The Oral-Systemic Link is Broadening Your Services
Now you can bill medical insurance providers to pay for them
In December 2005, Reader's Digest published an article entitled, "How your dentist can save your life: Your dentist may be the most important doctor you see this year," which discussed the story of a patient who died from an oral infection.1 This headline is just as true today as it was then. Research is suggesting that a visit to the dentist is becoming even more important than a visit to your primary care provider, and some of the treatment provided during that visit is getting easier to pay for thanks to the modern way that dentists can now bill medical insurance providers for certain services.
New Codes, New Options
Many billing codes, both old and new, have been updated as the science behind each code has evolved, but many of these codes are not covered under reimbursement plans that are specifically for dental care. However, the good news is that these codes may instead be covered under a medical plan, because many dental services are now considered a medical necessity.
For example, some dental plans have added a way to help cover additional patient visits. The key to how these visits are charged and billed is in how they are coded. These additional patient visits would not be billed directly to the patient's dental insurance. Instead, they would be billed to the patient's medical insurance as a rider add-on.
Your patients are already in a position to make changes to maximize their complete oral and overall health; we as dentists, hygienists, and front-office billers simply need to change how we approach our patients' overall health as well. By starting to conduct risk assessments to begin the process of identifying a patient's additional health concerns, we become eligible to receive payments from a number of the medical insurance options that each patient may have.
Many major dental insurance providers are joining this trend as it becomes more mainstream, including Cigna Dental.2 Cigna added a program that incorporates total oral health.3
Our duty as dentists is to keep each patient healthy and safe. Part of this involves keeping our knowledge and skills current and referring patients to specialists when necessary. "To ‘Do No Harm' is really the Golden Rule," says Jane Gillette, DDS, a spokesperson for the American Dental Association (ADA). "Dentists practice ‘Do No Harm' in many ways, but one universal expression is dedication to keeping their knowledge and skills up-to-date. New science and technology can quickly emerge. In response, dentists complete a tremendous number of hours in continuing education annually to provide patients with the highest level of science-based, effective, and safe care."4
Evaluating Overall Health
As our patients' dental providers, it is up to us to become informed about their overall health. Total patient care extends beyond a yearly teeth cleaning and an x-ray exam. Total patient care also extends to the patient's entire body and the possible diseases it might be fighting on a daily basis. One of the daily battles that a patient might be facing is diabetes. Available benefits for patients with diabetic issues are another reason that we should be billing for overall health services, such as HbA1c testing that is conducted in our dental practices. To move to the wellness benefits within the dental plans (eg, Delta, Aetna, Blue Cross, etc), we must be able to participate with our patients in their overall health and well-being without trying to sell and to educate them in why it is important that we as their dental healthcare providers join them in their total healthcare.
Treatment Considerations for Diabetic Patients
According to the ADA, "Someone with diagnosed diabetes incurs one of every four healthcare dollars, and one of every seven healthcare dollars is spent directly treating diabetes and its complications."5
Studies show that people with diabetes-an estimated 12 to 14 million people in the United States-are more susceptible to the development of oral infections and periodontal disease.6
When diabetic patients have blood sugar levels that are not well controlled, they should talk with both their dentist and physician about receiving proper dental care. Dental procedures should be as short and as stress-free as possible. In addition, it's a good idea to schedule morning appointments for diabetic patients because blood glucose levels tend to be under better control at this time of day.7
Oftentimes, oral infections are more severe among diabetic patients than non-diabetic patients. People with diabetes may also experience a burning mouth or tongue sensation and diminished salivary flow, which can lead to a higher incidence of tooth decay. Furthermore, diabetic patients with poorly controlled blood sugar levels tend to have a greater incidence of oral health problems, notably gum recession (ie, shrinkage). People with diabetes who receive proper dental care and control their insulin levels stand a better chance of avoiding periodontal disease.
These patients should pursue good dental healthcare to prevent oral infections. Oral infections require immediate treatment, and dentists may prescribe antibiotics, medicated mouth rinses, and/or more frequent cleanings to avoid complications related to bacterial colonization. To keep their teeth and gums healthy, diabetic patients should remain aware of their blood sugar levels and have their triglyceride and cholesterol levels checked regularly. These may have a direct correlation with a patient's chances of developing a periodontal disease or his or her chances of having one already.
As someone who is concerned with your patients' overall health, you may now be asking yourself, "Why am I not providing my patients with the HbA1c in-office, point-of-service test and billing the code for an encounter visit?"
Coding for HbA1c Testing
In HbA1c testing, a blood test is performed to measure glycosylated hemoglobin levels. Plasma glucose binds to hemoglobin, and the HbA1c test measures the average plasma glucose concentration over the life of red blood cells (ie, approximately 90 to 120 days). HbA1c levels may be used as a diagnostic reference for patients with suspected diabetes and to monitor blood glucose control in patients with known diabetes. HbA1c levels should be monitored at least every 6 months in patients with diabetes and more frequently when the level is >7.0.8
The ADA's Code on Dental Procedures and Nomenclature (CDT Code) "D0411 HbA1c in-office point of service testing" has not been covered by dental insurance that I am aware of. However, because this is a test performed all the time by medical doctors, nurses, and patients, you can bill it to your patient's medical insurance provider. Remember: any time that you have an encounter with a patient, for any reason, it can be coded and billed. "An encounter is an interaction, regardless of the setting, between a patient and a practitioner who is vested with primary responsibility for diagnosing, evaluating, or treating the patient's condition. It may include visits, appointments, as well as non-face-to-face interactions. It is also a contact between a patient and a practitioner who has primary responsibility for assessing and treating the patient at a given contact, exercising independent judgment."9
So why should an encounter code be used for this test? The action being performed is screening, not actually providing treatment. Screening is the testing for disease or disease precursors in asymptomatic individuals, so that early detection and treatment can be provided for those who test positive for the disease.10
When billing medical insurance providers for HbA1c testing, clinicians should use the International Statistical Classification of Diseases and Related Health Problems (ICD) 10 Code "Z13.1 Encounter for screening for diabetes mellitus." The specific American Medical Association Current Procedural Terminology (CPT) Code used will depend on the type of test performed, including the following:
"83036 - Hemoglobin; glycosylated (A1C)." This code is used when whole blood is tested using quantitative high performance liquid chromatography/boronate affinity.11 Most oral physicians do not perform this, but they can send a patient to his or her medical doctor or a laboratory, if needed.12
"83037 - Hemoglobin; glycosylated (A1C) by device cleared by FDA for home use." This code should be used if the HbA1c test is performed using an FDA-approved testing device for home use. To perform the test, a capillary or venous blood sample is obtained, and a drop of blood is placed in buffer solution and shaken to lyse the red blood cells. The sample is then transferred to the testing device where the HbAIC levels are measured and the results are displayed.
The Bottom Line
Because dentists are increasingly broadening their focus to address their patients' overall health, learning when and how to bill medical insurance providers for services is becoming important to practices' bottom lines. In addition to encounters, dental practitioners can also bill for "related services." Related services are defined as "services that are directly related to the performance of a preventive service" and are adjudicated under the Preventive Care Services benefit.13 For example, blood drawing (ie, venipuncture or finger or heel stick) is considered payable under the preventive benefit if billed as a deterrent. As the link between oral and systemic health is further understood, the services rendered by dentists will continue to evolve, and learning to bill medical insurance providers will be essential for survival in this practice environment.
About the Author
Christine Taxin is the founder and president of Links2Success, a practice management consulting company for the dental and medical fields, and the owner of Dental Medical Billing University, a congolomerate of dental and medical billing experts that offers online billing training for dental professionals.
1. Ostler L. What Being a Doctor Is About! The American Academy for Oral Systemic Health Website. aaosh.org/doctor. Published October 30, 2013. Accessed October 2, 2018.
2. Cinga Website. https://cignaforhcp.cigna.com. Accessed October 2, 2018.
3. Cigna Oral Health Integration Program. YouTube Website. www.youtube.com/watch?v=zrqIztv71I8. Published October 20, 2014. Accessed October 2, 2018.
4. Ethics: The 5 Promises ADA Dentists Make to Their Patients. Seventh District Dental Society Website. www.7dds.org/news/2015/10/26/ethics-the-5-promises-ada-dentists-make-to-their-patients. Published October 26, 2015. Accessed October 2, 2018.
5. American Diabetes Association. The Cost of Diabetes. American Diabetes Association Website. www.diabetes.org/advocacy/news-events/cost-of-diabetes.html. Edited April 30, 2018. Accessed October 2, 2018.
6. Delta Dental. Diabetes and Oral Health. Delta Dental Website. www.deltadentalins.com/oral_health/diabetes.html. Accessed October 2, 2018.
7. National Institute of Diabetes and Digestive and Kidney Diseases. Diabetes, Gum Disease, & Other Dental Problems. U.S. Department of Health and Human Services Website. www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/gum-disease-dental-problems. Published September, 2014. Accessed October 2, 2018.
8. Hemoglobin A1c. ClinLab NAVIGATOR Website. www.clinlabnavigator.com/hemoglobin-a1c.html. Accessed October 3, 2018.
9. Template Encounters Section (Entries Optional). Publications for Templates/Value Sets for Consolidated CDA (ccda-) Website. ccda.art-decor.org/ccda-html-20150727T182455/tmp-2.16.840.1.1138220.127.116.11.2.22-2013-01-31T000000.html. Accessed October 2, 2018.
10. 2018/19 ICD-10-CM Diagnosis Codes. Z13. ICD10Data Website. www.icd10data.com/ICD10CM/Codes/Z00-Z99/Z00-Z13/Z13-/Z13. Accessed October 3, 2018.
11. CPT Code Venipuncture - 36415 and 36416 -Billing Tips - Not Seperately Paid. Medicare Payment and Reinbursement Website. www.medicarepaymentandreimbursement.com/2010/06/cpt-venipuncture-36415-not-seperately.html. Accessed October 3, 2018.
12. Coding Glycosylated Hemoglobin (A1c) and Hemoglobin Variants by HPLC. CodeMap® Website. www.codemap.com/biorad/hplc.pdf. Accessed October 3, 2018.
13. Preventive Care Services. UnitedHealthcare Website. https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/preventive-care-services.pdf. Effective October 1, 2018. Accessed October 3, 2018.