Determining Medical Necessity When Cross Coding

Determining Medical Necessity When Cross Coding

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How To Determine Medical Necessity in your Dental Practice

When medical insurance receives a new claim from a dental practice, their first question is always “Why is this dental procedure medically necessary?” Determining medical necessity is the first step for any medical case and it is your responsibility to prove why medical insurance should pay for treatment. Using your patient intake form and health history in collaboration with the clinical assessment, you will be able to clearly determine whether the patient’s treatment is a medical necessity. 

Patient Intake and Health History

Every time a patient comes into your practice they should be updating their health history. This helps your office learn more about your patient but is also your first indicator that there may be a medical billing opportunity.  On the health history you will start to see both what medical conditions and medications could be affecting the oral cavity.  One thing commonly missing from intake forms and medical histories, is a clear place for a patient to record their primary concern or reason for the visit.  It’s important to add this section, as it will start to identify the patient’s Chief Complaint.  

Patient Chief Complaint

To answer the question of medical necessity you need to be able to clearly explain and justify why the procedure is required. Using the patient’s chief complaint is a simple way to get started.  The Medical Dictionary defines a chief complaint as:

“The primary symptom that a patient states as the reason for seeking medical care.”

Medical Dictionary

The patient’s chief complaint can be identified on the intake form or during the conversations being had with team members. Where it is identified depends on the organization and flow of your unique dental office. Once the chief complaint is identified, it is then recorded in the patient’s chart notes. Patients can have more than one chief complaint.  They may be here because of pain on the lower left, and also because of a bad taste in their mouth.  

In a trauma case, ensure that your team is leaving detailed notes as to how the trauma occurred. You can simply copy these from an Accident Report Form that the patient fills out upon arrival. 

Notating The Chief Complaint

When notating a patient’s chief complaint, it is critical that you have a concise statement that describes the patient’s problems, conditions, and symptoms, including severity of pain, duration of problem and results caused by said problem. You can use the patient’s own words (e.g., tooth pain, jaw pain, blood while brushing, etc.). If you do not notate a clear chief complaint, your case will likely be denied.   

EXAMPLE: Patient presented today with pain on the lower left reporting a 8 out of 10 in severity.  The patient indicates this started 4 days ago and is getting worse each day.  The pain was significant enough today, that she missed work.  She is taking ibuprofen 800 mg every 6 hours and is getting very little relief.  

Below is a table showing what to do and what not to do when notating a patient’s chief complaint.

Do Don't

Specify the reason for the visit

  • "Patient presents for follow-up evaluation of implant.”

Specify who requested a consult and why

  • “Consult requested by Dr. Jones for evaluation of periodontitis.”>

Fail to pecify the reason for the visit

  • "Patient presents for follow-up.”

Fail to specify as a consult (who requested and why). Imply referall or transfer of care.

  • “Patient referred by Dr. Jones.”>

Patient Health History

When the patient fills out a thorough health history, you can easily see their medical conditions and current medications. Below is a partial list of common medical conditions that can be tied to the oral cavity.  If you do not have these included in your health history, you will want to add them so you don’t miss a medical billing opportunity.

Clinical Assessment  

The clinical assessment is made up of any data you collect.  This can include radiographic findings, intra oral photos, tools like vitality tests, percussion, or even screening tools like PH test strips. Once the clinical assessment is completed by the clinical team, the provider will use this information to determine a diagnosis and create a treatment plan.  During this section, it is critical that the provider explains the diagnosis in detail, as well as the prognosis and consequences if left untreated.  A large part of medical necessity is proven within the clinical assessment section. 

EXAMPLE:  Took 2 BWX and a PA that all confirmed that the patient has a large apical infection on #14.  The infection is starting to encroach on the floor of the sinus cavity.  The infection has already caused a significant amount of atrophy.  With endodontic therapy and a build up and final restoration to seal off the access and prevent additional bacteria, the prognosis is good.  Treatment is critical as there is no other way to remove the infection, not even with an antibiotic. The periapical infection needs to be treated immediately to avoid the spread of infection, sinus complications and continued bone atrophy.  Failure to treat this immediately could lead to major health concerns, especially considering the patient already has an underlying heart condition.  Treatment is medically necessary.  

Tips for Working With New Patients: When working with new patients, the intake form and health history are critical in determining if there is potential to bill medical insurance. We suggest adding a “medical billing potential” assessment to all new patients to see if there is a possibility to bill any treatment to medical. 

Tips for Working With Existing Patients: For your existing patients, you can address medical necessity in your morning huddle. For example, John has a history of diabetes and periodontal disease. Proactively address the likelihood that the case could be billed to medical insurance.   

Putting Them Together

Once you have the patient’s health history and clinical assessment done you can start to build the narrative. It’s important to remember that when billing medical insurance the stronger your case illustrates the relationship between the body and the necessary dental treatment the more likely you are to get the claim paid. In order to quickly determine if this case is ideal for medical billing, we have developed some questions to ask yourself before you proceed.  

Does the patient’s oral condition or diagnosis affect the rest of the body?   Yes or No

This question determines the relationship between the mouth and the body. As dental providers you are responsible for the oral cavity and when you can prove that something in the oral cavity is negatively affecting other parts of the body, medical insurance is more likely to pay for treatment.

For example: The patient is suffering from red and swollen gums. These symptoms, along with the perio chart and radiographs are consistent with periodontal disease. Due to the fact that the patient also has diabetes, and there is a correlation between periodontal disease and diabetes, scaling a root planing treatment is medically necessary. Diabetes is a medical condition, and failure to treat this condition could result in exacerbating their diabetes, making blood sugars even more difficult to control and eventually leading to periodontal infection and more negative effects on the overall health of the patient.  You now have an argument for why this patient’s periodontal treatment is medically necessary.

Does the patient’s medical condition or medication affect the oral cavity? Yes or No

This question helps to identify if a medical condition or medication has a negative effect on the oral cavity. If we can show this correlation, we have a strong case for medical billing.   

For example: your patient is suffering from acid erosion, which is clearly evident with an oral evaluation.  The patient has indicated in their medical history that they suffer from GERD. Because there is clinical evidence that GERD causes an increase in acid in the mouth, and that acid eroded the teeth, we can argue that the GERD caused the acid erosion. Because the patient is diagnosed with a medical condition that caused this damage, restoring the damaged teeth is medically necessary.

Are we screening for medical conditions? Yes or No

As a dental provider, you have the opportunity to screen for a variety of medical conditions. By asking this question, you can determine if these screenings can be billed to medical insurance. Some screenings may also be used to determine if you move forward with dental treatment.   

For example: Patient presents in hygiene for a routine exam. The patient elects to complete the screening services you offer, including HbA1c, oral cancer screening and PH testing.  Because all of these screenings are specific to medical conditions each can be billed to medical insurance.  The medical necessity in this example doesn’t come from the patient’s health history, but more from a preventative medical perspective.  

Practice Makes Perfect

Once you practice and implement these steps in your dental practice, you will start confidently determining medical necessity for your patients. Medical insurance is a fantastic option for patients and provides another source of payment. 

After asking the three suggested questions above, if you answered YES, this case is ideal to consider for medical billing. Your next step is to complete a Verification of Benefit. The Verification of Benefit sets you up with the information you need to make an educated decision on whether or not to continue with medical insurance.

If you want more information on determining medical necessity you can enroll in one of Devdent’s medical billing online courses.

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