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    Medical billing for dental surgery: What you need to know

    It’s not always easy to get medical insurance to pay for dental operations, but these tips will help make the process a lot smoother.

    Sometimes, one of the most difficult parts of performing dental surgery is helping your patients figure out how they’re going to pay for it.

    You see a deteriorating oral health situation that can impact their whole-body health, but they’re focused on the cost of the procedure. Unless you can find a way to help them pay, you’re not going to be able to solve their problems.

    Medical billing for dental surgery can make it easier for your patients to afford treatment. Dental insurance often has very low benefit caps. Meanwhile, if a surgery is medically necessary, medical insurance may reimburse for nearly 70 percent of the cost. When you add medical billing capabilities to your office, life gets easier for your patients. However, making the switch means changing how you think about necessity.

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    Documenting medical necessity

    To receive reimbursement from medical insurers, you need to make a case that proves that dental surgery is necessary for the patient. To make your case, you need to explain your decision process in terms that a medical insurer can understand, using ICD-10 codes and CPT codes. These codes may appear similar to the CDT codes that you’re familiar with, but they’re more detailed and take time to learn.

    Dental model on pile of moneyTo succeed in your medical billing claims, you’ll need to document:

    • The primary presenting situation
    • Any secondary, supporting diagnosis
    • The diagnostic code for the treatment you plan
    • Surgical pre-authorization
    • Medical Necessity, in the form of a letter of medical necessity
    • Support from the patient’s Primary Care Physician, in the form of a supporting letter of medical necessity
    • The procedures performed at each surgery location

    This information lets you give the medical insurance company a complete picture of the care you’ve provided. It makes a compelling case that the issue you treated was a medical issue, not simply a dental one, and that it should be eligible for reimbursement by the patient’s medical insurer.

    Pre-authorization

    You’ve probably dealt with pre-authorization in your own life, with your own family. It’s usually fairly easy to contact the insurer by phone, explain the procedure and the date, and receive pre-authorization for treatment.

    While some insurers will provide retroactive pre-authorization after the fact, the surgeries you’re performing don’t happen on a moment’s notice. Have your office call for pre-authorization when the surgery is scheduled. Being proactive on pre-authorization will save you and your patients headaches later on and can make the difference between the acceptance and rejection of a medical claim for dental surgery.

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    When you contact the insurer, you should also collect information on what coverage your patient has and how the insurer will reimburse for surgery. It’s essential that you get information on co-pays and deductibles upfront, so you can help your patients plan for their part of the cost.

    The Letter of Medical Necessity

    In the Letter of Medical Necessity (LMN) you have a chance to outline your case for surgery. You must use ICD-10 codes properly in this letter, or the insurer won’t accept your reasoning and will not pay for the surgery. In general, you should limit yourself to four diagnostic codes in the letter. List the codes in order, from the most important to the procedure to the least important. For instance, you might start with periodontal disease, but also mention the patient’s heart disease and Type II diabetes, since these conditions both complicate the surgery and make treatment more urgent.

    Christine Taxin
    Christine Taxin is the founder and president of Links2Success, a practice management consulting company to the dental and medical ...

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