patient arrives at your office in pain, having
fallen and fractured a tooth. She's taken to the
treatment room, where you determine that she needs
a root canal and crown. Your insurance coordinator
says the patient does not have dental insurance
coverage. Due to the nature of this case, you
begin treatment. Later, the patient tells your
financial coordinator that she will only be able
to pay $50 today and a maximum of $50 per month
These production dollars could sit uncollected
in A/R for years. Collection costs alone will
significantly erode the value of those fees.
A solution to this common problem is filing dental/medical
cross-coded insurance claims. Cross-coding is
an effective and relatively easy way to increase
practice revenue and reduce the costs associated
with A/R collections.
Why use it?
Medical insurance has significant advantages
over dental insurance.
Most medical plans do not have yearly maximums,
so when claims are filed with medical insurance,
the dental yearly maximum is not depleted.
Also, most dental plans follow the guidelines
of allowing benefits for full-mouth x-ray series
once every three to five years. The American Medical
Association (AMA) allows this service every two
When medical insurance can be filed in addition
to dental, it can greatly reduce co-pays for patients,
as well as attract new patients who do not have
When to use it
You may file dental procedures under a patient's
medical plan in any of the following four categories:
• Infection that is beyond the tooth apex
and not treatable by entry through the tooth.
• Pathology that involves soft or hard
• Procedures related to dysfunction.
• Emergency trauma procedures.
How to use it
The implementation of a dental/medical cross-coding
system in your office involves several steps.
Redesign your patient registration form to add
a section for medical insurance information. The
requested information should include the patient's
name, date of birth and Social Security number.
You also will need the name of his or her employer,
as well as the patient's marital status, group
number, insurance ID number, claim filing address
and the insurance carrier's phone number. If the
patient is a child and a full-time student, you
will need the name of the school.
Indicate that some procedures may be filed on
the patient's medical plan as a courtesy, but
the final responsibility of payment of fees is
theirs. HMO and PPO plans may decline benefits,
pay the subscriber or pay a lower percentage.
The subscriber has the right to file with the
medical insurer as the primary payer, as long
as it is not stated in the plan that dental insurance
must be filed first for dental procedures.
You also will need to become familiar with CPT-2005,
ICD-9, V and E codes and modifiers.
CPT-2005. Dental insurance companies require
CDT-5 codes along with their word descriptions.
HCFA 1500 forms (see "How To…"
page 10) require CPT-2005 codes as the description
of service with no word descriptions.
ICD-9. These are the diagnostic and surgical
codes used to establish a medical necessity. More
than one code can apply to a procedure and decisions
as to the diagnoses must be made on every claim.
V and E codes. These codes are used to classify
factors affecting health and the seeking of medical
services. V codes are used when situations other
than a disease or injury are entered as diagnoses.
E codes are used as the classification of the
external cause of the injury. An example of this
would be the patient who fell and broke a tooth.
You will need to find out how and where she fell
to determine the E code.
Modifiers. Located in the appendices of CPT-2005,
modifiers are attached to a procedure code when
the circumstances of the code have changed, but
not the definition. For example, you'd use a modifier
if you provided only one component of a procedure;
i.e., you read an x-ray taken by another professional.
Modifier 26, "Professional Component,"
identifies that you provided a professional, not
technical, contribution to this procedure.
A modifier also may be used when several doctors
perform a service. Other modifiers provide for
partial and adjunctive procedures, as well as
services performed multiple times.
Not all third-party payers recognize modifiers.
But if you are permitted to attach modifiers,
they can help with claim acceptance.
Cross-coding isn't difficult, but problems occasionally
arise. Here are some tips to resolve some of these
No check. If three to four weeks have passed
since submitting your claim, and you have not
received a benefits check, call the insurance
company. If the claim is denied, insist that they
give you the reasons for denial.
If a phone call does not produce the desired
results, send a letter requesting an explanation
of the denial so that you may make any necessary
corrections and ask for a reconsideration of the
claim. By law, the insurance company cannot discriminate
against you because you are a dentist. If the
policy states "no dental claims," advise
them that it is a medical claim. Your last resort
will be to have your patient contact the state's
The right codes. The biggest obstacle is choosing
the correct codes, because incorrect coding will
cause the greatest delay in payment.
Prepare a list of the most common appropriate
procedures and assign the corresponding CPT-2005
and ICD-9 codes. This can be a handy reference
tool for the actual preparation of the claims.
Dental/medical cross-coding manuals can be of
great assistance with this.
You can purchase coding manuals from the AMA
"Maximizing Medical Reimbursement in the
Periodontal Practice" by The Z Group LLC
is a resource that can help with dental/medical
cross-coding. HCFA 1500 forms can be purchased
from any medical-office supply store.
Practices should collect payment-in-full at the
time of service. Patients should be told that
the medical claims are being processed as a courtesy;
any benefits received will promptly be refunded
to the patient.
It is certainly worth the time and effort to
implement a dental-medical cross-coding system.
You will be able to add a valued service for your
patients that should reap financial rewards for
Posted by dentalproducts.net.
Originally published in the March 2005 Dental
Practice Report. Copyright 1999-2005 Advanstar