Dentists: Bill medical insurance for frenectomy!
We are on a mission to raise awareness about medical coverage for frenectomies. We at Nierman Practice Management are often asked if medical insurance will reimburse dental practices when performing frenectomies for patients suffering from tongue-tie. The answer is yes; many do offer coverage! It’s heartening to know that many medical insurers cover this vital procedure. But before we discuss medical plans, let’s delve into why frenectomies are essential to infants and children. Frenectomy is the procedure in which the dentist cuts the lingual frenulum. It is necessary when the frenulum is unusually short or tight (ankyloglossia or “tongue-tie”). In the newborn, a frenectomy is indicated when the abnormal frenulum impairs the infant’s ability to breastfeed.
This policy from a major insurance company says it all:
“Lingual or labial frenectomy, frenotomy, or frenuloplasty is medically necessary for ankyloglossia when feeding difficulties exist for infants, or articulation problems exist for children.”
Coverage criteria do vary. For example, we located a Blue Cross policy that does not specify infants and children but instead says that they cover the frenectomies for any of the following symptoms.
Here’s medical policy language for frenectomy outlining the need for treatment:
- difficulty feeding/eating
- difficulty chewing (mastication)
- difficulty swallowing
- speech impairment or difficulty with articulation
Coding tip: Using the proper diagnosis and procedure codes is essential. The most commonly used diagnosis code is Q38.1 (ankyloglossia). Dental practices may also consider diagnosis codes representing difficulties feeding and speech issues, such as R63.39 (Other feeding difficulties). The medical procedure code you select to report the service depends on whether it is a lingual, labial, or buccal frenectomy.
When billing frenectomies to medical insurance:
- Identify diagnosis (ICD-10) and medical procedure (CPT) codes
- Document the patient’s medical history & need for the procedure
- Submit services on a medical claim (the CMS 1500)
We suggest calling the medical insurer in advance to verify deductibles, coinsurance amounts, and if a pre-authorization is required for coverage. Providing the diagnosis and procedure codes during the call helps make the process smooth. You can also ask about the coverage criteria.
System to make medical billing easy and profitable:
Equally as important as knowing the coverage criteria and medical codes is having a system for documenting the medical need for the procedure. This system should streamline using the appropriate medical codes and submitting them on the CMS 1500 medical claim or to the medical billing service. Numerous dental practices enjoy the ease of DentalWriter software to bill their patient’s medical insurance for these life-changing procedures. Many dental offices outsource medical billing; others bill in-house. Your dental practice has an opportunity to help infants and children access this vital procedure that will make a significant difference in their lives.