Revenue Cycle – Differences Medical vs Dental

Plan Architecture and Coverage Philosophy

Before diving into some of the technical differences between medical and dental, understand the basic plan architecture and how those plans behave. Think of dental plans as a bank of benefits. This bank of benefits can be visualized by a vending machine that has a certain amount of benefits behind each button. Press the button for an exam, and there are two of those available to you in the plan year. After that, the bank of benefits is empty for that service. For certain radiological services, the bank of benefits occurs at a stated frequency. Other services, maybe every year. When you either exhaust what is in those vending machine windows, or when the plan pays its set maximum amount of dollars, the coverage ends. The plan philosophy is that you utilized those benefits within a plan year, limited by either exhausting the benefit or reaching the dollar limit, whichever occurs first.

Think of medical, on the other hand, as an ocean of coverage, but to get there you have to have a special type of vessel. You just can’t reach in and get the coverage, you have to get there through an approved means. That means is medical necessity. Services in the medical plan are available once medical necessity is established. Establishing medical necessity is at the very cornerstone of the medical plan. Medical necessity is established by the clinical documentation, telling the healthcare story of the patient, justifying that a medical condition exists and that the service represents something necessary to that patient’s health. From the documentation, appropriate ICD-10 codes are developed and the entirety of the clinical story is represented on the claim. This plan architecture and coverage philosophy is, in my view, the fork in the road between medical and dental.

Benefit Architecture and Code Sets

The medical side of healthcare is organized by type of service. Hospital inpatient, hospital outpatient, same-day surgery, physician office, ambulance, various therapy services, rehabilitation, skilled nursing and so on. There are a lot of categories and the benefits are aligned with the major category. If you go to see your doctor, the benefit is based upon that type of service, even if there are multiple services rendered in that day. With some exception, you will incur a copay on your provider office visit and the rest is covered by the plan. For other services, the benefits are organized by those major service lines. If you go to the hospital, your benefits are based upon a hospital stay.

Dental, on the other hand, is organized by code. For each code, there is an allowable amount as well as a fixed dollar or percentage due from the patient. Because the number of CDT (Current Dental Terminology) codes is far less than CPT (Current Procedural Terminology) codes used in medical, organizing benefits by code in dental is plausible.

Diagnosis Code Usage

While the current ADA 2019 and ADA 2024 dental claim forms do have a provision for diagnosis codes, very few plans require any type of ICD-10 diagnostic code to process a dental claim. However, on the medical side of healthcare, the ICD-10 diagnostic code is at the very center of the stage. Without those appropriate codes, no claim will be processed. This represents a major contrast between medical and dental where those differences do exist.

Co-Morbidities

There’s a term that draws a lot of questions. A co-morbidity is a condition that is present with the patient, but may not be part of the problem-focused visit that is currently underway. A patient that presents in a physician’s office for a laceration may be obese, diabetic, a smoker and have hypertension (high blood pressure) among other things. The laceration is being sutured and the physician diagnoses the laceration along with the other co-morbidities that are present. Those are other diagnosis that are present which serve to paint a healthcare picture of this patient with the claim form data. The dental side of healthcare is currently not using diagnosis codes in many cases and when they do, I often see only a problem focused diagnosis. Here’s another stark contrast between dental and medical.

Patient Responsibility

The dental side of healthcare has, for the most part, nearly half of the reimbursement coming from the patient. For certain plans, this will be less (Medicaid) but overall, this is the split. Medical on the other hand, has closer to 15% of total dollars coming from the patient. Yes, for lower cost services, this percentage is higher but overall, that’s what you see.

Complexities With Code Sets on Claim Forms

For this article, I am only focusing on those codes that would be present on a professional claim form in medical (1500) versus the ADA 2024 dental claim. The medical side of healthcare has a long, long list of modifiers that may accompany a CPT code to further describe the service provided. Dental has tooth number and tooth surface, but those are straight-forward in their coding where medical would require an intensive knowledge of those modifier codes and their appropriate usage.

Not only does medical have CPT codes, but they also have a long list of HCPCS (Healthcare Common Procedure Coding System) to to usher in a whole new list of charge items.

One of the little-known items on the professional medical claim form is the qualifier code. This very obscure two-character code is quite powerful. It is used in several places on the professional (1500) medical claim form and the dental claim form has no counterpart.

Summary and Conclusion

When you enter the world of medical services, the claim form is more complex than most tax forms that I have seen in my career. For that reason, Revenue Cycle, Coding and Payor Relations have grown to become a profession. The knowledge to understand and function successfully in the space continues to be at the forefront of a healthcare venture, whether medical or dental based. For those providers in dental who “cross over” into the medical side of healthcare, I do recommend a tour guide to lead you through the wilderness.