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Julie
#1 Posted : Tuesday, June 2, 2015 1:12:25 PM(UTC)
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Julie

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Hello, I took a class that stated we are able to bill medical insurance in the dental office. Our office sees a majority of medicare (supplemental dental plans) and medicaid patients. I found out that if we would like to bill medicare, we need to be a provider. Well, I have applied to be in network, but medicare stated that since we are a dental office, we will not be compensated. They will process our application for ordering and referring only- with this type of application, we will not be able to bill.
1. How do we apply to be able to bill?
2. Do we need new NPI?

Also, for medicaid, they also stated that we will not be able to bill medical b/c of the fact that we are dental office. I inquired about registering to be a medical provider, but we are not able to do that b/c we are not a physician.

So, do we as a dental office, just bill the medical insurance with using the CMS form and using proper diagnosis codes and billing codes that will ensure that we are paid?
Also, where can we find an office reference manual to get information on how we can bill- like timely filing limit, and any other restrictions or preauthorizations, etc. or do we just get that info when we call for eligibility?

Thank you for your help.

Julie

courtneydsnow
#2 Posted : Tuesday, June 2, 2015 2:41:54 PM(UTC)
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courtneydsnow

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Hi Julie!

Great questions, and yes dentists absolutely can bill medical insurance for medically necessary procedures performed in the dental practice!


In order to bill Medicare Part B, you need to enroll as a Part B provider, using the 855i or 855b enrollment form. Link to both of those below:

855i: http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855i.pdf
855b: http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/CMS855B.pdf


In order to bill Medicare DME for sleep apnea appliances, you will need to enroll your location as a DME supplier using hte 855s enrollment form, here is a link to that one:
http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms855s.pdf


As far as your NPI, you can enroll for a Type II NPI for your Medicare DME enrollment at least, for billing Medicare Part B and commercial insurers, you can use your dentist's personal NPI if you choose.

Now keep in mind that original Medicare does not cover "routine dental services", here is a link to information on dental services that are medically necessary Medicare Part B may cover:
https://www.cms.gov/Medicare/Coverage/MedicareDentalCoverage/index.html?redirect=/MedicareDentalCoverage/

For Medicare, DDS and DMD is considered a physician! Here is a Medicare manual stating that (page 5 you will see dds/dmd listed as physician):
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedEnroll_OrderReferProv_FactSheet_ICN906223.pdf


And yes, you will use the CPT/HCPCS procedure codes on a medical claim to bill the medical insurance, and for many procedures you may need to supply your treatment notes (SOAP notes) with the insurer to get a pre-authorization approved or a claim processed.

For information like a timely filing limit, that can usually be found right on the insurers website! Here is a link to a recent tip of the week we did over timely filing:
http://dentalwriter.com/news_view.aspx?articleid=69

For information about navigating medical billing for the dental office for medically necessary procedures, we here at Nierman provide our clients with wonderful resources like a full suite of study groups and training videos to go over every step of the process. The DentalWriter software really help you get the whole job done to :)

Hope this helps, please let me know if you have any further questions!
courtneydsnow
#3 Posted : Tuesday, June 2, 2015 2:43:49 PM(UTC)
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courtneydsnow

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Oh and here is the language for dental service by Medicare Part B :)

"Currently, Medicare will pay for dental services that are an integral part either of a covered procedure (e.g., reconstruction of the jaw following accidental injury), or for extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw. Medicare will also make payment for oral examinations, but not treatment, preceding kidney transplantation or heart valve replacement, under certain circumstances. Such examination would be covered under Part A if performed by a dentist on the hospital's staff or under Part B if performed by a physician.
Statutory Dental Exclusion
Section 1862 (a)(12) of the Social Security Act states, "where such expenses are for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth, except that payment may be made under part A in the case of inpatient hospital services in connection with the provision of such dental services if the individual, because of his underlying medical condition and clinical status or because of the severity of the dental procedure, requires hospitalization in connection with the provision of such services."
Background
The dental exclusion was included as part of the initial Medicare program. In establishing the dental exclusion, Congress did not limit the exclusion to routine dental services, as it did for routine physical checkups or routine foot care, but instead it included a blanket exclusion of dental services.
The Congress has not amended the dental exclusion since 1980 when it made an exception for inpatient hospital services when the dental procedure itself made hospitalization necessary.
Coverage Principle
Coverage is not determined by the value or the necessity of the dental care but by the type of service provided and the anatomical structure on which the procedure is performed.
Services Excluded under Part B
The following two categories of services are excluded from coverage:
A primary service (regardless of cause or complexity) provided for the care, treatment, removal, or replacement of teeth or structures directly supporting teeth, e.g., preparation of the mouth for dentures, removal of diseased teeth in an infected jaw.
A secondary service that is related to the teeth or structures directly supporting the teeth unless it is incident to and an integral part of a covered primary service that is necessary to treat a non-dental condition (e.g., tumor removal) and it is performed at the same time as the covered primary service and by the same physician/dentist. In those cases in which these requirements are met and the secondary services are covered, Medicare does not make payment for the cost of dental appliances, such as dentures, even though the covered service resulted in the need for the teeth to be replaced, the cost of preparing the mouth for dentures, or the cost of directly repairing teeth or structures directly supporting teeth (e.g., alveolar process).
Exceptions to Services Excluded
The extraction of teeth to prepare the jaw for radiation treatment of neoplastic disease.
An oral or dental examination performed on an inpatient basis as part of comprehensive workup prior to renal transplant surgery or performed in a RHC/FQHC prior to a heart valve replacement.
Definition
Structures directly supporting the teeth means the periodontium, which includes the gingivae, periodontal membrane, cementum of the teeth, and the alveolar bone (i.e. alveolar process and tooth sockets)."
Julie
#4 Posted : Tuesday, June 2, 2015 3:43:57 PM(UTC)
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Julie

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Thank you for all of your great information and insight, you have been very helpful.

I think what I may need to do now is to delete the application I sent in through the peccos webportal and reregister using your very helpful links.

Now, do you know anything about children's medicaid? Do I need to apply for a new npi for this one as well? or use the ones we have the regular NPI and the new one you informed me to register for NPI type II
do you have any helpful links for medicaid and how I will be able to apply to be able to bill medical insurance for medicaid? (We are already a provider of dental for medicaid)

Thank you very much.

Julie
courtneydsnow
#5 Posted : Tuesday, June 2, 2015 5:39:02 PM(UTC)
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courtneydsnow

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Hi Julie!

Great question - Medicaid enrollment is state by state, if you would like to tell me the state you are in I am happy to find some provider enrollment information for you for your state :)

Julie
#6 Posted : Tuesday, June 2, 2015 6:03:55 PM(UTC)
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Julie

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Texas
courtneydsnow
#7 Posted : Tuesday, June 2, 2015 6:18:40 PM(UTC)
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courtneydsnow

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Ok great! Here is the link to Texas Medicaid new provider enrollment information where you can download and view the provider manual, get to the enrollment forms, etc :)

http://www.tmhp.com/Pages/ProviderEnrollment/PE_TX_Medicaid_New.aspx

Julie
#8 Posted : Tuesday, June 2, 2015 6:47:33 PM(UTC)
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Julie

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Actually, that is where I was and when I called in, they stated that I can not apply as a medical provider b/c we are a dental office. They also stated we are not allowed to bill medical medcaid insurance.

Would you know how to go about this?

Julie
Guest
#9 Posted : Friday, June 5, 2015 11:35:03 AM(UTC)
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If our practice is owned by one dentist, but he hired a couple of dentists, would he fill out the 855i and say he is a non physican practitioner? and put his specialty as dentist?
or would he do the 855b and say he is a clinic or group practice- do they ask for a specialty? if so, what would we put?

Also, we are starting another practice where we have two owners, will we do a 855b application for that?

Thank you for your help.

Julie
courtneydsnow
#10 Posted : Monday, June 15, 2015 8:45:57 AM(UTC)
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courtneydsnow

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Hi Julie & Guest!

Julie - under Medicare, a dentist actually falls into the physician category. It is possible that Medicaid holds a different policy for it, however CMS is for Medicare & Medicaid services. I would try back and explain that you are not attempting to practice medicine as a dental office, but are simply looking to be able to utilize your patients medical benefits for Medicaid services that are medically necessary and referred by a physician, but must be performed in a dental practice setting. (i like to use Medicare's LCD for sleep apnea appliance as an example, that clearly states it must be done by a DDS/DMD, and must be referred by a physician).


Guest - the 855i application is for Medicare Part B for an individual practitioner, and the 855b is for group practices, so it all depends on the way the business is set up! So yes likely with 2 owners, you will be looking at the 855b.

Instead of applying to Part B as a non-physician practitioner, you will actually apply as a physician practitioner (DDS/DMD is considered a physician under Medicare. There is an option to select "Oral Surgery (dentist only)", and there is also a space for "other" than you can write in "DDS" or "DMD".

Leah
#11 Posted : Wednesday, April 13, 2016 10:13:09 AM(UTC)
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Good Morning,

I work for a dental office and we are currently trying to find information on Dental procedures that we can bill medically. I was reading through some of these post and we are basically trying to figure out how the ICD 10 codes coincide with Dental? We also are looking into becoming a Medicare enrollee. I deal with dental insurance all the time and Medical insurance is all new but reading some information on Medical insurance some of the procedures that we do would help the patient use some of their Medical insurance and keep their dental for Crowns, Bridges, Dentures, etc. Can you help me out on some of this information. Thank you

Leah L.
llockmon@midamericadental.com
courtneydsnow
#12 Posted : Wednesday, April 13, 2016 2:50:09 PM(UTC)
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courtneydsnow

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Hi Leah!

Those are great questions but far too much information to cover in an e-mail!!!
We have great crosscoding courses that are a day and a half around the country that does a great job going over ICD & CPT codes, what medically necessary services performed in dental practices are covered under medical insurance, how to complete a medical claim form, etc.
Here is a link to our crosscode course schedule: https://niermanpm.com/dental-continuing-education/medical-billing-in-dentistry
Guest
#13 Posted : Wednesday, November 16, 2016 9:56:41 AM(UTC)
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The dentist that I work with in treating OSA is under the impression that we cannot submit a claim to Medicare on behalf of the patient. We are a non-participating DME provider. It is her understanding that we have to give the claim form to the patient to submit themselves. Can you enlighten me, please? It seems that every time I ask the office manager or DDS, I'm getting incomplete answers to my questions.

Thanks in advance!
courtneydsnow
#14 Posted : Wednesday, November 16, 2016 10:00:46 AM(UTC)
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courtneydsnow

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Hi guest!

Great question. Yes, if you enrolled as either a participating or a non-participating DME supplier you submit the claim on behalf of the patient. From my understanding, as a Medicare provider/supplier, you are actually required to do so!

Hope this helps!
Guest
#15 Posted : Wednesday, March 29, 2017 3:24:12 PM(UTC)
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I am the sleep care coordinator for a dental practice. Does the dentist have to be an oral surgeon before applying to be a non participating medicare provider? Thank you!
Guest
#16 Posted : Wednesday, March 29, 2017 3:28:05 PM(UTC)
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courtneydsnow
#17 Posted : Thursday, March 30, 2017 7:56:12 AM(UTC)
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courtneydsnow

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Hi guest!

No it does not have to be an oral surgeron, general dentists can enroll to be non-participating Medicare providers or DME suppliers.

I noticed you mentioned you are a sleep coordinator, are you looking to enroll as a non-participating DME supplier in order to bill Medicare for oral appliances to treat OSA?

If so, that is done by using the 855s enrollment form. Here is a link to it:
https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms855s.pdf


The Medicare Part B provider application is different, that enrollment form in the 855i or 855b.

Hope this helps!
Guest
#18 Posted : Wednesday, April 5, 2017 1:36:30 PM(UTC)
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Yes, Courtney--I am a licensed Respiratory Care Practitioner in NC and am working with a general dentist to start her Sleep Apnea program. We will be enrolling as a non-participating provider. Thank you for the link! I think there is another form I have to submit, as well, is that correct? Thank you Thank you Thank you!!!

Jo
courtneydsnow
#19 Posted : Friday, April 7, 2017 10:24:24 AM(UTC)
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courtneydsnow

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Hi Jo!

So to enroll the location as a DME supplier in order to bill for E0486 (oral appliance for OSA that a DDS/DMD delivers), the 855s application is where you start.

If you want to enroll the location as a non-particiapting DME supplier, you will not complete the 460 (participating provider agreement).

However, you do need to complete an EFT (ELECTRONIC FUNDS TRANSFER) agreement along with the 855s, here is a link to that: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms588.pdf

There is a section of the 855s application that outlines the mandatory documents to send along with the application (section 12, found on page 21 of the 855s).

How, as a Respiratory Care Practitioner, if you are looking to enroll as a Medicare Part B provider as well, you will be looking at the 855i or 855b. Here are the thinks to those:

855i: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855i.pdf

855b: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms855b.pdf


Hope this helps!

Edited by user Friday, April 7, 2017 10:24:59 AM(UTC)  | Reason: Not specified

Guest
#20 Posted : Tuesday, April 25, 2017 3:52:22 PM(UTC)
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Hi, I've looked searched all over and can't find any info regarding my dilemma:

I recently submitted an 855i for a general dentist at our office. Noridian (the MAC for our state) has told us now (through several different reps) that general dentists CANNOT enroll with Medicare Part B, but we can use the 855-O as a referring/ordering provider ONLY.

I've argued that DDS falls under the "physician" category but have been told repeatedly that non-oral surgeons still cannot use the 855i. Does anyone have any experience with this issue? Has any general DDS been able to get their 855i through Medicare? This is getting very frustrating.
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