Question Dental Codes in Medical Setting

[Loni1984]

I work at an FQHC where we have both medical and dental services. We get a lot of patients that come to medical complaining of tooth pain or infections. Our medical providers were choosing codes K08.89 and K04.7 and neither code was getting reimbursement from any payer type. The coder has tried utilizing the K12.2 Cellulitis and abscess of mouth. This code was actually getting reimbursed by payers, but our providers disagreed with the use of the code. I was thinking that our best choice would be R22.0 Localized swelling, mass, and lump, head. The medical providers are providing an E/M level service with a dental referral and often a prescription for antibiotics. Does anyone have any documentation and coding tips for medical visits that are related to dental pain and infections?

 

[Pam Warren]

I wish I had a better answer. Dental diseases are not generally covered by medical insurance companies. There's nothing that says your provider cannot see a patient for mouth/tooth pain, but it's likely not going to be covered, since your patient's insurance company is expecting their client to see a dentist for oral health. From a compliance perspective, you should code exactly what the patient was seen for, and not 'code to get paid'. In other words, if the pain is caused by a tooth abscess you shouldn't code for an infection in the mucous membranes of the oral cavity. You may need to let patients know that you can see them, but their insurance might not cover the services. Why should your practice take the financial hit when the patient should go to the dentist in the first place? And if they're drug seeking for mouth/tooth pain, that's another issue altogether as you may be dealing with an addict who is relying on you for medications that they probably should not be taking. That is a huge issue here.
The only opportunity I know of is with pediatricians who can do basic tooth/mouth evaluations for kids under the age of 3 on Medicaid, billing D0145 with a Z code for the appropriate screening. Otherwise, dental care is considered outside the scope of practice for a pediatrician (or family practitioner for that matter).