January 26, 2023 • 10 mins read

Dysfunctionally Functioning

Exploring the concept of dysfunctionally functioning, a term used to describe a situation where a system or process is not working as it should.



Laurie Owens

CPC | CPB | COC | Director Of Medical Billing Education for Devdent

Dysfunctionally Functioning

Daily we are asked or ask the question, “How are you?” Despite the fact that not much attention is paid to the question, the response (unless you have been on hold with insurance for 1 or 2 hours), is usually “I’m fine.” This is all well and good, but does it really get answered truthfully? We see patients that endure chronic daily headaches, migraines, and jaw pain from arthralgia (pain in joint), and the list of head and jaw-related issues goes on and on.

Patients that have these types of problems are dysfunctionally functioning. The term dysfunctional or dysfunctionally functioning describes that they are functioning with a dysfunction.  I, personally, am one of them, that is until Dr. Alan Anderson of Salt Lake City helped me with Botox therapy.

We know that dental insurance for these types of treatment is pretty limited because dental insurance is mainly focused on “teeth” issues.  When Botox, TMD, and myofunctional/myofascial therapy are needed, dental insurance coverage is minimal to none.  

This cannot fault dental insurance companies as the treatment for these services (unless they want wrinkle reduction with no conditions) would fall under medically necessary if documented correctly.

Tip #1 – Get the complete story.

There could be prior trauma involved, such as a car accident, sports injury, and more that are involved and necessary for coding the treatment.

When your office sees a patient that has physical ailments including TMD, facial, headache/migraine; you must document, document, document.

Noting not only the current dysfunction but how the patient got there.  This will show a progression and not that they jumped to your treatment before trying alternate methods. These treatments include medications, chiropractic treatments, neurology, etc.

Tip #2 – Get a pre-authorization.

If your patient needs multiple rounds of treatment, ALWAYS GET THE SERVICES PRE AUTHORIZED.

There is a gap of knowledge when it comes to dental insurance versus medical and what kind of policies there are.

EPO – Exclusive Provider Organization

         Will only pay for BASIC emergency treatment.

HMO – Health Management Organization

              Must have a referral from PCP (primary care provider).

PPO – Preferred Provider Organization

              Is able for treatment without a referral.

Medicare – Must be registered for Medicare part B

              Verify if codes are covered on

Federal – Tricare (If you bill, you are accepting their fee and will have to write off the difference.)

              Must have a referral from Tricare provider.

Over the last few weeks, we have spoken to several dentists that are doing Botox, TMD, and Myofunctional/Myofascial Therapy.  One spoke about billing an EPO policy as an “emergency” for Botox due to migraines.  This would be okay if there had been one instance, but they had three more “emergencies” in four-month intervals, and all the medical records were hand-written (which is a HUGE no-no).  

Needless to say, the doctor did not like what was said, but the truth is the truth.  We cannot tell the patient that medical insurance will cover a procedure if we have not obtained pre-authorization and have been educated about the different types of plans there are. Without education, you are simply working towards a bad patient review.

Tip #3 – ALWAYS get a medical referral.

Guide the provider to remark about the physical aspects of necessary treatment such as muscle reconditioning (remember the tongue is a muscle also), therapy for speech development, or abnormal jaw function.

Myofunctional and Myofascial therapy are “new” for dental insurance and “old” for medical insurance. If you are completing manipulation or non-manipulation, ensure that it is timed with start/stop time (not including exam and diagnostics).  

When performing tens therapy, note how many leads are being used, supervised or unsupervised, and how the patient responded to therapy.

Be aware of your patients that are truly functioning with their dysfunction and that it not only affects them but also their whole family.

With these three tips in mind:

#1 – Get the complete story

#2 – Get a pre-authorization

#3 – ALWAYS get a referral

Keep on medical billing for dentistry and see what courses are available at Medical Billing | Devdent.

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