clinical experience that allows the participant to develop skills and expertise. (10/31/2015) Provider ID#

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1 ZZ NPI Earn 1 CE credit This course was written for dentists, dental hygienists, and assistants Dental-Medical Cross Coding 101 A Peer-Reviewed Publication Written by Marianne Harper Abstract The need for dental-medical cross coding is growing in today s dental practices. Cross coding may be perceived as being too difficult to implement but this course will provide a detailed look at all aspects of medical coding and lay the foundation for a seamless implementation of cross coding. Dental practices that implement cross coding have an enhanced ability to increase reimbursement for their patients. Publication date: Aug 2013 Expiration date: July 2016 Educational Objectives: At the conclusion of this educational activity participants will be able to: 1. Describe medical necessity and which dental procedures can be classified as medically necessary 2. Describe the different types of medical insurance plans and those that require referrals 3. Implement the different coding systems used for medical insurance 4. Learn how to complete the medical claim form 5. Learn how to add narrative information to the medical claim form JP Author Profile Marianne Harper has expertise in revenue and collection systems, business office systems and training dental practices in dental-medical cross coding. Ms. Harper is a well respected consultant, trainer, lecturer and author. Author Disclosure Ms. Harper is CEO of The Art of Practice Management. She can be reached at a.p.m.1@suddenlink.net. Supplement to PennWell Publications ThiscourseisapprovedforAGDcreditsonly it is not approved for ADA credits This educational activity was developed by PennWell s Dental Group with no commercial support. This course was written for dentists, dental hygienists and assistants, from novice to skilled. Educational Methods: This course is a self-instructional journal and web activity. PennWelldesignatesthisactivity for1continuingeducational Credit Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or third party has had DentalBoardofCalifornia:Provider4527,courseregistrationnumberCA#: any input into the development of course content. ThiscoursemeetstheDentalBoardofCalifornia srequirementsfor1unitofcontinuingeducation. Requirements for Successful Completion: To obtain 1 CE credit for this educational activity you must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%. ThePennWellCorporationisdesignatedasanApprovedPACEProgramProviderbythe CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with products or AcademyofGeneralDentistry.Theformalcontinuingdentaleducationprogramsofthis services discussed in this educational activity. Heather can be reached at hhodges@pennwell.com programproviderareacceptedbytheagdforfellowship,mastershipandmembership Educational Disclaimer: Completing a single continuing education course does not provide enough information to result maintenancecredit.approvaldoesnotimplyacceptancebyastateorprovincialboardof in the participant being an expert in the field related to the course topic. It is a combination of many educational courses and dentistryoragdendorsement.thecurrenttermofapprovalextendsfrom(11/1/2011)to clinical experience that allows the participant to develop skills and expertise. (10/31/2015) Provider ID# Registration: The cost of this CE course is $20.00 for 1 CE credit. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.

2 Educational Objectives: At the conclusion of this educational activity participants will be able to: 1. Describe medical necessity and which dental procedures can be classified as medically necessary 2. Describe the different types of medical insurance plans and those that require referrals 3. Implement the different coding systems used for medical insurance 4. Learn how to complete the medical claim form 5. Learn how to add narrative information to the medical claim form Abstract The need for dental-medical cross coding is growing in today s dental practices. Cross coding may be perceived as being too difficult to implement but this course will provide a detailed look at all aspects of medical coding and lay the foundation for a seamless implementation of cross coding. Dental practices that implement cross coding have an enhanced ability to increase reimbursement for their patients. It used to be so simple! Dentists treated their patients and filed dental claims for those covered by dental plans. Physicians did the same for their patients. Rarely did this ever cross over. Times have changed in dentistry and now there s more of a need to cross over through dental-medical cross coded claims. Cross coding is actually not new to dentistry. Trauma claims and third molar extraction claims have often been suspended by dental plans with the requirement that the claim be filed with the patient s medical plan first. This can create quite a dilemma. There is definitely some work involved with getting past the we re dental attitude. Medical coding is different and often times more difficult than dental coding. Yes, it will require some extra work to learn how to cross code but this should not be reason enough not to. This course can be the first step to accepting the challenge and learning how to cross code. The most important consideration regarding cross coding is the medical necessity to do so. Medical necessity requires that the services and procedures be in compliance with recognized medical standards and be appropriate and necessary for: diagnosis or treatment prevention of a medical condition improvement of a condition rehabilitation of lost skills 1 The American Medical Association s definition of medical necessity is threefold: In accordance with generally accepted standards of medical practice Clinically appropriate in terms of type, frequency, extent, site, and duration Not primarily for the convenience of the patient, physician, or other health-care provider. 2 The conditions that the dentist determines to be medically necessary must be part of the documentation in the patients records. Should a practice not have adequate documentation of medical necessity and an audit occurs, it can result in financial problems for a dental practice. 3 Dental procedures that consitute medical mecessity include: Exams, radiographs and consultations for medically necessary dental procedures Many oral surgical procedures Excisions Biopsies Reconstruction due to trauma or genetics Endodontics due to trauma or a medical condition TMD procedures including treatment of myofascial pain conditions Emergency treatment of oral inflammation Non-surgical sleep apnea treatment Patients with medical conditions such as diabetes, heart disease, pregnancy, hormonal conditions, Parkinson s disease, Alzheimer s disease Dental treatment required due to patients needing radiation treatment Implants Loss of teeth due to trauma Loss of teeth due to systemic conditions (e.g. tumors, cysts, radiation therapy, cancer, genetics) Bone atrophy that results in dentures that won t seat correctly, resulting in difficulties with chewing and getting good nutrition Patients needing a dental clearance prior to surgery 4 Many dental procedures will not fall under these guidelines, so dentists must be careful to only file cross coded claims for those that are medically necessary. Keep in mind that medical plans have differing language in their contracts as to what they will cover, so there may not be coverage for all of these procedures. When these procedures are filed with a medical plan, they should not be filed concurrently with dental. If they are medically necessary procedures, they should be filed with medical as primary

3 Comparisons of medical and dental insurance are as follows: Most medical plans do not have annual maximum allowances Medical plans quite often have a much higher deductible than dental but helping patients meet their deductibles is still a major benefit to a patient. There are several different types of medical insurance plans: Indemnity Preferred Provider Organization (PPO) Capitated plans such as HMO s referrals required 5 Point of Service plans (combination of PPO and HMO) referrals required 6 Tricare referrals required for Prime and possibly required for Standard 7 Medicare providers must be enrolled to file 8 Workers Compensation The primary difference between dental and medical plans is that medical requires the use of diagnosis codes to prove why a procedure was necessary. The diagnosis code set used for medical claims at present is the ICD-9. These codes are used to describe illness, injury, and symptoms. Within this code set is a subset of codes referred to as the V and E codes. For dentistry, the V codes are mostly used to help explain medical history factors that influence treatment such as diabetes, heart disease, history of stroke, etc. E Codes are used most often in dentistry to provide the external cause and place of occurrence of trauma events. Diagnosis codes must be prioritized on the claim form. The most significant diagnosis, the one that explains the problem being treated and the main reason for care, is referred to as the primary diagnosis code. Up to three additional codes, including V and E codes, can follow the primary. What is similar between dental and medical insurance claim filing is that procedure codes are required. Medical procedure codes are called CPT Codes. Similar to the dental procedure code set, the codes are divided into categories. These categories are evaluation and management; anesthesia; surgery; radiology; pathology and laboratory; and medicine. 9 The evaluation and management codes are not like the dental exam codes. They are much more complex and have different criteria for their use. Dental practices need to cautiously choose codes from this section as most of the mid-level to high-level codes require a time factor and the evaluation of multiple body systems. 10 Filing high-level evaluation and management codes by dental practices can result in audits. Part of the difficulty in cross coding is that very few CPT codes exactly parallel dental procedures. There are some insurance carriers that will actually accept CDT codes on the medical claim form. It is always wise to check with the carrier and use them if allowed. It reduces the confusion and time involved with narratives when you can use an actual CDT code. If the carrier does not accept CDT codes, there will be times when there is no close match and you will have to use a very non-specific CPT code. This will require a narrative to explain the nature of the procedure. Within the CPT code set is a subset of codes called Modifiers. There are times when you will need to communicate that a procedure was altered by a specific circumstance and that is accomplished with Modifiers. Examples include; the need to report that a procedure is less involved than the code normally used, or the need to explain that more than one type of procedure was performed on the same date by the same provider. Modifiers would also be used to explain that an exam and x-ray were performed on the same date of service and should be paid as separate entities. There are many more modifiers and it is important to know when and how to use them. The medical claim form is called the CMS-1500 and is the form required by most medical insurance carriers. There are some significant differences between this form and the dental claim form. We are accustomed to using plain white paper and having our dental software print the forms and fill in the blanks. Medical claim software is completely different. Medical claim software only fills in the blanks, so the forms must be purchased. Copied forms will not scan correctly. These forms look quite a bit different from dental forms because they are printed in red. It is essential that the medical claim form be completed accurately because claim form completion errors can result in denials. Below is a breakdown on how to complete the CMS claim form. In the top blank area of the claim form, over to the right, is the area where the insurance carrier name and address should appear. This is a four line field, so if the mailing address is only three lines, be sure to skip a line to make the city, state, and zip code appear on the fourth line. Box 1 asks for the type of plan that you are filing. It ranges from a choice of Medicare, Medicaid, Tricare/Champus, CHAMPVA, Group Health Plan, FECA BLK Lung, and Other. It is very important to check off one of these. Box 1a through 11d (except box 10) are the areas where patient demographic information is entered including primary and secondary subscriber and insurance plan information. Box 10 asks if the patient s condition is related to employment, auto accident, or another type of accident. One of these boxes must be checked. The information provided in this box helps the carrier determine if workers compensation or liability insurance would have primary responsibility for payment. Box 12 is where the authorization for the release of medical information or other information is provided to process the claim. Signature on File can be used. Box 13 is where the authorization is provided for assignment of benefits and Signature on File can be used. Box 14 may request different information depending on the carrier including; the date applicable to any of the

4 conditions listed or the date of service for the treatment being performed. Box 15 asks if the patient had the same or similar illness previously and to give dates. If this does not apply, it can be left blank. Box 16 asks for dates that the patient was unable to work in the current occupation. If this does not apply, it also can be left blank. Box 17 is used to report referring provider information. It requires both the name of the referring provider and the NPI number of that provider. The NPI number is entered in box 17b. Box 18 asks for hospitalization dates if related to the current procedures. If this does not apply, it can be left blank. Box 19 can be used to provide narrative information but must be done concisely and can possibly eliminate the need for a separate narrative. As explained above, there are times when there is no parallel CPT code for a dental procedure so narrative information must be provided. This box can also be used to report information such as See Attachment or Corrected Claim. Concise narratives can also be entered in the shaded area above box 24 on the claim form. The qualifier ZZ must be listed first. For reporting procedures with tooth numbers or quadrants, enter ZZ, then the CDT code, then the JP qualifier for tooth number(s) or JO for quadrant(s) using quadrant codes (10 for maxillary right, 20 for maxillary left, 30 for mandibular left, and 40 for mandibular right). Box 20 asks for information on whether an outside lab is involved with the procedure. Check yes or no accordingly. If yes, and the lab charges the practice a fee, enter the amount of the fee in the Charges area. Box 21 is used for reporting the diagnosis code(s). The primary code is reported in box 1. Secondary codes and/or V and/or E codes can be listed in boxes 2, 3 and 4. Box 22 is used only for Medicaid resubmissions. Box 23 is where a prior authorization number is entered. Box 24 has several sub-boxes: 24A The date of service is entered in both the from and to sections 24B The place of service is entered here. 11 is the indicator for office. 24C This box is used to indicate an emergency but is often not used. There are specific instructions on its use in the NUCC guidelines D The procedure codes are entered here. If any modifiers are required, there are four boxes provided following the procedure code boxes. 24E This box is labeled diagnosis pointer. This is the area used to report which of the diagnosis codes is most significant to each procedure. If the first diagnosis code listed applies, enter number 1 in the box. If the second, third or fourth diagnosis code listed is the most significant to the procedure, enter either 2,3 or 4 in this box. 24F The fee for each procedure is entered here. If the same procedure is performed several times, such as four third molar extractions, the procedure code must be listed only one time, then multiply the fee by the number of times the procedure was performed. 24G This box is where the number of units of each procedure code is indicated. In many cases, it will be one (1). However, in the case where more than one of the same procedure was performed and the procedure is reported on one line, you must enter the number of times it was performed. In the case of 24F above, the number 4 would be entered. An exception to this is when you perform a procedure that involves a multiple. Attention must be paid to the descriptor of the code to determine this. As an example, the CPT code for one to three implants in a dental arch (21248) requires the number 1 to be entered in the days/units box if up to three implants were placed in an arch. Keep in mind that the units of that procedure code are being indicated, not the number of implants. 24H is for EPSDT Family Plan cases only. Box 24J is used to report the treating provider s NPI number. Box 25 Place the Federal tax ID number here and check off if it s a social security number or an EIN number. Box 26 A patient s account number can be placed here or it can be left blank. Box 27 Use this box to indicate if assignment of benefits has been accepted or not. Box 28 The procedure code fees are totaled in this box. Box 29 This box can be left blank unless coordination of benefits is necessary. It is not intended for reporting patient payments. Box 30 The total balance due is reported in this box. Box 31 The signature of the provider is entered here. Box 32 The name and address of where the services were rendered is noted here.. Box 33 The name, address, and telephone number of the billing entity is placed here. Box 33a Enter the billing provider s NPI number or the treating provider s NPI if there is only an individual NPI number. Some of the major dental practice management software have cross coding capabilities and will either provide the codes or provide an area to enter the codes. In addition, these programs will fill in the CMS-1500 claim form. If the practice software does not include this feature, there are programs that can be purchased online such as instaclaim.com, availity.com, and that will fill in the claim form. With a better understanding of cross coding through this course, the process can be simplified to help improve patient reimbursement and remove barriers to dental treatment

5 References: 1. Medical Necessity, Illinois Department of Insurance. September asp, Accessed 2/27/13 2. American Medical Association. mm/372/i99cms13doc.doc, Accessed 3/15/09 3. How to Ensure Proper Reimbursement and Avoid a RAC Audit, Orion Healthcorp Orion%20White%20Paper.pdf, Accessed 2/27/13 4. Dental and Oral Surgical Procedures, UnitedHealthcare Oxford. January 1, oral_surgical_procedures.pdf, Accessed 2/27/13 5. Health Maintenance Organization, Wikipedia. org/wiki/health_maintenance_organization, Accessed 2/27/13 6. FAQ: How Do Referrals Work in a POS Plan?, Go Insurance Rates, September 25, Accessed 2/26/13 7. TRICARE Authorizations and Referrals, Military.com Benefits Accessed 2/26/13 8. What s new with Medicare enrollment?, American Medical Association medicare-enrollment-process.page, Accessed 2/26/13 9. American Medical Association, 2013 Current Procedural Terminology, Professional Edition (American Medical Association, Chicago, 2012), p. X 10. American Medical Association, 2013 Current Procedural Terminology, Professional Edition (American Medical Association, Chicago, 2012), p. 7, 8, Health Insurance Claim Form, National Uniform Claim Committee July claim_form_manual_v8-0_7-12.pdf, Accessed 2/26/13 Author Profile Marianne Harper has expertise in revenue and collection systems, business office systems and training dental practices in dental-medical cross coding. Ms. Harper is a well respected consultant, trainer, lecturer and author. Author Disclosure Ms. Harper is CEO of The Art of Practice Management. She can be reached at a.p.m.1@suddenlink.net. Online Completion Use this page to review the questions and answers. Return to and sign in. If you have not previously purchased the program select it from the Online Courses listing and complete the online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the Take Exam link, complete all the program questions and submit your answers. An immediate grade report will be provided and upon receiving a passing grade your Verification Form will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or printed anytime in the future by returning to the site, sign in and return to your Archives Page. Questions 1. Medical necessity must always be established for any cross coded claim. Of the following, which dental procedure does not present a medical necessity: a. Reconstruction due to trauma or genetics b. Single implant placement performed as a result of tooth loss due to decay c. TMD procedures d. Non-surgical sleep apnea treatment 2. Which of the following types of insurance plans will probably not require a referral from the primary care provider: a. Capitated plan (HMO type) b. Tricare Prime (active duty military plan) c. Point of Service plan d. Preferred Provider Organization 3. Which of the following statements is incorrect about diagnosis codes: a. Modifiers are used to explain why a procedure is altered by a specific circumstance and are part of the diagnosis code set b. V codes are used to show medical history factors that influence treatment and are part of the diagnosis code set c. E codes are used to show the external cause and place of occurrence for trauma and are part of the diagnosis code set d. Diagnosis codes are used to explain why a procedure was performed by indicating illness, injury, or symptoms 4. The CPT code set is divided into categories. Which category provides the codes for an exam: a. Evaluation and Management b. Surgery c. Anesthesia d. Pathology and Laboratory 5. CMS-1500 claim forms can be obtained by: a. Copying another CMS-1500 claim form b. Downloading forms online c. Purchase d. Printed from medical claim completion software 6. Certain boxes of the CMS-1500 claim form can be left blank. Which of the following cannot: a. Box 15 b. Box 1 c. Box 16 d. Box Narratives are often necessary with cross coded claims because: a. Narratives are used to indicate diagnosis codes b. Many CDT codes have no parallel CPT code, so non-specific codes like require narratives to explain the nature of the procedure c. Narratives are used to provide the place of service d. Narratives are used to provide the dates of service 8. In coding four third molar extractions that have the same CDT code (e.g. D7140), which of the following is not correct: a. Only one procedure code line on the claim form should be filled in for the extractions b. The fee for one extraction should be multiplied by four and entered in box 24F c. The number 1 should be entered in the Days/Units box 24G d. The shaded area above the procedure code area can be used to indicate the tooth numbers by entering ZZ 7140 JP Which of the following should be placed as the first diagnosis code (primary diagnosis) on the claim form: a. V Code b. The code for the problem being treated and the main reason for treatment c. E Code d. CPT Code 10. What is the most likely outcome if an insurance carrier requires prior authorization for a procedure and it is not obtained prior to performing the procedure: a. The carrier may pay a lower percentage of benefits or deny payment b. The carrier may begin an audit c. The carrier may fine the practice d. The practice may automatically be contracted with the carrier 11. Narratives included on the claim form must be: a. Very detailed b. Placed at the top of the claim form c. Placed in box 19 and must be concise d. Handwritten 12. Where else can narrative information be placed on the claim form? a. At the top of the claim form b. In box 10 c. In box 32 d. In the shaded area of box The code sets that help to explain how a procedure is altered by a specific circumstance are: a. V Codes b. Modifiers c. E Codes d. ICD-9 Codes 14. If the same procedure code is performed more than one time, which of the following is not the proper way to code it? a. Enter all with one procedure code b. Enter each individually c. Multiply the fee for one by the number of times the procedure was performed d. Indicate in the Days/Units box the number of times the procedure code was performed 15. Audits and fines may result from: a. Use of high level evaluation and management codes by general dentists when evaluation of multiple body systems was not performed b. Not filling in every box of the CMS-1500 claim form c. Using Signature on File in box 12 d. Completing the CMS-1500 claim form by hand

6 ANSWER SHEET Dental-Medical Cross Coding 101 Name: Title: Specialty: Address: City: State: ZIP: Country: Telephone: Home ( ) Office ( ) Lic. Renewal Date: AGD Member ID: Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 1 CE credit. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call Educational Objectives 1. Describe medical necessity and which dental procedures can be classified as medically necessary 2. Describe the different types of medical insurance plans and those that require referrals 3. Implement the different coding systems used for medical insurance 4. Learn how to complete the medical claim form 5. Learn how to add narrative information to the medical claim form Course Evaluation 1. Were the individual course objectives met? Objective #1: Yes No Objective#4: No Yes Objective #2: Yes No Objective #5: Yes No Objective #3: Yes No Pleaseevaluatethiscoursebyrespondingtothefollowingstatements,usingascaleofExcellent =5toPoor =0. 2. To what extent were the course objectives accomplished overall? Please rate your personal mastery of the course objectives How would you rate the objectives and educational methods? How do you rate the author s grasp of the topic? Please rate the instructor s effectiveness Was the overall administration of the course effective? Please rate the usefulness and clinical applicability of this course Please rate the usefulness of the supplemental webliography Do you feel that the references were adequate? Yes No 11. Would you participate in a similar program on a different topic? Yes No 12. If any of the continuing education questions were unclear or ambiguous, please list them. 13. Was there any subject matter you found confusing? Please describe. 14. How long did it take you to complete this course? 15. What additional continuing dental education topics would you like to see? If not taking online, mail completed answer sheet to Academy of Dental Therapeutics and Stomatology, A Division of PennWell Corp. P.O. Box 116, Chesterland, OH or fax to: (440) For IMMEDIATE results, go to and click on the button Take Tests Online. Answer sheets can be faxed with credit card payment to (440) , (216) , or (216) Payment of $20.00 is enclosed. (Checks and credit cards are accepted.) If paying by credit card, please complete the following: MC Visa AmEx Discover Acct. Number: Exp. Date: Charges on your statement will show up as PennWell AGD Code 554 PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS. COURSE EVALUATION and PARTICIPANT FEEDBACK We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included with the course. Please all questions to: hhodges@pennwell.com. INSTRUCTIONS All questions should have only one answer. Grading of this examination is done manually. Participants will receive confirmation of passing by receipt of a verification form. Verification of Participation forms will be mailed within two weeks after taking an examination. COURSE CREDITS/COST All participants scoring at least 70% on the examination will receive a verification form verifying 1 CE credit. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. PennWell is a California Provider. The California Provider number is The cost for courses ranges from $20.00 to $ PROVIDER INFORMATION PennWell is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE Provider may be directed to the provider or to ADA CERP at cotocerp/. The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from (11/1/2011) to (10/31/2015) Provider ID# Customer Service RECORD KEEPING PennWell maintains records of your successful completion of any exam for a minimum of six years. Please contact our offices for a copy of your continuing education credits report. This report, which will list all credits earned to date, will be generated and mailed to you within five business days of receipt. Completing a single continuing education course does not provide enough information to give the participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. CANCELLATION/REFUND POLICY Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing by the Academy of Dental Therapeutics and Stomatology, a division of PennWell CROSS813DE