Cross-Coding: When Dental Procedures are Medically Necessary

Posted by admin | March 16, 2017 , (0) comments

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Although many dental procedures are the sole realm of dentistry, some procedures require applying medical codes. To be filed as a medical code, the procedure needs to be defined as medically necessary. Procedures that are considered medically necessary align with the American Medical Association’s three-part definition of medical necessity: (1) the procedure is in line with generally accepted medical practice, (2) the frequency, type, extent and duration of the procedure is appropriate, and (3) the procedure is not primarily for convenience. Therefore, teeth whitening would probably not be considered medically necessary. Examples of dental procedures that are medically necessary include: excisions, biopsies, many oral surgeries, oral cancer screenings and sleep apnea procedures.

When a dentist completes a medically necessary procedure, the submission of the code for insurance reimbursement differs from a purely dental practice. These procedures are filed with medical as the primary. They should not be concurrently filed with dental. CMS-1500 is the medical claim form that dentists should submit for medically necessary dental procedures. Diagnosis codes must be submitted on this form.

To determine the proper code for the medical procedure, dentists and their staff must consult the ICD-10. In the past, SNODENT (Systematized Nomenclature of Dentistry), an electronic nomenclature for electronic dental records, mapped dental procedures to the medical equivalent. Dentists could reference SNODENT to determine a standard term for a dental disease and to find the medical equivalent. As of this writing, SNODENT was completely mapped to ICD-9, the previous standard for medical coding that was replaced by ICD-10. The American Dental Association (ADA) is currently developing a “cross-walk” connecting the SNODENT vocabulary to ICD-10. Hopefully, dentists will soon be able to consult the more familiar SNODENT to determine the appropriate medical code for a medically necessary dental procedure.

Dentists face a unique challenge by having to code for both dental procedures and medical procedures. For many years, dentists filed separate claims for dental plans. Physicians had a completely separate set of codes. However, integration of the two coding systems has benefits for both. The set of data compiled from the medical billing codes is more complete. This data is used to highlight issues and track diseases. Dentists can add to this knowledge by filing medical codes properly for the procedures that require it. The American Dental Association hopes to make the process easier with the release of SNODENT cross-mapped with ICD-10. Until then, dentists must grapple with meeting the specifics of ICD-10. Keeping detailed notes about each procedure can assist with later coding. Although dentists must meet two different needs, dental and medical, the cross-coding can be hugely beneficial to the medical industry as a whole.

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