Dental Sleep Medicine Insider September 2015 | Page 14

MYSTERIES OF MEDICAL BILLING IN THE DENTAL WORLD Dr. Tara Griffin is a partner with Dr. Gy Yatros at Dental Sleep Solutions. She is a 1998 graduate of the University of Kentucky College of Dentistry. Over the past three years she has limited her practice to dental sleep medicine and the management of TMD. She holds professional memberships in the AADSM, AAOP, AASM, AHS, AAPM, and the ADA. She can be contacted at [email protected]. Those of us who treat TMJ disorders and orofacial pain (OFP) understand the role dentists play in improving our patients’ quality of life. We understand the meaning of “living a life free of pain” and want to help our patients any way we can. It is no secret that getting paid for our time and expertise when treating TMD is not an easy task. Dentists are becoming increasingly frustrated that medical payers will cover treatment of OFP and headaches by a neurologist but not a dentist. It can also seem obscene when insurance will cover a $50,000 TMJ surgery for a patient but not a conservative nonsurgical procedure such as a splint. Laws and rules for medical billing vary from state to state. For this reason, the services of a medical billing company can be invaluable when treating TMD. Due the variation in coverages and rapidly changing world of medical coding, an inquiry into whether the recommended procedure is a covered benefit is needed. This is difficult because while most insurances no longer accept the S8262 code for a TMJ splint, a few still do although that is likely to change soon. So what codes should be used now? That’s difficult to say. Some allow the D7880 code to be billed while others only recognize 21085. One insurance may have a TMJ exclusion on oral appliances but will cover the splint if it is documented for head or facial pain and not a TMJ disorder. A medical billing company can verify benefits and exclusions using specific diagnosis codes and procedures codes to determine what is covered. They can find out which procedures may meet specific insurance’s definition of medical necessity (ex. splints, TENS, low level laser, injections) or is it more beneficial to do a global fee for “all inclusive TMD therapy” vs. billing adjustments separately? It is for these reasons that consistent documentation of medical necessity with diagnosis codes is key when attempting to get medical insurance to reimburse for TMD treatment. Dr. Tara Griffin Submitting a successful preauthorization request as well as a successful medical claim for TMD is not an easy task. Many medical insurances are requiring submission of claims electronically and do not process written claims. Gathering the necessary documentation and putting into a format that will support your diagnosis and medical necessity can be challenging. This is where utilization of a software specifically designed for dentists to medical bill for TMD treatment and sleep apnea appliances is critical. Having it done right the first time will save a lot of time and frustration down the road, especially if a medical insurance company decides it wants to audit your records. While working with medical insurance can seem like an uphill battle, we are fortunate to have organizations such as the AAOP and AACP fighting for all dentists to streamline TMD coverage. The life-changing treatments we can provide for sleep apnea and TMD sufferers deserve the same recognition as those provided by other healthcare practitioners.