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Claims Processing: Dental Claims vs. Medical Claims

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There are some similarities between preparing dental claims and medical claims. For example, patient and insurance demographics and insurance information that must be provided to medical carriers are similar.

However, there are some very significant differences between the two. While dental carriers typically require a procedure code. Medical carriers not only require procedure code(s) but also the reason why the procedure(s) were performed or the patient’s diagnosis.

Diagnoses are classified in code form in the ICD-9-CM “International Classification of Disease, Ninth Revision – Clinical Modification” manual. Without at least one diagnosis code that supports the procedure(s), the medical claim will not be paid. There must be an appropriate diagnosis to establish the medical necessity of the procedure. This is probably the most important part of successful dental-medical cross coding.

Another very significant difference between dental and medical coding systems is the time period and frequency between updates, deletions and revisions. All medical code sets update yearly and medical carriers generally offer no grace periods on using outdated codes.

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The medical claim form also has some major differences compared to the dental claim form. Most medical carriers require the CMS-1500 (08-05) claim form. Medical carriers require these preprinted, red-inked forms because these forms are the only ones that scan correctly. Hand-written claims and comments or copies are not accepted.

Apex EDI can provide the best medical electronic billing for all of your medical claims and dental claims. The main benefit to implementing a dental-medical cross-coding system is satisfied patients who recognize your willingness to help them save their dental plan allowance and access medical benefits. Grateful patients can become your most valuable marketing asset.

Articles with this disclaimer may not represent the beliefs or core values of Apex EDI. The above is simply a summary taken from the industry’s general community to help readers stay up-to-date on what people are talking about.

Posted in: Claims Processing

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