Can I File that to Medical
Our customer support team receives calls regarding medical claims filing on a daily basis. Most medical coding questions received fall into one of three categories: general information about how a claim is filed, how to file an accident related claim, and how to file a claim for biopsies and cancer treatment. This article will provide basic answers to frequently asked questions about how medical claims are filed and the type of dental procedures typically reimbursed.
General Information
Q:
What claim form is used to file a medical claim? Where can I find it?
A:
The current medical claim form is the Healthcare Finance Administration (HCF) CMS 1500 (02-12). These forms are available at many office supply stores, as well as through our website, www.practicebooster.com. However, you may be able to generate a medical claim form through your dental practice management software.
Complete instructions on how to complete this form can be found at www.nucc.org.
Q:
Can I report dental codes on a medical claim?
A:
Some medical plans will allow dental codes to be submitted on a medical claim form. This is typically limited to procedures without a clear corresponding medical code. For example, there is currently no medical code to report the extraction of a tooth, so the medical payer may allow a dental code to be reported.
Medical procedures are described by either Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes. A CPT or HCPCS code is always required if there is one available to clearly describe the procedure performed. Note that some medical payers do not allow dental codes to be submitted at all. In that case, an unlisted or nonspecific CPT or HCPCS code should be assigned.
Q:
I understand I need a diagnosis code. What is that and how do I find it?
A:
ICD-9-CM is the medical diagnosis code set currently in use. ICD-9-CM will remain in effect until the implementation of ICD-10-CM, which is scheduled for October 1, 2015. (Note: All diagnosis codes referenced in this article will be ICD-9-CM codes.)
All claims submitted on a medical claim form require at least one diagnosis code. This is true whether you are submitting a dental procedure code (CDT) or a medical procedure code (CPT). Think of a claim as telling your story in numbers. The procedure code tells what procedure was performed, and the diagnosis code completes the story by telling why that procedure is necessary. Medical practices have been required to link diagnosis and procedure codes for many years, but it is still a new process for most dental practices.
Diagnosis codes can be found through online sources. There are many publications that list the entire ICD-9-CM code set (approximately 16,000 codes). While ICD-10-CM is not yet in effect, a draft is available of the nearly 70,000 codes included in this code set. Also, our new publication, Diagnostic Coding for Dental Claim Submission, is specifically designed to cover both ICD-9-CM and ICD-10-CM codes that are commonly used in the dental practice and reported on the 2012 ADA Dental Claim Form. (Visit www.practicebooster.com for details on this new guide.)
Accident Related Claims (Trauma)
Q:
Does medical insurance cover a procedure for a broken tooth?
A:
Most medical insurance plans provide coverage for traumatic (accident related) damage to teeth. This includes fillings, root canals, crowns, extractions, bridges, and sometimes implants. Interdental wiring to stabilize an evulsed or loosened tooth is typically covered by the patient’s medical plan as well.
Q:
My patient broke a tooth while biting into a piece of hard candy, and she wants the claim filed to her medical insurance. Will this be reimbursed?
A:
Processing policies of major insurance payers, including BlueCross/BlueShield and Aetna, state that dental services may be considered medically necessary for the reconstruction of natural, sound teeth following accidental, external trauma. This would include sports accidents, falls, automobile accidents, blows to the mouth, and other incidents resulting in damage to the mouth, teeth, and gums.
Teeth fractured by biting or eating do not meet the criteria listed above, and restorations on those teeth are not typically reimbursed by medical insurance. That being said, sometimes, if the patient is insistent, it is best to file the medical claim anyway. This can go a long way in creating goodwill with the patient. Even if the claim is denied, some patients may choose to submit an appeal to the medical plan.
Q:
Our patient fell in the shower, hit his face on the bathtub, and fractured a crown. Will this be covered?
A:
As previously noted, medical carriers will consider benefits for restorations to natural, sound teeth. If a tooth restoration is damaged, whether it is a crown, bridge, denture, or filling, it will generally not be considered for reimbursement. Again, it may be best to file the claim if the patient requests.
Q:
The procedures we performed are not covered by medical codes. What procedure codes can I use?
A:
Remember, some medical payers recognize dental codes. Ask a representative from the patient’s medical plan if it allows the reporting of dental codes on the claim form. If not, all procedures (e.g., extractions, root canals, crowns, etc.) should be filed using the unlisted code 41899 (unlisted procedure on a dentoalveolar structure). Because this is a nonspecific code, include a brief description on the claim form and attach a narrative.
Q:
Is there a diagnosis code to report a damaged tooth?
A:
Yes, a diagnosis code may be assigned to describe a damaged tooth. Some commonly used diagnosis codes include the following:
- 873.62 Open wound of gum (alveolar process) uncomplicated
- 873.63 Tooth (broken) (fractured) (due to trauma) without mention of complication
- 521.81 Cracked tooth
- 525.63 Fractured dental restorative material without loss of material
- 525.64 Fractured dental restorative material with loss of material
An external cause code, or “E” code, is often assigned as a secondary code to describe an accident. A couple of examples are:
- E886.0 Accidental fall on same level from collision pushing or shoving by or with other person in sports
- E888.1 Accidental fall resulting in striking against other object
Q:
Our practice is not in-network with any medical plans. Will we receive reimbursement for our claims?
A:
When possible, always contact the patient’s medical plan prior to treatment to determine if benefits are available. Some medical plans waive deductibles (including out-of-network deductibles), copays, and coinsurance for accident related treatment. This does not apply to all plans and the patient may need to file a request and/or appeal to the payer for this benefit, especially if the service was provided out-of-network.
Q:
We are not enrolled or do not participate with Medicare. Can I still file for emergency dental services?
A:
Medicare excludes all routine dental coverage, including extractions or treatment for teeth that are damaged or lost due to trauma. There is no obligation for dental practices to file for these procedures. If your practice is not enrolled as a Medicare provider, you are not allowed to file. If a patient chooses to file a claim, Medicare will deny all non-covered procedures.
Medicare’s statement on coverage of dental services can be found at here.
Pathology (Biopsies and Excision of Lesions)
Q:
I filed a claim for a biopsy to my patient’s dental insurance, but it was denied stating it should be filed to medical. Will medical insurance cover this?
A:
All medical plans, including Medicare, provide coverage for the removal of suspicious lesions. A biopsy is probably the most common medically necessary procedure performed in dental practices.
Q:
What procedure code(s) do I use to report a biopsy?
A:
Biopsies and the removal of lesions are filed to medical plans using CPT codes. The correct procedure code is determined by the lesion’s location. Some of the more commonly used procedure codes for biopsies and excisions are:
- 40808 Biopsy, vestibule of mouth
- 40810 Excision of lesion of mucosa and submucosa, vestibule of mouth, without repair
- 40812 Excision of lesion of mucosa and submucosa, vestibule of mouth, with simple repair
- 40814 Excision of lesion of mucosa and submucosa, vestibule of mouth, with complex repair
- 41100 Biopsy of tongue, anterior two-thirds
- 41105 Biopsy of tongue, posterior one-third
Q:
How do I find the correct diagnosis code to report?
A:
Typically, a biopsy is submitted to a pathology laboratory for examination. Do not submit a claim until the pathologist’s report is received. The report will indicate whether the lesion is benign or malignant and will include the diagnosis. Often, the report will actually list the appropriate diagnosis code; that code can then be entered on the medical claim form. Always include a copy of the pathologist’s report with the medical claim submission.
Q:
What if no specimen was sent for pathology examination?
A:
Occasionally, an obviously benign lesion is removed in its entirety and no pathology report is available. In this situation, report the procedure with the appropriate benign lesion code. The diagnosis code must be selected to describe the nature of the lesion. For example, an excision of a mucocele with a simple repair would be assigned the procedure code of 40812 (excision of lesion of mucosa and submucosa, vestibule of mouth, with simple repair) and the diagnosis code 527.6 (mucocele of salivary gland).
Q:
Are other cancer related treatments reimbursed by medical insurance?
A:
Most medical plans, including Medicare, will allow reimbursement for extractions in preparation for head and neck radiation. In addition, restorative surgery and some dental services may be allowed following radical oral cancer surgery. It is always advisable to have any treatment of this type approved by the patient’s medical payer prior to performing the treatment.
Q:
What about appliances such as radiation shields and fluoride gel carriers for cancer patients?
A:
Although coverage for these appliances may vary, most plans will provide coverage for radiation shields. However, fluoride gel trays are typically not covered by the medical payer. Medical coding and billing is an open opportunity for dental practices to explore. While all dental procedures will not be reimbursed by a medical plan, many can be reported for consideration. Our support team is available to assist you with any question you have regarding medical codes. We can be reached by email at support@ameridentibilling.com.