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

by | Published on Mar 4, 2022 | Specialty Billing

When a Dental Procedure is Considered Medical and Billable to a Medical Insurance?
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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 office revenue took a hit. Faced with these challenges, dental billing practices are increasingly relying on dental billing companies to grow revenue and increase profitability.

One revenue boosting strategy that dentists can take advantage of is billing medical insurance for dental procedures. Medical plans often reimburse procedures that dentists routinely perform when the services are considered medically necessary. 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.

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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 by maximizing their insurance coverage.

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 may 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 proceduresMedical insurance will cover some types of oral surgeries, such as those to correct a non-dental physiological condition which results in a severe functional impairment. One example is a complicated wisdom tooth surgery that may require more than standard dental procedures to complete. If the procedure requires general anesthesia, it may be billed to the medical plan. Other surgical procedures covered include soft and hard tissue biopsies, such as the excision of cysts and tumors of the maxilla, mandible and surrounding tissues. Extractions and placement of dental implants are also usually covered though tooth root replacement falls under what is allowable by a patient’s medical plan.

Treatment for traumatic injuriesTraumatic 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)

Know What may not be Covered

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

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

 Successful medical billing begins with an understanding of the various code sets available that allow for proper cross coding and/or the use of the appropriate code set. Always report what you do using the most accurate code to describe the procedure performed. It is imperative that only procedures and diagnoses supported by the clinical documentation be reported.

A key consideration for successful claims submission is understanding dental-medical cross coding. When submitting claims to a medical plan, dentists should understand the code sets and know payer rules:

  • CDT: The CDT code set is used when reporting dental procedures to a dental payer. Many medical payers will accept the CDT code when there is no appropriate medical cross code (CPT) or when the CDT is the most accurate code to describe the dental procedure performed. Before claim submission, determine if the payer allows the submission of CDT codes.
  • Use the correct ICD-10, CPT, and HCPCS Use the appropriate ICD codes to report diagnoses, symptoms and procedures and communicate to the payer why a procedure may be medically necessary. Report the latest procedure codes to describe all therapeutic/medical, and surgical treatments. For dentists, the HCPCS code set is used to report durable medical equipment such as oral sleep apnea and temporomandibular joint disorder appliances. The appropriate modifier or qualifier should be used when required.

Category I codes CPT codes are used in dentistry. Category I CPT codes are divided into six sections:

    • Evaluation and management: 99202-99499
    • Anesthesia: 00100–01999; 99100–99150
    • Surgery: 10000–69990
    • Radiology: 70000–79999
    • Pathology and laboratory: 80000–89398
    • Medicine: 90281–99099; 99151–99199; 99500–99607
  • Clearly state the reason the medical treatment was provided: In addition to the ICD-10 codes, every claim should be submitted with documentation supporting the medical necessity for the need for the surgery in an inpatient setting. Claims without such proof of medical necessity will be denied. If the dental procedure is not the primary procedure performed, the patient’s medical records must include documentation of the primary procedure.
  • Make sure that the documentation is legible, relevant and sufficient to validate the services billed.
  • Use the CMS-1500 Health Insurance Claim Form.

Know Insurer Rules

Not all medical plans cover dental benefits. Every plan that does will publish the dental procedures they will specifically cover. Policies vary based on individual plans and also depending on the state. Plans will have their own rules regarding coverage of medical services by dentists and knowing these rules is an essential for accurate claim filing.

As medical billing uses CPT and ICD-10 codes and is different from dental billing that uses CDT codes, there is a learning curve. Staying up to date with payer rules is critical to accurate claim submission. Being aware of what the patient’s medical plan will allow for dental procedures and billing the procedures correctly is critical for appropriate reimbursement. Practices can reach out to a dental billing company to determine whether to file a medical or dental claim. Experts will provide dental insurance verification services to determine whether procedures to be done are medically billable under the patient’s plan. They will help you file accurate claims using the correct codes to boost practice revenue while ensuring patients have access to the dental care they need.

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Natalie Tornese

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

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