Ask the Expert...Medical Billing Basics - Part II

All too often, medical claims are denied simply because the fundamentals of medical billing are not understood. Learning by trial and error is very costly to a practice in terms of both time and money. Medical Billing Basics—Part I in our December 2011 edition of Insurance Solutions Newsletter addressed common questions such as which dental procedures are most often covered by medical plans, how to research medical benefits, how to obtain medical preauthorization/predeterminaion, how to request a network gap exception, where to obtain medical forms, etc. Medical Billing Basics—Part II highlights many of the additional questions that are frequently asked by dental teams who are interested in learning how to bill certain dental procedures to medical plans.

Q: We are a general dentistry office. How do we know when we should try filing with a patient’s medical insurance?

A: If a dental procedure is necessary because of trauma, a systemic disease (such as Sjogren’s disease), cancer/radiation therapy, xerostomia caused by medication, a pathological TMJ disorder, sleep apnea, the need for a surgical excision, etc., then there is a possibility that the procedure is covered under the patient’s medical plan. It is important to always call the patient’s medical carrier and give the applicable diagnosis codes and procedure codes before deciding to submit the claim to medical.

Q: Where can we get a questionnaire template for medical carriers that would cover all dental procedures that might be covered so only one call is made to the medical carrier?

A: When checking medical benefits, you should only verify benefits for the treatment at hand or treatment planned in the near future. Medical carriers are not likely to give you a complete “run-down” of benefits.

Q: Are evaluations (E&M) ever covered under medical plans on the same day as the treatment procedure?

A: In some cases E&M visits may be covered on the same day as a procedure. We first need to review the concept of the global surgical package, which is part of certain procedure codes in CPT. One of the components of the global surgical package is “subsequent to the decision for surgery, one related E&M encounter on the date immediately prior to or on the date of the procedure.” This means in order to bill for and be reimbursed for an E&M service on the same day as the procedure, the documentation in the patient’s record must be able to stand alone as a separate E&M visit. A modifier is necessary to report to the carrier that you did perform a separate and identifiable E&M service on the day of the procedure. Modifier 25 reported along with the procedure code will notify the carrier that you did perform a separate E&M on the same day as the procedure. Modifier 57 notifies the carrier that the service that was performed resulted in the initial decision to perform surgery. Keep in mind that not all carriers will cover the E&M on the same day as a procedure. However, without the modifier reported in addition to the E&M code, the service will not likely be covered.

Q: What is the highest level of E&M code typically billed by a dentist?

A: The level of E&M code that is reported should always be based on the documentation in the patient’s record and the guidelines in CPT. It is very difficult for most dental practices to reach the higher levels of E&M codes due to the amount of documentation that is necessary by CPT standards. Most dental practices report either a level 2 or level 3 E&M visit.

Q: When billing for extractions, if the medical carrier doesn’t pay for the pre-op exam, x-rays, etc., can we bill them to the dental carrier?

A: You can bill the dental carrier for the exam and x-rays if they are not covered by the medical carrier. It is not necessary to submit to medical first for these services. You can submit the claim for the exam and x-ray directly to the dental carrier. However, if the patient does have coverage under his/her medical plan, billing medical as the primary carrier may save some of the patient’s dental benefits for other services.

Q: If sedation is not covered as a separate procedure, can we lump the fee into the fee for the primary procedure?

A: According to medical billing guidelines, you must report the services separately. The guidelines for billing anesthesia vary from carrier to carrier, which is why it is so important to obtain the coverage guidelines from each patient’s medical carrier before performing the service. Coverage guidelines for anesthesia are often available on the medical carrier's website.

Q: What is a CPT code’s global period based on?

A: The American Medical Association determines the global period for certain procedures. Some procedures have a 0-day, 10-day, or 90-day global period, which means that certain procedures performed during that time frame are not separately billable. Global periods are listed in certain CPT books. If you purchase a medical procedure book (CPT), be sure that it includes the global periods— some medical procedure code books do not contain the global periods.

Q: Is the global period standard for all carriers or does it vary by carrier?

A: The global period for a CPT code is the same for all carriers and is established by CPT/American Medical Association.

Q: Where can we put a narrative on the medical claim form?

A: Typically, brief narratives are submitted either in field #19 or on the shaded line directly above the procedure code line. Medicare’s claim form instructions ( ) describe the information that should be entered in box 19 or included on a separate paper attached to the claim: “When reporting an 'unlisted procedure code' or a 'not otherwise classified' (NOC) code, include a narrative description in item 19 if an adequate description can be given within the confines of that box. Otherwise, an attachment should be submitted with the claim. The carrier will return the claim as unprocessable if an 'unlisted procedure code' or 'NOC' code is indicated in item 24d, without an accompanying narrative in item 19 or on a separate attachment.”

Q: Do you have any experience with medical carriers only paying imaging centers for CT scans or requiring special licensure for providers who take CT scans?

A: Yes. Some carriers now require facilities to become accredited prior to paying for MRI and CT scans. United Healthcare is one such carrier. Medicare recently adopted this requirement as well. When Medicare adopts a new policy, other carriers tend to follow. Along with the requirement for the facility to be accredited, many insurance carriers now require patients to obtain preauthorization before receiving the scan. As such, it is important to call the patient’s medical insurance plan before performing (or referring the patient for) a CT scan or MRI to determine if a preauthorization is required.

Q: What happens if the first diagnosis is made in our office instead of a primary care doctor? Do we need a primary care physician’s diagnosis before we can send a claim to medical insurance, or is the dentist’s diagnosis good enough?

A: If the diagnosis is within the scope of the dentist’s license, the dentist can report his/her diagnosis. However, some medical plans may want the diagnosis confirmed by a physician. For example, a dentist is qualified to diagnose xerostomia caused by medication(s) the patient is taking. However, a physician (MD) would need to confirm the diagnosis of Sjogren’s Syndrome, GERD, bulimia, etc.

Q: We are a general dentistry office, but we often submit claims for wisdom teeth extractions, bone grafts, and other surgical procedures. We often receive requests from medical carriers for MD evaluation letters. Obviously, our patients do not see a physician for wisdom teeth extractions. How should we respond to this request?

A: Are medical carriers asking you for a copy of the referral from the primary care provider (PCP)? Patients covered by HMO plans are often required to obtain a referral from their primary care physician before seeking treatment of any kind. Without an official referral from the primary care physician, the services may not be covered since the patient did not follow the protocols required by his/her insurance plan. As noted on our medical phone preauthorization template (available in the Staff Support/Forms section of the Insurance Solutions Newsletter website), this is something to ask the medical plan when calling to obtain preauthorization before performing treatment. It is the patient’s responsibility to obtain the referral, but you may need to remind the patient of this requirement.

Accident-related Claims

Q: If a patient sustained a documented injury from an accident several years ago and now needs additional dental work related to the original accident, can we still file through medical, or has it been too long?

A: Coverage for accident-related injuries varies by carrier. Some carriers only cover services performed within the first 24 hours, others up to 90 days, while others may cover services within two years of the accident. I have also seen examples of services being covered years after an accident. It will depend on the wording of the patient’s medical policy. In these instances, I would never assume there will be coverage. I would always check with the carrier.

Q: Should we send a letter of medical necessity with the initial accident claim or wait until the medical carrier requests it?

A: Hold off sending the letter of medical necessity until the carrier requests additional information. A properly completed CMS 1500 form has sufficient information to get the claim initially processed. Completion of box 10 (where the type of accident is described) and detailed and accurate ICD-9 codes in box 21 often give the carrier enough information to process the claim. When services are accident-related, carriers may require additional information from either you or the patient to verify that the medical carrier is liable for the claim.

Q: An accident patient was covered under both dental and medical insurance. Dental paid at its level, and medical paid the entire amount after the deductible. This left about $1,000 as a credit on the patient’s account. Where should we send the overpayment refund?

A: When the medical plan pays on an accident claim, it is typically considered primary. Did you notify the dental plan on the initial claim that the services were necessary due to trauma and that you were also billing the medical plan? Be sure to disclose all plans (medical and dental) that you intend to bill. You should notify the dental plan of the overpayment (sending both EOBs) and ask the dental plan to notify you in writing of the refund amount that is due. Send the refund check back to the dental plan after you receive its written refund request. This will ensure that the money is properly credited back to the patient’s benefit year maximum.

Q: I work in a pediatric dental office, and the vast majority of medical claims we file are dental trauma claims. The treatment is usually rendered on the date of the trauma, so we are not able to obtain a preauthorization ahead of time. Also, we are almost always considered out-of-network, so our patients usually have to pay a large deductible. What would be your suggestion about obtaining preauthorization?

A: Some carriers will allow an out-of-network dentist to treat the initial emergency services even if there are contracted providers in the area. Either you or the patient should phone the medical carrier before treatment so the appropriate preauthorization can be obtained, if necessary. You may need to request a network gap exception, which may be available when the medical plan does not have a participating provider in the area who is qualified to deliver the necessary emergency services.

Q: If a patient sustained a documented accident 30+ years ago and now needs additional dental work that is related to the original accident, can we still file it through medical, or has it been too long?

A: Coverage for late effects of trauma vary from plan to plan. Some only cover if the current plan was in effect at the time of the original accident. Others cover even if the current plan was not in effect at the time of the accident. You will need to check with the patient’s current medical plan to know what the time limitations are for trauma-related injuries. Be sure to add this to the list of questions you ask when you call the medical carrier to obtain preauthorization for services you intend to perform.


Q: Are dental procedures ever covered by Medicare?

A: According to the CMS website (, Medicare excludes coverage for services "in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth." Medicare may, however, provide coverage for the extraction of a tooth as part of a repair of a fractured jaw, maxillofacial surgery for pathological or traumatic medical conditions (for example, in case of a serious injury, prosthetic rehabilitation to replace or treat certain oral and/or facial structures related to covered medical and surgical interventions, such as cancer surgery), and extraction of teeth prior to radiation treatment of the jaw.

Q: Can we bill Medicare if we have not enrolled in Medicare?

A: Dentists must specifically enroll in Medicare in order to receive payment from Medicare.

Q: Why can’t our dental office bill Medicare as we would for a patient on any other type of insurance, even if we are not in-network?

A: Federal law prohibits any provider from billing Medicare unless he/she has enrolled as a participating or nonparticipating provider. By enrolling, Medicare is able to verify your credentials and require you to accept its fees.

Q: If a patient has Medicare but we do not participate with Medicare, can the patient be paid by Medicare directly?

A: Yes. However, Medicare will not pay a dentist who has not specifically enrolled in Medicare. One exception is a dentist who enrolls in Medicare as a DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies) supplier. DMEPOS dentists will be paid for oral sleep apnea appliances that meet Medicare’s criteria.

Medicare patients can use CMS form 1490S to bill Medicare directly for reimbursement of qualifying services (assuming the dentist has not opted out of Medicare). Send an email to with “Medicare Patient Form” in the subject line, and we will send you an electronic copy of CMS form 1490S.

Keep in mind that when patients submit form 1490S for reimbursement, Medicare carriers are required by law to send a letter to providers reminding them that federal law requires providers to bill claims for non-routine services to Medicare for patients if the provider has not specifically opted out of Medicare. Dentists who refuse to submit potentially covered Medicare services for their patients are put on a “watch list” for non-compliance. To have a claim processed by Medicare, dentists must first enroll in Medicare. Medicare rules are complex. If you would like to be notified of our next webinar on Medicare Billing for Dentists, send an email to with “Medicare Webinar” in the subject line.

Q: In our office we are not contracted with any dental insurance companies. We bill our patients' dental plans, but patients are responsible for our full fee. Is it advisable to sign up for Medicare or not?

A: Since most dental procedures are not covered by Medicare and Medicare fees are notoriously low, most dental practices do not participate in Medicare. However, if you perform a potentially covered service for a Medicare patient, federal law requires you to enroll in Medicare if you have not formally opted out of Medicare. So, it is a good idea to opt out of Medicare every two years if you do not want to bill Medicare for potentially covered non-routine services and if you do not want to have to accept Medicare fees and follow Medicare's Advanced Beneficiary Notice requirements.

Q: How important is it for a general dentist to enroll in Medicare as an ordering/referring provider?

A: It is very important for a dentist to enroll as an ordering/referring provider. All dentists need to enroll in PECOS—even if they do not intend to participate in Medicare. Enrolling in PECOS as a referring provider will allow your patients' claims to be paid if you refer them to a radiology lab, pathology lab, oral surgeon, etc. If you are not enrolled as an ordering/referring provider, the claims for the pathology lab, radiology lab, etc., may not be paid.

Q: If we enroll as an ordering/referring provider, do we still have to opt out of Medicare if we do not want to bill Medicare (and accept its fees) for potentially covered services?

A: Yes. If you do not want to bill Medicare and accept its fees for covered services, you will need to officially opt out of the Medicare program and enter into private written contracts with Medicare-eligible patients in your practice.

Q: As a BCBS provider we participate with limited dental for those who have Medicare. Does that mean we are automatically enrolled in Medicare?

A: To enroll in Medicare you would have been required to complete a 30+ page application and make a decision as to whether to become a participating or non-participating provider (both are enrolled in Medicare). If you do not remember completing an extensive application, then you are probably not enrolled in Medicare. It may be that you are somehow affiliated with a Medicare Advantage plan through BCBS.

Q: I was recently told that over 30 companies across the country administer Medicare claims, and each has its own processing policies. If this is correct, do we need to call each Medicare carrier before we submit a claim to that particular administrator?

A: Over 30 subcontractors across the country process Medicare claims, and all have their own interpretations of Medicare guidelines. Fortunately, most of the Medicare claims you submit will be sent to your local Medicare carrier, so you will become familiar with its specific policies. Most Medicare carriers/contractors publish their payment guidelines on the internet and are relatively easy to find.

Q: If a Medicare patient falls and breaks a tooth, do we have to submit to his/her dental insurance first? What if the patient has maxed out his/her dental plan for the year?

A: According to the Medicare manual, Medicare does not cover “services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth.” In the situation you have described, there would be no coverage under Medicare (Part B).

Q: If a patient who has Medicare as his/her only form of insurance wants to be seen for a toothache, is this billable to Medicare? Would we have to bill it even though we are not in the Medicare network?

A: The original Medicare (Part B) program does not cover the treatment of a toothache or any other routine dental procedure. There are only a handful of dental procedures potentially covered by Medicare. TMJ appliances and oral sleep apnea appliances may be covered if the case meets Medicare’s medical necessity criteria. Oral biopsies are also covered by Medicare in certain situations. While most dentists do not enroll in Medicare, some do enroll as participating or non-participating providers. The decision often depends on the age of the patient population that the dentist treats and the type of services he/she provides. Keep in mind that the original Medicare (Part B) program, which covers the majority of U.S. citizens over age 65, is not the same as Medicare Advantage (Part C). Do not confuse the two programs. Some Medicare Advantage plans provide coverage for routine dental services.

Q: If we are billing medical claims but are not planning to get involved with Medicare, must we sign up with Medicare before we can opt out?

A: Some Medicare contractors allow dentists to opt out without having to first enroll. Other Medicare contractors require dentists to enroll first before formally opting out. It varies depending on who your local Medicare carrier is. Send an email to with “Medicare Update” in the subject line if you would like to receive additional information about Medicare.

Q: I was told by our local Medicare carrier that our office could apply for a Medicare provider number, but it would be a waste of time because we are a dental practice and Medicare never covers dental procedures.

A: Although most of the procedures performed in a dental practice are not covered by Medicare, there are circumstances when a service may be covered by Medicare, such as biopsies, certain TMJ services, sleep apnea appliances, etc. The dentist is required to enroll in Medicare before receiving payment from Medicare for covered services. Dentists who provide oral appliances for sleep apnea will need to enroll as a Medicare DMEPOS supplier in order to receive payment from Medicare.

Q: If we only want to order/refer services for Medicare, do we have to sign up for Medicare, or can we just enroll in PECOS as an ordering/referring provider?

A: A dentist can enroll in PECOS as an ordering/referring provider without enrolling in Medicare. Send an email to for more detailed information on PECOS.

Q: If we have opted out of Medicare, will our patients be able to get biopsy or excision services covered?

A: If you have opted out of Medicare but have enrolled in PECOS as an ordering/referring provider, you can refer Medicare patients to another provider for biopsies or excisions. Once you opt out of Medicare, you cannot submit claims to Medicare for services you provide for two years—nor can the patient. However, you can refer the patient to another Medicare provider for the services, if you are enrolled in PECOS.

Q: I have worked in our practice for three years and was told that we “opted out” of the Medicare program a long time ago, but we have no documentation to support this. Who can I contact to verify this information or obtain our provider's previous Medicare ID number?

A: Opt-out affidavits are only good for two years and private patient contracts with Medicare patients are also required in order for your opt-out affidavit to be valid. It is unlikely that your provider still has a valid opt-out on file with Medicare. However, you can view the names and NPI numbers of all providers who are enrolled in Medicare’s Provider Enrollment System at If your provider is in Medicare’s PECOS system, you should be able to verify his/her current status. If he/she is not in the PECOS system, Medicare will not accept claims from him/her, and Medicare will not pay for services he/she refers or orders (i.e., lab tests)