Maximize Medical Insurance Benefits

by Rose Nierman, CEO Nierman Practice Management


If you have medical billing mastered for Obstructive Sleep Apnea (OSA) cases, it’s time to consider billing other procedures to medical insurance. Once you discover that medical billing success revolves around documentation, you can explore what’s needed to bill medical for other services such as TMJ treatment, CBCT (cone beam), medically necessary exams and oral surgeries. More states are now mandating that health plans must cover TMJ treatment and accidents to teeth. In some instances, dental plans instruct dental offices to first bill a patient’s medical insurance for oral surgeries (this can maximize benefits and end up saving the dental benefits for restorative dentistry). And yet another billing scenario involves clearance exams (and radiographs) to rule out oral infection before a medical surgery or chemotherapy. Many medical insurance policies are now paying for these clearance exams with ICD Code Z01.818:
Encounter for preprocedural examination NOS
Encounter for examinations prior to antineoplastic chemotherapy

Services to consider for Medical Billing

  • Exams
  • Panorex, CBCT
  • TMJ Disorder, Craniofacial Pain Services
  • Sleep Apnea Therapy
  • Bone Grafts & Implants
  • Impacted Teeth Removal
  • Frenectomies, Biopsies and other Dental Surgeries including Anesthesia
  • Clearance Exams
  • Accidents to Teeth
  • Botox injections for “Painful Bruxism”

Whether billing for OSA or other procedures, preparatory steps include asking the right questions and creating the patient’s story in SOAP reports. When reviewing medical history focus on the loss of function, pain or infection to help determine if services are medically necessary.

When you learn the ropes for cross-coding (billing medical insurance in dentistry), you’re focused on navigating claim form boxes and connecting ICD-10 codes (diagnosis) to the appropriate and corresponding CPT codes (procedures).

A new biller has all the ICD, CPT, and claim form fields correct but may forget the one thing that could make all the difference – documentation. Accurate documentation for oral appliances includes a sleep study and or CPAP Intolerance Affidavit. Subjective symptoms such as morning headaches and the score from an Epworth Sleepiness Scale (higher than 10) also need to be documented in S.O.A.P. reports. S.O.A.P. reports are your decisive advantage with medical insurance.Still not sure if documentation is that important? Keep reading and you’ll find out shortly why this could be your downfall.

What needs to be in an S.O.A.P. report?

S. – Subjective Complaints of the Patient. Use a Patient Questionnaire unique to TMJ disorder, loss of function or obstructive sleep apnea screening. Report your Review of Systems (ROS) which is a verbal medical history summarizing organ systems which documents the level of medical history taking.

O. – Objective Findings of the Provider. In addition to a dental screening for OSA, perform an airway exam. It’s also important to rule out if the patient has been diagnosed with TMJ disorder or periodontal disease since some insurance companies exclude a patient as a candidate for oral appliance therapy when these conditions are present. When there is no clear-cut diagnosis of periodontal disease or TMJ disorder, include this fact in your SOAP reports. These baselines often need to be stated upfront to prevent preauthorization and claim delays.

A. – Assessment by the provider with ICD diagnosis codes included. Having a SOAP report with the codes printed leads to approvals in the preauthorization phase and documentation which conforms to claims submitted.

P. – Plan The plan outlines what services are in the treatment plan moving forward for this patient and includes recall and referrals.

Since you will be generating a SOAP report for medical insurance, be sure to forward the reports to the other healthcare providers the patient sees. Sending reports to medical providers, whose care the patient is under, is respectful and spreads the word that you are the leading sleep apnea, TMD or surgical dentist in your area.

Avoid submitting medical exams without knowing the documentation required to support the exam code levels. Insurers may request this documentation in post-payment reviews. Post payment reviews ensure that providers do not perform up-coding on these codes. For example, a Level 4 evaluation and management code is typically 45 minutes – but time alone is not the determining factor. It’s essential to also document that the presenting problems are of moderate to high severity, the history taking and exam are comprehensive, and the level of decision-making is moderate to high.

SOAP reports are typically one-half to two pages and provide the documentation that medical insurance and the patient’s other providers want and need.

Taking a little extra time to SOAP up the patient’s story ensures that you don’t take a bath with medical insurance and physician referrals.

Rose Nierman, RDH, is the Founder and CEO of Nierman Practice Management, an educational and software company (DentalWriter™ and CrossCode™ Software) for Medical Billing for Dentists, TMD and Dental Sleep Medicine advanced treatment, and co-founder of the SCOPE Institute, a non-profit educational organization dedicated to the advancement of sleep apnea, craniofacial pain treatment, and medical billing within dentistry. Rose and her team of clinical and medical billing experts can be reached at Rose@Dentalwriter.com or at 1-800-879-6468.

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