If I were a betting person, I would bet that everyone who reads this has been impacted, touched, or has dealt with family or friends affected by cancer. While we hope and pray that treatment options including mastectomy, surgery, chemotherapy, and radiation will make our loved ones cancer-free, there is a chance that it won’t or it will impact other areas of health. Oral health is one such area that should be monitored before, during, and after cancer treatment to ensure that any side effects are identified and treated quickly.

How does cancer treatment affect oral health?

Below are some of the effects of chemotherapy and radiation treatments that manifest in the oral cavity:

• Bisphosphonate Osteonecrosis – emergent bone infection
  
  
• Dysgeusia – complete lack of taste and decreased sensitivity
  
  
• Fungal and Viral Infection – will cause lesions or candida
  
  
• Osteoradionecrosis – bone death due to radiation
  
  
• Trismus (lockjaw) – spasm of the muscles of mastication
  
  
• Oral Pain – caused by sensitivity, lesions, sores
  
  
• Xerostomia – severe dry mouth by salivary ducts not producing
  
  
• Oral Mucositis – erythematous and ulcerative lesions of the oral mucosa
  
  
• Stomatitis – inflammation of the mouth and lips

Understanding dental care before, during, and after chemotherapy and radiation treatment will also guide you through the medical billing for dentistry.

Before Cancer Treatment:

You should have your patient in at least one month prior to beginning treatment. The goal is to coordinate with the oncology team and complete a comprehensive treatment plan that eliminates or stabilizes oral disease that could complicate cancer treatment.

You should request the following information from the oncology team:

1. Underlying disease
   
   
   – Cancer type, stage, prognosis
   – Request diagnosis codes that will be used for the care
   – Aplastic anemia status with complete blood count (CBC)
   
   
2. Present medications and those that will be added
   
   
3. Other medical considerations (also request diagnosis codes)
   
   
4. – Cardiac disease including murmurs
   – Pulmonary disease
   – Intravenous access line
   – Coagulation status (INR)

In the information exchange, you should provide to the oncology team:

1. Dental caries
   
   
   – Number of teeth and severity
   – Number of teeth that should be treated before cancer treatment begins
   
   
2. Endodontic disease
   
   
   – Teeth with pupal infection
   – Teeth with periapical infection
   
   
3. Periodontal disease
   
   
   – Overall status
   – Number of teeth that need treatment
   
   
4. Teeth requiring extraction. *Note: Medicare will not pay if this is done after or during treatment.*
   
   
5. The time necessary to complete treatment.

Medical billing before cancer treatment can include:

99213 – Level 3 Office Visit


70486 – CBCT image


70355 – Pano or 70320 – FMX


41899 (with a qualifier) – Extractions


41899 (with a qualifier) – Crowns


41805 – SRP or Caries


41823 – Osseous


41806 or 41826 – Root canal therapy

What you will need in order to bill:

1. Copy of the referral letter or order.
   
   
2. ICD-10 codes associated with cancer, provided by the oncology team.
   
   
3. Detailed notes documenting the findings of the exam and the possible complications if left untreated (SOAP Notes).

During Cancer Treatment:

All dental care during cancer treatment should be discussed with the oncology team BEFORE care is rendered. Chemotherapy makes saliva thicker, which can lessen the patient’s ability to cleanse the oral cavity. This results in the possible appearance of stomatitis, mucositis, or viral and fungal infections that could require attention. Additionally, fabricating trays and MI paste will help re-mineralize teeth during treatment.

Medical billing during cancer treatment:

First, it should ONLY be done in an emergency unless otherwise directed by the oncologist.


99213 – Level 3 Office Visit (no probing)


A4248 – Chlorhexidine Irrigation (non-alcohol) 1ml

You will need:

1. Copy of the referral letter or order.
   
   
2. ICD-10 codes associated with cancer, provided by the oncologist.
   
   
3. Clinical chart notes (SOAP notes).

After Cancer Treatment:

Special care should be taken after cancer treatment to ensure that routine oral hygiene care is suited to your patient’s condition. Some substitutions and extra care are required, such as the use of a foam toothbrush if a regular toothbrush isn’t feasible due to causing trauma.

Routine Oral Hygiene Care:

• Toothbrushing: Electric and ultrasonic toothbrushes are acceptable if the patient can use them without causing trauma and the oncology team agrees.
  
  
• Soft nylon-bristled brush (two to three rows): 2-3 times daily, rinse frequently. Foam toothbrush if necessary.
  
  
• Toothpaste: Non-mint with fluoride. Use 0.9% saline if toothpaste causes irritation.
  
  
• Flossing: Once daily. Atraumatic technique with modifications as needed.
  
  
• Bland rinses: 0.9% saline, sodium bicarbonate solution, or 0.9% saline plus sodium bicarbonate solution.
  
  
• Fluoride: 1.1% neutral sodium fluoride gel, 0.4% stannous fluoride gel.
  
  
• Topical antimicrobial rinses: 0.12% to 0.2% chlorhexidine oral rinse for management of acute gingival lesions (no alcohol) or povidone iodine oral rinse.

Medical billing after cancer treatment can include:

99213 – Level 3 Office Visit


70486 – CBCT image (sparingly if possible)


70355 – Pano or 70320 – FMX (sparingly if possible)


41899 (with a qualifier) – Extractions


41899 (with a qualifier) – Crowns


41805 – SRP or Caries


41823 – Osseous


41806 or 41826 – Root canal therapy

What you will need in order to bill:

1. Copy of the referral letter or order.
   
   
2. ICD-10 codes associated with cancer, given by the oncology team.
   
   
3. Detailed notes documenting the findings of the exam and the possible complications if left untreated (SOAP Notes).

Billing medical insurance for dental care throughout cancer treatment will not only help your patient, but it will also benefit your practice as well. When dentists work in cooperation with the oncology team, we can do our best to provide care for our patients and support them through the difficult cancer treatment period before, during, and after.