Imagine you surgically extract a patient’s wisdom tooth. You submit a claim with the correct CDT code and all the important documents. After that, you start waiting for the reimbursement. But you receive an EOB with a claim denial, which says that the procedure isn’t covered. It’s a huge and unwanted surprise!
Wondering why? It’s because there are certain dental procedures that are medically necessary but aren’t covered in dental insurance. You need to cross-code them using CPT codes and send them to medical insurance, which actually covers them.
This is where medical-dental cross-coding steps in. It’s different from simple dental billing, as it requires expertise in dental billing and coding services with medical linkage.
Eager to know how to code claims in such a situation? This blog guides you on how you can save thousands of dollars by simply applying these easy steps of medical-dental cross-coding in billing.
Let’s navigate through this junction where medical and dental billing procedures overlap.
What is Medical–Dental Cross-Coding in Dentistry?
Medical-dental cross-coding is a unique step in the mid-revenue cycle process of dental RCM. In this process, a practice submits a patient’s medically necessary dental procedure to the medical insurance using ICD-10, CPT, and HCPCS, instead of CDT codes.
Coding is a complex procedure, whether it be in dental or medical procedures. However, it becomes even more complex when you are stuck between CDTs and CPTs.
What are Common Situations for Medical–Dental Cross-Coding?
Medical-dental cross-coding isn’t a routine task for dental practices. It only becomes necessary when your patient needs a procedure that is covered by their medical insurance. The following conditions mostly make medical-dental cross-coding compulsory for claim submission:
- Obstructive Sleep Apnea (OSA)
- Temporomandibular joint disorders
- Oral Surgery and Trauma
- Dental Treatment under General Anesthesia for Special Needs Patients with Cleft Palate/Craniofacial Anomalies
- Biopsy of Oral Lesions
- Diabetes and Periodontal Disease
What are the Codes to Master for Medical-Dental Cross-Coding?
When you’re submitting claims under medical-dental cross-coding, make sure you master the following codes:
CDT Codes
The CDT codes are the alphanumeric codes, set by the American Dental Association (ADA), that report a procedure to dental insurance for reimbursement. CDT codes are applicable for dental procedures in medical cross-billing, when there is no applicable CPT code, or the payer accepts the CDT code.
CPT Codes
Current Procedural Terminology (CPT) codes are often referred to as Level 1 codes, set by the American Medical Association (AMA). These are used to report procedures to medical payers. These codes are used for medical procedures in claims submitted via the CMS-1500 form.
HCPCS Codes
HCPCS codes are often referred to as level 2 codes, which are used to report medical services, equipment, or supplies. For dentists, this code set is used to report oral sleep apnea and temporomandibular joint disorder appliances, which are considered durable medical equipment (DME). The HCPCS code set is maintained by the Centers for Medicaid and Medicare Services (CMS). These codes are used when the services, supplies, and equipment aren’t covered by CPT codes.
ICD-10-CM Codes
The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes are diagnosis codes, which are defined and maintained by the National Center for Health Statistics (NCHS). These are diagnosis codes that help understand why a procedure is performed. Diagnosis detects the condition requiring treatment.
What is the Step-by-Step Procedure for Accurate Medical–Dental Cross-Coding?
Let’s review the complete step-by-step process of medical-dental cross-coding.
Step 1: Confirm Procedure’s Eligibility for Cross-Coding
Cross-coding works in only specific situations. Not all dental procedures qualify for it. You require it only when a procedure affects overall health or is linked to other physical systems, and isn’t covered by dental insurance.
The following cases are usually eligible for medical-dental cross-coding:
- Biopsies or pathology
- Infections
- Oral surgeries
- Sleep apnea treatment
- Trauma (accidents, injuries)
Step 2: Verify Patient’s Medical Insurance
Next, get the proper details of medical insurance and check for patients’ benefits and eligibility. Additionally, if a major procedure requires pre-authorization, obtain it from the payer to avoid claim denials.
Step 3: Verify Medical Necessity
Verifying medical necessity is the most important step in cross-coding. As we’ve mentioned, medical insurance only pays when the dental treatment is performed due to health-related issues. You need to make it clear by:
- Checking signs of illness
- Finding out what’s wrong
- Identifying risks to the health of the patient
Let’s simplify it with an example: if a patient needs tooth removal, you need to justify it with reasons that this issue can lead to infection, swelling, or a risk to other parts of the body.
Step 4: Document Everything Properly
When you’re mapping a dental procedure to medical insurance, you need sufficient documentation to prove the medical necessity. Therefore, document everything properly. The following are some common required documents for medical-dental cross-coding:
- Clinical notes
- Diagnostic images (CT scans or X-rays)
- Lab results
- Narrative explaining medical necessity
- Treatment plan
Note: Some procedures may require different documents, depending on the type of procedure.
Step 5: Use Correct Diagnosis Codes (ICD-10-CM)
Since the claim is submitted to medical insurance, use the correct ICD-10-CM codes for the conducted procedures to follow the insurer’s protocols.
Step 6: Select Appropriate Procedure Codes (CPT & HCPCS)
Medical insurance doesn’t accept CDT codes, so map the CDT codes to CPT (Current Procedural Terminology) codes and HCPCS where necessary.
Step 7: Submit the Claim Correctly
When you collect all the requirements, use a medical claim form (CMS-1500) instead of a dental claim form. Here, you need to be extra careful while filling out the form. Your form should include the following:
- ICD-10 codes
- CPT codes
- Provider’s NPI number and other related details, like practice address
- Supporting attachments
Step 8: Track Claim Status
After claim submission, do not relax and wait. But track the claim status with follow-ups. Here, you should call the payer to confirm if they have received the claim or check the status on the payer portal. A speedy status tracking provides you enough time to gather the missing documents for resubmission or an appeal.
Step 9: Handle Denials and Appeals
Denial management is an important step to keep your dental revenue cycle smooth. You can collect your due payment if you review the reasons provided in the explanation of benefits (EOB). Following that, you arrange for additional information and submit or appeal.
How to Map CDT Codes to CPT or ICD-10-CM Codes?
As we’ve discussed, if a dental payer doesn’t reimburse for a dental procedure that’s linked to a medical reason, medical insurance covers it. If a CDT code has an alternative CPT code, use the CPT code for that procedure, and the ICD-10-CM code, if available, for diagnosis.
The table below explains a few close examples where you can map a CDT code to a CPT code:
| Dental Scenario | CDT Code | Closest CPT/HCPCS | Possible ICD-10-CM |
|---|---|---|---|
| Surgical extraction of impacted tooth | D7240 (Removal of impacted tooth) | 41899 (often used when no exact CPT exists) | K01.1 |
| Biopsy of oral lesion | D7286 | 40808 or 41100 | K13.70 |
| Sleep apnea oral appliance | D5999 | E0486 | G47.33 |
| Panoramic radiograph | D0330 | 70355 | Depends on reason (pain, trauma, infection) |
| TMJ evaluation | D9310 | 99203 (if allowed/provider eligible) | M26.62 |
| Alveoloplasty with extractions | D7310 | 41874 | K08.409 |
Note: These are just examples. Requirements may vary according to each patient’s condition, coverage plan, and the payer’s provider manuals. So, follow your payer’s requirements for billing and cross-coding.
Is Outsourcing the Best Option for Medical-Dental Cross-Coding?
Medical-dental cross-coding isn’t easy. Your billers need proper ways to map the CDT codes to CPT, HCPCS, and ICD-10-CM codes when required.
The best solution is to work with a billing partner that deals with multiple payers and knows all the nuances of medical-dental cross-coding. Top dental RCM companies, like TransDental, hire experts well-versed in these complex billing processes. By combining skill sets with robust technologies like robotic process automation solutions, these RCM companies excel in medical-dental cross-coding processes.
Right coding leads to clean claims and maximum revenue growth for your practice. So, choose a billing company that masters medical-dental cross-coding for insurance.
Final Thoughts
Medical-dental cross-coding is a very complicated process in dental RCM. It needs a structured step-by-step procedure to expedite reimbursement and recover revenue in case of claim denial. It’s important to understand the proper mapping structure for CDT codes to CPT and ICD-10-CM codes, and utilize it in coding for accurate claims and maximum profits.
Frequently Asked Questions (FAQs)
What is medical-dental cross-coding in simple terms?
Medical-dental cross-coding is the way to bill a patient’s medical insurance for certain dental procedures that are medically necessary. In most cases, CDT codes are replaced by alternative CPT codes, making sure that practices are reimbursed properly.
Is medical-dental cross-coding legal?
As long as the procedure is medically necessary and properly documented, billing medical insurance is a valid and accepted practice.
Which dental procedures qualify for cross-coding?
Dental procedures related to trauma, infections, oral surgery, sleep apnea, or medical conditions like TMJ disorders are eligible for cross-coding.
Why do cross-coded claims get denied?
Most claims are denied due to simple issues like missing documentation, incorrect coding, or a lack of proof of medical necessity. However, even small errors can lead to a denial. Invalid CPT coding and lack of documentation supporting the medical necessity of a procedure are the major causes of denial.
Do I need special codes for medical dental cross-coding?
ICD-10 codes are required for diagnosis, and CPT codes are required for medically necessary dental procedures. HCPCS codes may also work to report some supplies or equipment when CPT codes aren’t available.
