the envelope fully expecting it to contain a payment
for a patient. Instead, you notice that there
is no insurance check. Quickly scanning the explanation
of benefits, you see the dreaded words "Due
to the emergency nature of this claim, file with
medical insurance as the primary carrier".
You suddenly get a sick feeling in the pit of
your stomach because you have no idea how to file
a medical claim, and you hate to disappoint your
patient. Fear not. Although it is considerably
different than filing a dental claim, medical
billing is easy once you know the basics.
While it is well known that trauma-related dental
services can be billed to medical plans, there
are other dental services that can also be billed
to medical. In order for a dental service to be
considered for payment under a medical plan, the
service must be a medically necessary procedure
that is based upon a medical diagnosis. Examples
of such services are exams and consultations for
oral-facial medical conditions, oral surgery procedures
such as hard and soft tissue biopsies, periodontal
procedures caused by or exacerbating a medical
condition, procedures relating to oral dysfunction,
TMD procedures, procedures for myofascial pain
conditions, medically necessary radiographs, etc.
There are several advantages to filing medically-related
dental services with medical plans. Dental plans
typically have yearly maximums that medical plans
seldom have1. When medical or trauma-related services
are covered under both a dental and medical plan,
the patient’s out of pocket expense may
be significantly reduced. You may see an increased
case acceptance for those procedures that fall
under the guidelines for filing medical, especially
for patients who do not have a dental plan. Lastly,
a willingness to file dental procedures that are
medically-related will be seen as a value-added
service by your patients.
Today’s dental practices need to become
familiar with the medical billing process. Over
the past decade, research has exposed a relationship
between oral infection and systemic health conditions,
causing dental professionals to look more closely
at the link between a patient’s oral health
and overall physical health2. A carefully developed
patient medical history form that includes entries
for cardiovascular disease, high blood pressure,
diabetes, and respiratory disease is essential
on new patient registration forms and recare update
forms. Periodontal pathogens are suspected to
have an effect on these conditions. The information
provided on the patient’s medical history
form in combination with the dentist’s clinical
findings and, on occasion, information obtained
from the patient’s physician are used to
determine the diagnosis codes that are needed
to file medical claims.
Medical insurance is diagnosis driven. Medical
carriers need to know why procedures are performed.
Diagnosis codes provide the answer to this and
are listed on a medical claim form following patient
demographics. Medical benefits will not be paid
without them. Providers currently use ICD-9 codes
(International Classification of Diseases) to
report the diagnoses and to establish medical
necessity. Diagnosis codes are divided into primary
codes, secondary codes, symptoms and ill-defined
conditions, and V and E Codes.
The primary diagnosis is the most significant
condition for which the procedure was performed
and must be listed first. Secondary diagnosis
codes are listed after the primary diagnosis and
are used to report any additional medical factors,
conditions, or symptoms. In addition, one may
need to use V and E to other information about
the diagnosis. V codes are used when situations
other than a disease or injury are entered as
diagnoses3. A V codes might be used when a patient
has a personal history of neoplasm of the tongue
that influences treatment (V10.01) or for a patient
who is having difficulties with mastication (V41.6).
E codes are used to classify the external cause
of the injury, such as how and where it happened4.
For example, E codes would be used if a child
is injured when falling out of bed (E884.2) at
his/her home (E849.0). E codes are also used to
indicate an adverse effect of therapeutic doses
of medication, such as an adverse effect from
an anticonvulsant drug (E936.1). In addition,
E codes also indicate late effects. Late effects
are residual effects that are present one year
or more after the original injury5. For example,
E929.0 codifies late effects from a motor vehicle
accident. V and E codes are rarely used as the
primary diagnosis codes and should be listed after
primary and secondary diagnosis codes. When a
specific diagnosis cannot be determined clinically,
codes can be found in ICD-9 for signs, symptoms,
and ill-defined conditions (e.g. 780.51 for insomnia
with sleep apnea)6.
While diagnosis codes are reported using ICD-9
codes, procedures are reported to medical plans
using CPT codes (Current Procedural Terminology).
Modifiers are sometimes used to clarify certain
types of procedures, such as when a procedure
is bilateral (-50). Modifiers are entered after
the CPT code in box 24. When more than one surgical
procedure is filed on the same claim, the most
significant procedure should be listed first7.
The biggest challenge to filing a successful medical
claim is selecting the correct codes. Dental offices
need to become familiar with the CPT and ICD-9
medical code books, obtain a good dental-medical
cross-coding book, or find a reliable resource
to help with current medical coding. At best,
incorrect coding will cause a delay or denial
of payment. At worst, incorrect coding can result
in serious legal consequences.
- Key Steps
Filing medical claims involves several key steps.
First, you will need to obtain the patient’s
medical insurance information. This can be done
by either re-designing your patient’s
registration form to request the information
needed or by using a separate medical information
form or by using a separate medical information
form. Emphasize in writing that while some procedures
may be filed with the patient’s medical
plan, the final responsibility for payment still
lies with the patient. Keep in mind that it
is always advisable to contact the medical carrier
prior to treatment to determine eligibility,
benefits and the following:
- The type of medical plan you are billing.
Keep in mind that HMO’s or PPO’s
may decline benefits, pay the subscriber, or
pay a lower percentage to non-participating
- The medical plan’s special requirements
for filing dental procedures with medical as
primary. The subscriber normally has the right
to file with the medical as primary as long
as it is not written in his/her plan that dental
must be filed first if the procedure is performed
by a dentist.
- If a pre-authorization or referral is required
for the procedures involved. (This is much more
common in medical than it is in dental.)
CMS-1500 Claim Forms Medical claims are billed
using CMS 1500 claim forms (formerly HCFA-1500),
which can be purchased from most medical or
office supply companies. CMS-1500 forms are
white with red print. As such, some medical
carriers will only accept an original CMS-1500
claim form because duplicated claim forms may
not scan correctly. Medical billing has become
so common in dental practices, however, that
many dental practice management systems have
the CMS-1500 claim form and medical codes pre-loaded
on their software.
Written medical pre-authorizations are generally
discouraged. Unless the patient’s medical
plan specifically requires one, offices rarely
receive a reply. It is advisable, however, to
take the time to inquire if procedures will be
covered by a patient’s medical plan, but
it is best to do so by phone. Some medical plans
actually require a phone preauthorization before
certain procedures are performed9.
Completing the Medical Claim Form
Completing the CMS-1500 form is relatively easy.
The following overview highlights some of the
basic elements of the medical form:
- Boxes 1 through 13 are similar to the patient
information requested on dental forms. It is
very important to spell all demographic information
correctly. Spelling errors can increase the
time it takes to get paid. Make sure to indicate
in box 10 whether the procedures were related
to employment or an accident. Box 13 determines
where the payment will be sent. Be sure that
you have the patient’s written authorization
to have benefits assigned to you unless you
have requested payment in full from the patient
at the time of service.
- Boxes 14 and 15 are used to indicate when
the symptoms first appeared.
- Box 16 is used for workers’ compensation
claims and indicates days unable to work.
- Box 19 can be used to explain medical procedure
codes (CPT) that end in 89 or 99. However, some
explanations/narratives may require more space.
If this is the case, a narrative letter can
be attached to the claim form.
- Box 21 has four entries for indicating the
diagnostic codes. These ICD-9 codes should be
listed in order of priority with the primary
diagnosis code listed first on line 1. Any secondary
ICD-9 codes and/or V or E codes can be listed
on the remaining lines.
- Box 24 has lettered boxes.
a. Dates of service (If both the from and to
dates are listed, then the number of days needs
to be completed in field 24-G.)
b. Place of service (the most common entry is
11 for office)
c. Type of service (The most common for dental
are "1" for medical care, "2"
for surgery, "3" for consultation,
"4" for diagnostic x-ray, or "7"
for anesthesia.) Note: This field is not required
d. List CPT Codes followed by any modifiers
that might be necessary (or HCPCS "D"
codes if the carrier recognizes them).
e. List the line numbers (e.g. 1, 2, etc.) of
the primary diagnosis code from box 21 that
applies to each CPT code. Some procedures may
have a different primary diagnosis code. For
example, if a nightguard is delivered for bruxism
on the same day that teeth are restored due
to an accident, the primary diagnosis codes
would be different.
f. Enter the fee for each code
g. Enter the number of days or number of services
that were performed for a given procedure code,
the number of anesthesia minutes, units of supplies,
etc. If only one service is provided, the numeral
"1" must be entered.
h-k. These fields are rarely used.
- Box 25 – Enter the Tax ID number for
the provider of service.
- Box 26 – The patient’s account
number can be listed here.
- Box 27 – "Yes" is checked
if you choose to have benefits assigned to you
and for those plans with which you are contracted
(e.g. Medicare). However, it is recommended
that you have patients pay at the time of service
unless your participating contract requires
• Box 28 – Enter the total of fees
for this claim
• Box 29 – Enter any payment received
from a primary carrier
• Box 30 – Enter the total of total
of fees or the difference when the primary carrier
payment is subtracted
• Box 31 – Enter the provider’s
signature and date
• Box 32 – Enter the location of
services if procedures were performed in a location
other than the patient’s home.
• Box 33 – Enter the practice billing
address, phone number, and group number. If
the insurance company has assigned the provider
a personal identification number, place it in
the PIN area of the box. Eventually, the NPI
(National Provider Identifier) will be entered
• It is advisable to attach a narrative
to the medical claim form to explain the medical
nature of the claim. Never write hand-written
notes on the claim form because this can cause
delays10. By the very nature of these claims,
it is advisable to include a narrative with
most claims. Remember to follow the K.I.S.S.
principle (keep it short and simple). Staple
the narrative to the right upper corner of the
claim so as not to interfere with the barcode
on the left.
Trauma claims require special handling. It is
a good idea to request that trauma patients provide
you with a copy of the emergency room report or
the police report if either applies. These should
be attached to the claim along with the narrative.
Also, liability carriers (e.g. homeowners insurance,
automobile insurance, etc.) will typically be
primary to medical carriers11.
Always proofread the claim prior to submission
to check for accuracy. It is a good idea to review
the medical claim with the dentist to verify that
you have selected the correct codes. After mailing
a medical claim, it is important to promptly track
it just as you track your dental claims. When
benefits are received, review the explanation
of benefits carefully. Payers may reduce payment
levels or combine procedures. Denials may occur
for no apparent reason or the carrier may indicate
that the procedures submitted are dental, not
medical. When submitting an appeal, it is crucial
that you (or the patient) insist that the medical
plan provide the exact contract language upon
which its decision was based. Encourage your patients
to handle their own appeals. Patients should be
encouraged to contact their employer, plan administrator
or insurance commissioner if they believe that
their claim was denied unjustly.
As mentioned previously, it is always best to
collect payment in full at the time of service
when filing claims to medical. Kindly remind patients
that you are processing their medical claims as
a courtesy to them, and because it is a medical
claim, benefits are being directed to the patient
rather than the dental office. By requiring patients
to pay in full at the time of service, they will
take more responsibility to follow up on delayed
or denied medical claims.
While you a short learning curve is to be expected
when submitting your first few medical claims,
it can be well worth the time and effort to submit
claims involving trauma, oral surgery, periodontal
disease exacerbating medical conditions, TMD,
sleep apnea, and certain implant and laser procedures.
Knowing how to bill medical-related dental services
to medical insurance plans will ultimately benefit
both your patients and your practice.
1. Republic Data Information Systems: The Guide,
Carrolton, TX, January 2000, p. 5
2. Rutledge RDH, C. and Landers, B.: Antimicrobial
Delivery Systems, Contemporary
Oral Hygiene, May 2005, p 22
3. Rowell, J. and Green, M: Understanding Health
Insurance, Delmar, 2002, p.101
4. Rowell, J. and Green, M: Understanding Health
Insurance, Delmar, 2002, p.102
5. McGraw Hill: ICD 9 CM, New York, 1995, p.296
6. McGraw Hill: ICD 9 CM, New York, 1995, p.208
7. Rowell, J. and Green, M: Understanding Health
Insurance, Delmar, 2002, p.169
8. Zahrebelny, O, Maximizing Medical Reimbursement
in the Periodontal Practice, The
Z Group LLC, Lincolnwood, IL, 2004, p.1-3
9. Zahrebelny, O,: Maximizing Medical Reimbursement
in the Periodontal Practice, The
Z Group LLC, Lincolnwood, IL, 2004, p. 1-5
10. Nierman, R: Medical Insurance Manual for Dentists,
PenWell Publishing Company,
Tulsa, OK, 2005, p.137
11. Rowell, J. and Green, M.: Understanding Health
Insurance, Delmar, 2005, p.278
12. Rowell, J. and Green, M.: Understanding Health
Insurance, Delmar, 2005, p.13