When a Dental Procedure is Considered Medical and Billable to a Medical Insurance?

by | Mar 4, 2022 | Blog, Dental Medical Billing | 0 comments

Over the past two years, dental practices across the nation faced many unprecedented challenges – from government health guidelines and regulations to changing social norms and new ways of working. With the impact of these developments on patient flow, dental office revenue took a hit. Faced with these challenges, dental billing practices are increasingly relying on outsourced dental billing services to grow revenue and increase profitability.

One revenue boosting strategy that dentists can take advantage of is billing medical insurance for dental procedures. Dentists can and are required to bill a patient’s dental treatment to their medical plan. While improving the practice’s bottom line, billing dental services to medical plans can help patients with complex issues get the comprehensive care they need in a cost-effective manner.

Billing Medical Insurance for Dental Procedures

 Integrating medical and dental is an important consideration in the coordination of care and improving patient outcomes under the Affordable Care Act.  Dental insurance plans have a low annual maximum benefit. When treating a patient who has medical and dental issues that are related, the dentist can bill the patient’s medical insurance for the procedure. This will reduce financial stress for patients and preserve their annual dental insurance benefits.

Medical insurance plans typically cover treatment provided by dentists as medical procedures, not dental procedures. The key to successful dental medical billing is knowing when a dental procedure is considered medical and billable to medical insurance. Here are three key considerations:

  • The service must have been provided to treat a diagnosed medical condition: Medical insurance will pay for a procedure if it is necessary to treat a diagnosed medical condition. All dental offices can bill medical insurance for evaluations, diagnostic procedures, and surgical services to diagnose or treat medical conditions. This means that dental offices can bill medical plans for treatments that impact the overall health of the patient.
  • The procedure should be medically necessary: Medical plans pay for procedures that are medically necessary, that is when the patient has a medical condition that impacts the problem that the dentist treats. For e.g., if a patient with uncontrolled diabetes needs emergency oral surgery for acute infection, dental procedures would need to be modified and the claim can be submitted to the patient’s medical plan.
  • The procedure should have a corresponding medical code: Medical insurers will reimburse dental services that have corresponding medical codes. Medicare Part B covers dental provider’s services that are Medicare benefits and within the scope of practice of the Dental Practice Act. Commercial medical plans pay for procedures performed by a dentist that is properly coded as medical procedures.

Procedures billable to Medical Insurance

There are specific categories of dental procedures that can be billed as medical (www.dentistryiq.com). Before billing the treatment to medical, a dental billing service provider will make sure that it falls under one of the following 4 categories: 

Diagnostic procedures

    —This includes any service to diagnose a medical condition such as examinations, consultations, medical x-rays and scans, stents, and testing to discover the sources of pain. For instance, x-rays to identify the source of tooth pain is a diagnostic procedure.

Non-surgical medical treatments

    —Dentists can bill non-surgical treatments used to treat a diagnosed medical condition covered by the medical plan. Examples include TMD orthotics and sleep apnea, emergency treatments for infection or inflammation, incisions and drainage of abscesses, custom home fluoride trays for patients undergoing cancer treatment.

Surgical procedures

    Medical insurance will cover some types of oral surgeries. One example is a complicated wisdom tooth surgery that may require more than standard dental procedures to complete. If the procedure requires general anaesthesia, it may be billed to the medical plan. Other surgical procedures covered include soft and hard tissue biopsies and extractions and placement of dental implants.

Treatment for traumatic injuries

    Traumatic injuries are those that require immediate care. Such injuries include motor vehicle collisions, sports injuries, falls, natural disasters and other physical injuries that can occur at home, on the street, or while at work. Dentists can bill medical insurance for treating traumatic injuries that are covered by medical plans. Coverage for the injury will include all treatments that restore the original look and function of the mouth, including restorative care, endodontic treatments, surgery, implants, and prosthodontics.

Here is a list of procedures that dentists can bill to medical insurance:

  1. Head and neck evaluations for orofacial medical problems
  2. Panoramic x-rays
  3. CT scans
  4. TMJ services
  5. Bone grafts
  6. Cyst removal
  7. Implants
  8. Alveoloplasty
  9. Sinus lifts
  10. Dental implants
  11. Dental repair of teeth due to injury
  12. Sleep apnea and/or mandibular repositioning appliances & services
  13. Treatment related to inflammation and infection
  14. Certain periodontal surgery procedures
  15. Treatment to correct congenital malformations
  16. Frenectomy (tongue surgery) for infants and children
  17. Extraction of wisdom teeth, under certain conditions
  18. Removal of multiple teeth at one time
  19. Infection is not treatable by entry through the tooth
  20. The pathology that involves soft or hard tissue
  21. Procedures to correct dysfunction
  22. Emergency trauma procedures
  23. Consultation for an excisional biopsy of oral lesions
  24. Dental disease secondary to cancer treatment (e.g., mucositis and stomatitis)

When billing medical insurance, dental offices should also know what may not be covered:

  • Routine x-rays as part of preventive dental care are not covered as they are not considered a medical diagnostic procedure.
  • Cosmetic treatments such as tooth-whitening do not come under medical procedures.
  • Preventive removal of teeth may be covered only if the patient obtains a referral from a physician.
  • For traumatic injuries covered by liability insurance, that insurance should be billed before billing medical insurance

Know Insurer Rules

Every insurance company has their own rules regarding coverage of medical services by dentists and knowing these rules is one of the main considerations for accurate claim filing. As an example, let’s take a brief look at Aetna’s coverage for dental services and surgery under medical plans. On their website, Aetna states that, except under limited circumstances, their medical plans do not cover dental services provided for the routine care, treatment, or replacement of teeth or structures (e.g., root canals, fillings, crowns, bridges, dental prophylaxis, fluoride treatment, and extensive dental restoration) or structures directly supporting the teeth. Some plans may cover specific dental related services and certain “dental-in-nature” oral and maxillofacial surgery (OMS) services that are related to the jaw or facial bones.

Aetna covers medically necessary medical services that are performed by a dentist if the performance of those services is within the scope of the dentist’s license, according to state law. Medical services provided by a dentist that Aetna medical plans may cover include, but are not limited to, the following:

  • Reduction of any facial bone fractures
  • Removal of tumours, treatment of dislocations, facial and oral wounds/lacerations
  • Removal of cysts or tumours of the jaws or facial bones, or other diseased tissues
  • Removal of bone-impacted teeth
  • Alveolar ridge closure as part of cleft palate repair and certain other palatal procedures
  • Dental service that is medically necessary and is incident to and an integral part of a service covered under the medical plan, for e.g., extraction of teeth prior to radiation therapy of the head and neck
  • Diagnostic services based on whether the primary procedure is covered under the medical plan
  • Dental services performed in conjunction with medically necessary reconstructive surgery, for e.g., radiation stents
  • Surgical placement of the dental implant body, but not the restorative procedure
  • Dental services accompanying reconstructive surgery

Billing Dental Care related to a Medical Condition – Know the Codes

A key consideration for successful claims submission is understanding dental-medical cross coding. When submitting claims to medical plans, dentists should:

  • Use the correct CPT and ICD-10 codes to identify the treatment provided
  • Clearly state the reason the medical treatment was provided
  • Use the CMS-1500 Health Insurance Claim Form

As medical billing uses CPT and ICD-10 codes and is different from dental billing that uses CDT codes, there is a learning curve. Practices can reach out to a dental billing company to ensure accurate claims filing and assure patients have access to the care they need.

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