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.