Cross Coding—Medical Coverage for Dental Treatments
Dental and medical insurance require different codes for their claims. Unlike dental insurance, which requires CDT codes for claims, medical insurance requires Current Procedural Terminology (CPT) codes for medical procedures and treatments and International Classification of Diseases (ICD) codes for medical diagnoses and diseases (Lupoli 2016). ICD codes “[establishes] the medical necessity of the procedure” (Apex EDI 2016). However, cross coding in dental and medical insurance may help patients take full advantage of their benefits.
Medical insurance could cover some dental treatments based on their medical necessity to the patients. For “a procedure [that] is considered medical in nature,” usually, clinics should send the claim to medical insurance first (Philhower and Blair 2016). After medical insurance approves it, clinics then send the claim “with the medical explanation of benefits (EOB)” to dental insurance (Philhower and Blair 2016). Some medical insurance companies permit “dental codes to be reported on the medical claim [forms]” instead of medical codes, but ICD codes must always be present on those forms (Philhower and Blair 2016). Some services that medical insurance accept are “Most tooth extractions,” “Anything related to an infection,” and “Sleep Apnea Treatments,” for example (Taxin 2016a). In a 2017 CDT code update, CDT codes that medical insurance may accept include, for example, “D0414—Laboratory processing of microbial specimen to include culture and sensitivity studies, preparation, and transmission of written report” and “D0600—Non ionizing diagnostic procedure capable of quantifying, monitoring, and recording changes in structure and enamel, dentin, and cementum” (Taxin 2016b). Future updates to the CDT could lead to more dental services that medical insurance could cover.
Medical insurance may also yield higher coverage on dental treatments for the patients. Though, according to Jim Philhower, “director of North America dental sales leadership and development for Henry Schein Dental,” and Charles Blair, “CEO of Dr. Charles Blair & Associates,” “Medical coverage varies by plan. Many medical plans provide limited benefits for dental procedures. Medical plans often have high deductibles and out-of-network limitations, which decrease the actual dollar amount of reimbursement available” (2016). Even so, Christine Taxin, “founder and president of Links2Success,” says, “For many of your patients, medical insurance may provide better coverage and lower out-of-pocket expenses than their dental coverage for the same procedure” (2016b). With the aid of medical insurance, patients may then be more willing to go through necessary dental treatments (Lupoli 2016).
Despite the separation between medical and dental insurance, cross coding represents one area of overlap between them. Fortunately, clinics’ employees can learn more about cross coding through books, software, and classes on the subject (Lupoli 2016). There is also dental software that accepts and contains medical codes and medical claim forms (Lupoli 2016). With the increasing connections between dental and medical insurance plans and their codes, clinics could help patients effectively utilize the benefits of their insurance plans even more in the future.