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Medicare Compliance & Reimbursement

DENTAL SERVICES:

2 Practices Succeed In Overturning 'Routine' Dental Denials

Published on Wed Apr 19, 2006

Medicare will cover dental services when they're medically related.

Providers aren't taking denials of "routine" services as the last word. Two practices found ways to appeal those denials and obtain their rightful reimbursement.

Medicare never pays for "routine" services such as dental care. But Medicare will pay for dental services that are an integral part of a covered procedure, such as a jaw reconstruction after an accident. Medicare will also pay for oral examinations preceding kidney transplant or heart valve replacement, according to the Centers for Medicare & Medicaid Services Web site.

Two practices succeeded in turning a denial for dental care into reimbursement, and providers can learn from their examples.

Success story #1: A patient underwent an aortic valve replacement and was on Coumadin therapy. Two weeks later, the patient had a dental abscess and received oral antibiotics on an outpatient basis, which failed to treat the abscess. After a consult, the infectious disease physician admitted the patient to the hospital and gave him IV antibiotics, according to Pat Larabee, coder with InterMed in South Portland, ME.

The carrier denied the IV antibiotics as routine dental services, and InterMed appealed the denial, including copies of the hospital records. The carrier also denied the appeal.

Finally, the third time around, a Qualified Independent Contractor approved the claim and paid InterMed.

InterMed received the payment because Larabee had included all the hospital records, including the cardiologist's progress notes, with a note explaining that the services were medically necessary. If the patient hadn't received IV antibiotics, he would have been at risk for potentially fatal endocarditis.

Success story #2: A patient with an abscess was discharged and then readmitted after his condition seemed to have worsened. The physician suspected the patient had sepsis because of a change in his mental status, including "extreme lethargy, fatigue and vague awareness" of his surroundings, according to Diane Brooks, a coder with Montgomery Hospital in Norristown, PA.

The physician performed X-rays and billed them using Current Procedural Terminology code 70355 (Orthopantogram). The carrier denied the claim, and Brooks appealed. She submitted the patient's discharge summary, which spelled out why the admitting physician felt the patient's change in mental status might indicate sepsis from a worsening abscess. She also included the interpretation of the X-rays. The carrier finally paid the claim.

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