Important Considerations for Billing Dental Surgeries

This is Loralee Kapp, a Solutions Manager with Managed Outsourced Solutions. I’m gonna discuss with you some important considerations for billing dental surgeries.

00:10 Types of dental surgeries

Dental surgeries are performed to treat a variety of conditions that affect the teeth, jaw and gums such as temporal mandibular joint also known as TMJ disorder, wisdom teeth removal, facial trauma, corrective jaw surgery and periodontal surgeries to treat gum conditions like gingivitis and periodontitis. Billing the patient’s medical insurance for medically necessary dental surgeries can help patients maximize their health benefits. Utilizing a professional billing company can help ease this task as well as help increase reimbursement rates.

00:47 Factors to consider when billing for dental surgeries

The following are important considerations to make when billing for dental surgeries:

00:52 Insurance verification – Verifying dental eligibility by collecting the patient’s demographics and insurance information allows you to check their coverage and if their insurance will pay for the surgery. Collecting the following information will aid in this process. It is important to gather:

• The patient’s name and date of birth
• The name of the primary insured
• Social security number of the primary insured
• Insurance carrier
• ID and group numbers, and
• Contact information for the insurance company such as – phone number, website and claim submission address

With this information on hand, you can contact the insurance company to verify coverage, effective dates, in and or out of network coverage, if prior authorization is required for surgery, the patient’s portion such as deductible, co-pay and coinsurance. This will also help your patients plan for their out-of-pocket payments. Relying on a verification specialist and the billing company can simplify these tasks for your practice.

01:55 Establishing medical necessity – Medical insurance plans will reimburse for surgeries performed by a dentist if they can prove it is medically necessary and is properly coded as a medical procedure. You must provide documentation proving medical necessity. This is done to prove that the patient is medically compromised by a problem that the dentist treats. For example, tooth removal for impacted teeth, removal of teeth before radiation therapy or organ transplant. Medical plans may also cover tissue biopsies and extractions for surgical replacement of dental implants. Use the correct ICD 10 codes and CPT codes to document all aspects of care provided. This documentation should include

• the chief presenting problem
• any secondary or supporting diagnoses
• diagnostic code for planned treatment
• prior authorization for the surgery
• letter outlining the medical necessity
• a supporting letter of medical necessity for the primary care provider
• procedures performed at the surgery location

This documentation should inform the payer that the patient’s concern is a medical one, not only a dental concern. All contributing factors for the patient’s medical history maybe stated in the letter to prove it is medically necessary.

03:19 Obtain a preauthorization– All dental surgery claims require a preauthorization from a medical plan. Dentist’s office must obtain this authorization before performing the surgery. Preauthorization involves contacting the insurance plan by phone or website in explaining the procedure and the day of the procedure. Failing to obtain a preauthorization may result in claim rejection.

03:45 Accurate coding –Know the proper ICD 10 codes and their uses. It is crucial for the insurer to note necessary information about the requested procedure. The first or primary diagnosis listed must relate to the most important aspect of the procedure being performed, followed subsequently by the secondary codes that pertain to the condition listed in order of lesser importance. The CPT codes on the claim must be listed in order, from the most expensive down to the least expensive procedure, not in the order that they were performed. This is done because payers reimburse for the first surgical procedure listed at the highest benefit level in each subsequent procedure at a lower or reduced rate. For example, the first procedure listed maybe paid out 100 percent, the second at 75 percent and any other additional services listed to be paid at 50 percent.

04:48 Filling out and submitting claims – After the dental surgery has been performed, the claim should be completed and submitted timely and correctly. The form should be checked thoroughly for typos and other errors that may lead to claims rejection or the delay of payment. The claims should be submitted to the insurance with all pertinent information provided including any supporting documentation such as lab or diagnostic imaging reports.

05:16 Outsourcing your verification authorization and billing needs – This is a great option to maximize your dental billing efficiency. Relying on experience companies that have experts dedicated to your practice and are up to date on all billing procedures such as – rules, claim submission processes, pricing coverage and the individual plans in each state, can enable you to focus more on your patient’s care, while resting assured that your billing needs are being handled by knowledgeable teams dedicated to ensuring that your back office needs are covered.