patient’s ability to chew post surgery. And appliances, we make appliances that go
into the oral cavity that help larger medical issues: Obstructive sleep apnea, TMD, bruxism,
all of these appliances are payable by medical insurance. And I don’t want you to think that the list
is all inclusive. This is just where you would wanna start if
you’re going to start medical billing in your practice. Medical insurance will pay for a thorough
evaluation of the head and neck. And this really is the basis for medical billing
in dental practices. But medical insurance will not pay for an
oral evaluation or a dental exam. But remember, a dental exam is part of an
oral evaluation, which is part of a thorough evaluation of the head-neck area. In my practice, I call that the Full Monty
examination. And that’s where we go beyond the teeth, beyond
the oral cavity, as part of our examination. And that is what medical insurance will pay
you for. If you only count the teeth, that’s a dental
exam. Medical insurance will not pay you to count
teeth or perform a dental exam. They will not pay you for an oral evaluation
only. Only if you go beyond the teeth, that’s when
medical insurance will pay you for your evaluation. And the truth is, you perform medically necessary
evaluations for these conditions every day. What does candida have to do with a dentition? What does lichen planus have to do with a
dentition? What does dry mouth have to do with a dentition,
other than it affects it? But there are systemic diseases that we evaluate
and diagnose all day long. We deal with impacted teeth. We deal with traumas, facial traumas. Little Johnny running through the house, tripping
on the rug, doing a face plant on the coffee table, breaking his face and/or teeth. We see this all the time. And if you do imaging, if you do advanced
imaging in your practice, there are medically necessary reasons that explain to the medical
insurance company why you’re doing these images, and that makes them payable. In my practice, I love treating obstructive
sleep apnea and TMD, and these are common diagnoses codes that would be related to these
type of conditions. And at the very least, do we or do we not
evaluate our patients for oral and maxillofacial cancer? Absolutely. That reason alone makes our examinations medically
necessary. And by being medically necessary, that means
payable by medical insurance. And you’re probably thinking, “Well, I thought
this course would be just about codes. Chris, give me some codes. I need some codes.” Well, here are some codes. These are common codes for procedures billed
by dental practices to medical insurance. My question is, do you perform any of these
procedures in your practice? I certainly think you do. And how about some more codes? Here are some more codes. If you’d like to have codes, here you go. Do you do any of these procedures in your
practice? Absolutely. And again, this is not an all-inclusive list,
just an idea to give you a taste of what medically billable procedures are. And you’re going to have to make a medical
diagnosis and go, “Oh, I can’t make a medical diagnosis, I’m a dentist.” Well, in fact, there’s no such thing as a
dental diagnosis. There are only medical diagnosis. And every diagnosis that we make on a daily
basis in our practice is a medical diagnosis. However, some of the diagnosis that we make
will involve teeth. Some will involve teeth, some won’t involve
teeth. The difficulty here is that we’re not used
to being asked for a diagnosis. We’re not used to explaining to an insurance
company why we perform procedures. And that’s the difficult part in this process,
is getting used to making a diagnosis and communicating it effectively. So what exactly does it take to be successful
with medical claims? Well, it really comes down to your ability
to take your dental practice and to separate it into its two component parts, the medical
part and the dental part. And by doing that, that’s gonna lead you to
medical necessity versus dental necessity. The dental part of your practice involves
the teeth. And there are benefits only to the teeth. That is dental necessity. Medical necessity, on the other hand, means
that there are benefits to the patient beyond their teeth or there’s an underlying ideology
that’s systemic in origin, that’s manifesting itself in the oral cavity, making this treatment
necessary. You’ve moved beyond the teeth, now you’re
at medical necessity. And understanding the difference between those
two is key in your success with medical billing because you don’t wanna waste your time asking
medical insurance to pay you for dental procedures. They don’t, they won’t. There are only specific circumstances where
medical insurance will pay for treatments of the teeth and those are trauma, because
trauma trumps everything. And in the case of maxillofacial trauma, medical
insurance will pay to put Humpty Dumpty together again, including the teeth and systemic origin
manifesting itself in the mouth. So the difference between medical necessity
and dental necessity is critical in your success with medical billing, the ability to separate
those two. Let me break it down this way. In its simplest form, you have teeth and you
have the other stuff. Treatments of the teeth are payable on a dental
claim form to a dental insurance company. Treatment of the other stuff is payable by
medical insurance. The TMD, the sinuses, the maxilla, the mandible
problems, their airway, gingiva defects, all of those things are payable by medical insurance. Let’s put this new thought process to the
test. On the screen is a radiograph of a patient,
and let’s say this was your patient. And he’s a new patient, and he presented with
a toothache in this part of his jaw. And he has some swelling and tenderness, and
he tells you that he had root canal treatment about, oh, let’s say about three years ago
and he never had it properly restored. And from time to time, he gets swelling and
pain like he has today. And he finds a dentist that’s willing to give
him antibiotics and it goes away, it comes back, it goes, it comes, it goes, it comes. And he’s here to have this resolved. And you discuss treatment options with the
patient and the patient elects to have the tooth removed. You administer a local anesthetic and you
remove the tooth. My question is, would you send this patient
encounter to medical insurance? Yes, you would, but only if you can see beyond
the teeth. Consider what actually probably occurred here. This patient reported having swelling and
pain, on again, off again, over three-year period. And that radioluscent area at the apex of
the tooth, what do you think is the likelihood that it’s become cystic? Yes, it has. The body will build its cell wall around the
abscess infected area to try to contain it. So let’s say that the patient has elected
to remove the tooth. What is the first thing that you do, doctor,
after the forcep is placed on the tooth and the tooth is removed from the mouth? Yes, you take a curette and you go down into
the socket and you do what? You enucleate the cyst or remove any remnants
of it. So in fact, what treatment was necessary to
relieve this patient’s complaint? Was it removal of the tooth? No. The patient needed to have the cyst removed. And how are you gonna get the cyst out of
the jaw, doctor? Well, there’s only two ways that I can think
of. You either lay a flap and you come in from
the side cutting a huge hole in the cortical plate and come in from the side and get it
out that way, or after the tooth is removed, go in from that position with a curette from
above through the extraction site and remove it that way. And the patient already made the decision. He’s given up on the tooth. So my question is, was there a fee attached
to removing the cyst? No, we give that away because all we can focus
on is the tooth. And medical billing requires you to go beyond
the tooth. Well, there were services provided beyond
the tooth. They’re not gonna pay you to remove the tooth,
but they will pay you to remove the cysts, which is actually the treatment the patient
required. And let’s finish with this case. On the screen is a orthopantogram of a patient,
let’s just say with hopeless maxillary dentition. And all of those teeth need to go, and that
the patient’s gonna require surgery to smooth their regular alveolar process and do some
grafting and probably some lifting of the sinuses with the placement of, let’s say,
four fixtures into the surgical site. And then a prosthetic will be made to replace
the dentition. Well, would you send that to medical insurance? Yes. Absolutely. It’s probably very helpful if you’ll forget
that this patient has any teeth. And let’s just say that they walked in and
magically, these teeth were no longer in their mouth, what issues in the bone would you be
treating? Those are the things that are payable by medical
insurance. That’s what is the medical necessity for the
claim that would be filed. It has nothing to do with the removal of the
teeth or the replacement of the teeth because those are dental conditions, but they will
pay you for procedures in the maxilla. So at this point, it’s my hope that you understand
the mindset and perspective that you need to approach medical billing in your practice. And if you’re trying to improve the overall
health of your patients, you have already been doing numerous things in your practice
that you have had no way to be compensated for. And medical billing helps you offer more of
these options to your patients and still run a successful practice. Through the next courses, we’ll get into the
specifics about how the codes work and what you need to know to incorporate this into
your practice. And I look forward to seeing you then.

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