Medical to Dental Billing, Truth or Dare?

April 30th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Categories:   Dental   Billing  

Is it true that medical benefits are only accessible by physicians?  This is NOT True!  Perhaps you have been told it is illegal for a dentist to bill a patient’s medical insurance, this is erroneous information. In fact, the Accountable Care Organization’s objective is to provide better management of care for improved outcomes by consolidating and integrating patient’s oral care into primary health care.

The Health Center Program (HRSA) reported “The surgeon general’s landmark report Oral Health in America brought national attention to the importance of and disparities present in oral health. Furthermore, the Institute Of Medicine (IOM) report improving access to oral health care for vulnerable and underserved populations showed that unmet oral health care needs and barriers faced by these populations have a great impact on overall health.” This is a huge step from focusing just on teeth, to recognizing the center of vital tissues and functions is the mouth.  Therefore we are now seeing primary care physicians reporting for oral health initiatives. How soon will it be before we see it required in dental offices? 

The National Network for Oral Health Access (NNOHA) put together a pilot program to adopt and implement oral health and created a guide with recommendations that include assessment, planning, training systems, updating health information, and patient evaluation systems. This is a great resource to consider.   

It is never too early to adopt this new model of medical/dental integration. Changes are coming, now is the time to get started learning how you can benefit your practice and your patients.  Keep in mind medical payers determine coverage based on the medical necessity of the covered procedure. Payment is not based on the degree of the provider. 

Dental to Medical cross coding and coordination of care is rapidly changing thanks to the Affordable Care Act.  For dental offices knowing how and where to get the information to accomplish medical billing is priceless.  For a great resource on cross-walking, documentation, and information on medical coding check out the Reimbursement Guide for Dentistry, the first resource of this kind available through

Do you dare to invest your time in your practice? 

Medical Billing is very different than Dental billing. If you dare…step out of your comfort zone and spend time learning this new concept so you are prepared if the ACO or Health Center Program (HRSA) mandates new measures to be reported. In addition your patients will thank you and your revenue will increase. For example, take the dental sealant measure primary care providers are required to report; if they don’t have a dental provider on staff they need to refer their patients to one.  Don’t be afraid of failure, you can be successful and confident using resources such as Find-A-Code to access guidelines and rules.  Find-A-Code offers individual payer policies for most major payers to ensure you are well-informed on medical necessity and claims processing.

Conditions that may be payable under your patient’s medical plan

  • Emergency procedures due to trauma
  • Appliances for mandibular repositioning and/or sleep apnea
  • Treatment associated with inflammation and infection
  • Dental repair of teeth due to injury
  • Exams for orofacial medical problems
  • Multiple teeth extractions at one time or wisdom teeth, under certain conditions
  • Various periodontal surgery procedures
  • Consultation for an excisional biopsy of oral lesion(s)
  • Consultation and treatment for temporomandibular joint problems
  • Infection that is beyond the tooth apex and not treatable by entry through the tooth
  • Pathology that involves soft or hard tissue
  • Procedures to correct dysfunction
  • Congenital defects

Using the 1500 Medical Claim Form

When billing medical plans you are required you to bill claims on a CMS-1500 claim form using Current Procedural Terminology or CPT codes and ICD-10-CM (diagnosis codes).  CPT codes are used to report medical and surgical treatments, evaluations and diagnostic services. When using CDT codes you are not required to submit a diagnosis code, however, CPT requires at least one diagnosis code reported on every claim; failure to do so will result in a rejected claim.  If you file electronically, it is likely you will not get your claim past the clearinghouse without a proper diagnosis code or ICD-10-CM.   

Medical payers determine coverage based on the medical necessity of the covered procedure; therefore, it is vital to any medical claim to understand what is medically necessary, to begin to determine coverage.  

Learn about guidelines and rules

AMA Guidelines:  The American Medical Assn (AMA) has their own rules on how Current Procedural Terminology (CPT) codes can be used. These can be found on each code set or Chapter when using Find-A-Code.

ICD-10-CM Official Guidelines:  The instructions and conventions of the classification take precedence over guidelines.  ICD-10-CM Official Guidelines FY 2018  Guidelines are also found on the code information page of each code.

NOTE: Keep in mind State guidelines always take precedence over other guidelines and rules, if you are unsure always follow the strictest rule or guideline.  


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ADA Dental Risk Assessment codes


Questions, comments?

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