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# How to Ensure Payment for Oral Surgery Claims?

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- October 25, 2023

Dealing with Oral Surgery Claims can be a significant portion of dental billing tasks in specific office settings. While it might appear uncomplicated at first glance, some intricacies often challenge smooth processing and resolving these claims. However, dental practices often need help to pay for oral surgery claims for several reasons, including coding errors and missing documentation. This blog post will discuss effective approaches dental practices can use to ensure timely payment for oral surgery claims.

## Understanding Coverage for Oral Surgery: Medical vs. Dental Insurance

Dental and medical health are intertwined, and specific procedures are covered under dental and medical insurance plans. The extent of coverage for oral surgery varies depending on your insurance providers and plan details. Generally, medical insurance plans can often partially cover major oral surgery procedures.
Engaging in a conversation with your dentist is advisable to gauge their experience in filing medical claims. They can offer insights into the likelihood of receiving coverage and assist in obtaining a predetermination of benefits. Additionally, directly contacting your medical insurance provider is crucial to determine if the intended procedure falls under their coverage, understand the expected coverage amount, and estimate potential out-of-pocket expenses. Similarly, reaching out to your dental insurance provider is essential, as they may provide more comprehensive coverage for such significant dental procedures.

## Practical Approaches to Secure Payment for Oral Surgery Claims

Pre-authorizations and referrals
When processing oral surgery claims, pre-authorizations and referrals play a crucial role. Reviewing the patient’s insurance plan requirements before commencing oral surgery treatment is essential. Under HMO plans, specialized treatments like oral surgery necessitate a referral. Ensuring the accurate completion of the referral form and attaching it to the dental claim during billing is paramount. Other plans, such as those for active military personnel and Medicare beneficiaries, also mandate pre-authorization for specialty treatments. To facilitate smooth payments, it’s vital to proactively submit the necessary forms well in advance, securing pre-approval for the treatment before the appointment.

### X-rays and Intra-oral Photos

In the realm of oral surgery claims, it’s imperative to integrate X-rays and intra-oral photos effectively. Never should oral surgery procedures be billed without accompanying X-rays providing essential support for the completed treatment. Specifically, periapical X-rays are crucial to ensure a comprehensive view of the entire root of the affected tooth. When dealing with wisdom teeth or complete mouth extractions, incorporating a panoramic X-ray becomes essential to present a clear view of all impacted teeth, encompassing their roots. While not a strict requirement, utilizing intra-oral photos proves immensely beneficial in bolstering claim approval. These photos, especially if they reveal visible decay or fractures, can significantly aid in substantiating the necessity of the claimed procedures.

### Effective Clinical Narratives

Creating a comprehensive clinical narrative is crucial. The narrative’s foundation is laid during the initial consultation, where a thorough assessment of all oral issues is conducted, and future treatment plans are mapped out. Maintaining complete and detailed chart notes is essential to ensure a solid basis for the narrative. After the completion of the surgical treatment, a meticulous clinical narrative must be crafted, providing a comprehensive explanation of the procedures performed and the rationale behind them. Specific treatments may necessitate additional detailed information within the narrative. For example, when performing bone grafts, it’s important to note that most carriers will only cover them if an implant is planned. Hence, clearly outlining any future treatment, including the anticipated service date, if available, is essential for a successful claim.
Additionally, when billing for anesthesia, it’s essential to understand that most insurance plans will only provide coverage if it is medically necessary. Therefore, providing specific medical justifications for its utilization is vital. A generic statement stating medical necessity may not secure claim approval and payment.

### Follow-up on Outstanding Claims

Insurance companies may take several weeks to process an oral surgery claim. If a claim is not processed within the expected period, dental practices should follow up with the insurance company to inquire about the status of the claim. Practices can also request payment if the claim has been approved but not yet paid. Follow-up is essential to ensure that claims are processed timely and that practices receive the correct service reimbursement.

### Appropriate CDT Codes

A critical aspect of the success of oral surgery Claims lies in accurately using CDT codes. This aspect is especially crucial for extractions due to the availability of eight distinct codes, making it easy to select the wrong one inadvertently. When reviewing chart notes and x-rays, a vigilant double-check is necessary to ensure that the extraction code aligns precisely with the treatment rendered. Carriers may consider it was upcoding if the chosen code does not align with the severity of the treatment as indicated by the x-rays.
Regarding anesthesia, precision in code selection is equally vital. It’s important to differentiate between the initial 30 minutes and any additional 15-minute increments. The 30-minute code should be applied only once per treatment, with any extra time necessitating using the 15-minute code. Overbilling can lead to claim denials, underscoring the importance of matching the anesthesia codes accurately with the treatment duration and avoiding excessive billing of units.

### Complete and Accurate Documentation

Insurance companies require specific documentation to process claims successfully. Dental practices must keep detailed records of all oral surgery procedures, including preoperative and postoperative X-rays, patient assessments, and surgical notes. Claims are likely to be denied, leading to a loss of revenue and increased administrative burden for practices without complete and accurate documentation. Moreover, the documentation should be sent to the insurance company as soon as possible to speed up the reimbursement process.

### Verify Insurance Coverage

Before performing any oral surgery procedure, dental practices must verify that the patient’s insurance policy covers the procedure. Practices can do this by contacting the insurance provider and obtaining information on the patient’s coverage, including co-payments, deductibles, and any exclusions related to the surgery. By verifying coverage before the procedure, practices can avoid denied claims and ensure that patients receive the right level of reimbursement.

## Conclusion

Oral surgery claims are essential aspects of dentistry billing critical to ensuring patients receive the necessary reimbursements for their procedures. Verify insurance coverage, follow up on outstanding claims, and use automated tools; dental practices can improve their chances of receiving timely reimbursement for oral surgery claims. These approaches can also help reduce administrative burdens and improve the overall efficiency of dental practices. Effective communication and adherence to insurance guidelines are crucial for reimbursing oral surgery claims.

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