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:
- Head and neck evaluations for orofacial medical problems
- Panoramic x-rays
- CT scans
- TMJ services
- Bone grafts
- Cyst removal
- Sinus lifts
- Dental implants
- Dental repair of teeth due to injury
- Sleep apnea and/or mandibular repositioning appliances & services
- Treatment related to inflammation and infection
- Certain periodontal surgery procedures
- Treatment to correct congenital malformations
- Frenectomy (tongue surgery) for infants and children
- Extraction of wisdom teeth, under certain conditions
- Removal of multiple teeth at one time
- Infection is not treatable by entry through the tooth
- The pathology that involves soft or hard tissue
- Procedures to correct dysfunction
- Emergency trauma procedures
- Consultation for an excisional biopsy of oral lesions
- 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.
Telehealth is not confined to one specific service as it covers a broad variety of technologies and procedures to address virtual medical, health and education services. As defined by ADA, Teledentistry provides the means for a patient to receive services when the patient is in one physical location and the dentist or other oral health or general healthcare practitioner overseeing the delivery of those services is in another. As the policy decision of ADA, teledentistry services received by patients have to be properly documented for reimbursement purposes. Dental practitioners can rely on dental billing companies to efficiently manage documentation of the procedures and for timely submission of claims.
Patients seek teledentistry services for urgent oral health and dental problems. Patient care involves the use of telecommunication technologies to facilitate timely delivery of treatment without the physical constraints of a dental hospital.
The common forms of teledentistry include:
- Synchronous teledentistry
Patients can have real-time interaction with the dentist with the help of a camera, speakers and microphone. The main feature of synchronous teledentistry is that virtual face-to-face meeting between the patient and dentist is possible. The patient gets on-the-spot feedback and e-prescriptions of medicines required to treat the condition.
- Asynchronous teledentistry
It doesn’t involve real-time interaction between the patient and the dental practitioner. Instead, patients are required to record the information regarding the oral health problem and hand it over to the dentist electronically. Dental practitioners review the dental information. Then, they reach out to the patient to prescribe medications and schedule some tests if required.
- Remote patient monitoring
The data on personal health and medical details are collected from the patient via telecommunication technologies and forwarded to a provider remotely located. These details can be utilized to provide adequate patient care and support.
- Mobile health (mHealth)
In this healthcare option, public health practice and education are made available for the patients with the help of smartphones, tablet computers, and personal digital assistants.
Even though there are four modalities of teledentistry, there exists only two teledentistry CDT codes as remote patient monitoring and mobile health (mHealth) services come either under synchronous or asynchronous teledentistry. Proper billing and coding of teledental services can burden dental practitioners when they are focused on better patient care. Dental billing service providers can relieve busy dentists from the complexities associated with teledentistry and properly manage the payments required for the services provided.
CDT Coding for Teledentistry
Teledentistry coding involves the reporting of both Place of Service (POS) code and CDT codes. Teledentistry codes have to be reported along with procedure (diagnostic codes) as the documentation of details requires both the codes for claim or encounter submission.
- POS code 02 : Place of Service Code
Telehealth – the location where health services and health-related services are provided or received, through telecommunication technology
Following are the two CDT codes which have to be reported along with other diagnostic codes.
- D9995 teledentistry – synchronous; real-time encounter
Reported in addition to other procedures (e.g. diagnostic) delivered to the patient on the date of service.
- D9996 teledentistry – asynchronous; information stored and forwarded to dentist for subsequent review
Reported in addition to other procedures (e.g. diagnostic) delivered to the patient on the date of service.
The dental practitioner overseeing the teledentistry event has to ensure that appropriate codes are entered after the evaluation of the patient’s dental health status. But this is difficult while striving to provide better care for the patients. However, a dental billing company can support dental practitioners with this task by submitting accurate medical claims.
Patients depend upon teledentistry to receive high-quality care at low cost, and the role health practitioners play to cater to the needs of the patients in the teledentistry environment is huge. Dental billing companies are fully aware about the facets of teledentistry coding and ensure accurate dental billing services, making the whole process of claim submission efficient and error-free.
Root canal is performed to treat damaged or diseased teeth. Dental practitioners have to deal with complaints of inflamed or infected pulp on a daily basis, and provide appropriate treatment. These dental services provided to patients have to be accurately documented on the medical claims submitted to dental insurers. Dental billing services can cater to the requirements of accurate dental coding of root canal procedure without giving dentists the hassles associated with timely submission of claims.
Root Canal Procedure for Patients with Acute Tooth Pain – Treatment strategy
- Imaging of affected tooth
A 3D X-ray image is taken of the tooth requiring root canal to accurately understand the features of the tooth’s structure.
- Administering local anesthesia
The inflamed region of the tooth is made numb by local anesthesia, which ensures painless root canal procedure.
- Creating a sterile environment through dental dam
A dental dam is applied around the specific tooth to block all other surrounding teeth and reduce the risk of infection from bacteria found in the rest of the mouth.
- Drilling of the affected tooth
A small hole is drilled along the biting surface of the tooth or into the back of the tooth to access the dead pulp chamber.
- Removal of dead pulp tissues and nerves
With the help of special root canal tools, the damaged tissues and nerves are removed.
The affected tooth is disinfected along the canals and the inner portion. It is the most important step of the procedure.
- Shaping the affected area for filling and sealing
In this step, flexible root canal tools are inserted along the canals of the teeth to shape the area for applying filler and sealer. Endodontists ensure that there is no remaining debris by thoroughly cleansing the area.
- Application of filling
Filling can be done either with Gutta- Percha Cones or sealers or with the combination of both. A post may be inserted to hold the temporary or permanent filling in place.
CDT Codes to Report Root Canal Procedure
- D9110: Palliative (emergency) treatment of dental pain-minor procedure
Before starting the root canal procedure, dental practitioners may have to provide emergency treatment to the patients approaching them with emergency dental problems. Palliative treatment is provided to ease the symptoms without curing the cause of underlying condition.
It includes cleansing of inflamed tissue and application of desensitizing medicament to the exposed root surface.
- D0330: Panoramic radiographic image
- D0340: 2D cephalometric radiographic image acquisition, measurement and analysis
- D0351: 3D photographic image
- D9210: Local anesthesia not in conjunction with operative or surgical procedures
- D3220: Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronal to the dentinocemental junction and application of medicament
- D3221: Pulpal debridement, primary and permanent teeth
- D3222: Partial pulpotomy for apexogenesis-permanent tooth with incomplete root development
- D3230: Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration)
- D3240: Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding final restoration)
- D4211: Gingivectomy or Gingivoplasty – one to three contiguous teeth or tooth bounded spaces per quadrant [Involves the excision of the soft tissue wall of the periodontal pocket by either an external or an internal level. It is performed to eliminate suprabony pockets after adequate initial preparation, to allow access for restorative dentistry in the presence of suprabony pockets, or to restore normal architecture when gingival enlargement or asymmetrical or unaesthetic topography is evident with normal bony configuration.
- D4212: Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth.
- D3310: Endodontic therapy, anterior tooth (excluding final restoration)
- D3320: Endodontic therapy, bicuspid tooth (excluding final restoration)
- D3330: Endontic therapy, molar (excluding final restoration)
- D3331: Treatment of root canal obstruction; non surgical access
- D3332: Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth
- D3333: Internal root repair of perforation defects
- D3346: Retreatment of previous root canal therapy-anterior
- D3347: Retreatment of previous root canal therapy-premolar
- D3348: Retreatment of previous root canal therapy-molar
A dental billing company knows the value of high-quality services that a dental practitioner has to provide their patients for the best outcome and proper medical reimbursement. So, error-free reporting of CDT codes is essential for seamless and robust management of the revenue cycle. The services rendered by dental practitioners are to be documented appropriately. Therefore, dental billing services have become inevitable to keep track of the ever-changing CDT codes.
Alveoloplasty is a common dental procedure done to reshape and smoothen out the jaw where a tooth or teeth have been extracted or lost. It can be done in conjunction with tooth extraction or after healing. Dentists can rely on experienced dental billing companies to report diagnoses and procedures performed correctly in dental claims.
Alveoloplasty reshapes and contours the jawbone’s natural structure that may have been lost due to bone loss from tooth extraction or other reasons. It can speed up the healing process and reduce blood loss after extraction of multiple teeth. In most cases, the procedure is typically performed in office during the extraction procedure.
According to the American Association of Oral and Maxillofacial Surgeons (AAOMS), alveoloplasty with extractions is recommended in conjunction with multiple extractions for irregular alveolus with sharp bony projections, for pre-prosthetic bone contouring, prior to radiation therapy for head and neck malignancy, and prior to cardiac surgery with valve replacement. The procedure can also be done in conjunction with any medical diagnosis where there is a risk of complications from oral infection.
CDT and ICD-10 Codes to Report Alveoloplasty
- D7310 – alveoloplasty in conjunction with extractions – four or more teeth or tooth spaces, per quadrant (used when bone recontouring is performed involving four or more teeth or tooth spaces)
- D7311 – alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces, per quadrant
These codes describe the anatomical area of bone encompassed in the alveoloplasty.
- D7140 – extraction, erupted tooth or exposed root (elevation, and/or forcep removal). (The code description includes routine removal of tooth structure, minor smoothing of socket bone and closure as necessary.)
- D7210 – surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated. (The code description also includes the minor smoothing of socket bone and closure.)
ICD-10-CM diagnostic codes indicate the specific reason for performing the extraction(s):
- C03 Malignant neoplasm of gum
- C03.0 Malignant neoplasm of upper gum
- C03.1 Malignant neoplasm of lower gum
- C03.9 Malignant neoplasm of gum, unspecified
- C41.1 Malignant neoplasm of mandible
- C79.89 Secondary malignant neoplasm of other specified sites
- D10.30 Benign neoplasm of unspecified part of mouth
- D10.39 Benign neoplasm of other parts of mouth
- D16.5 Benign neoplasm of lower jaw bone
- D00 Carcinoma in situ of oral cavity, esophagus and stomach
- D00.0 Carcinoma in situ of lip, oral cavity and pharynx
- D00.00 Carcinoma in situ of oral cavity, unspecified site
- D00.01 Carcinoma in situ of labial mucosa and vermilion border
- D00.02 Carcinoma in situ of buccal mucosa
- D00.03 Carcinoma in situ of gingiva and edentulous alveolar ridge
- D00.04 Carcinoma in situ of soft palate
- D00.05 Carcinoma in situ of hard palate
- D00.06 Carcinoma in situ of floor of mouth
- D00.07 Carcinoma in situ of tongue
- D00.08 Carcinoma in situ of pharynx
- D37.01 Neoplasm of uncertain behavior of lip
- D37.02 Neoplasm of uncertain behavior of tongue
- D37.04 Neoplasm of uncertain behavior of the minor salivary glands
- D37.05 Neoplasm of uncertain behavior of pharynx
- K04.4 Acute apical periodontitis of pulpal origin
- K04.6 Periapical abscess with sinus
- K04.7 Periapical abscess without sinus
- K08.0 Exfoliation of teeth due to systemic causes
- K08.419 Partial loss of teeth due to trauma, unspecified class
- L03.211 Cellulitis of face
- M26.72 Alveolar mandibular hyperplasia
- M26.73 Alveolar maxillary hypoplasia
- M26.74 Alveolar mandibular hypoplasia
- M26.79 Other specified alveolar anomalies
- M27.2 Inflammatory conditions of jaws
- R22.0 Localized swelling, mass and lump, head
- R22.1 Localized swelling, mass and lump, neck
- S01.522 Laceration with foreign body of oral cavity
- S02.5 Fracture of tooth (traumatic)
- T66 Radiation sickness, unspecified
- Codes D7310 and D7311 are used when the alveoloplasty is a distinct surgical procedure from extraction and/or surgical extractions.
- These codes may be reported in addition to the extraction codes D7140 and D7210 when supported by documentation.
- If an alveoloplasty is performed in conjunction with other separately identifiable procedures, modifier -51 has to be attached.
Just like any other surgical procedure, alveoloplasties must also be accurately documented in the patient chart. Failing to document the reason for the procedure and accurately describe the surgical procedure may lead to the claim denials by payers. Assigning inaccurate codes can also adversely affect reimbursement or lead to unnecessary delays in claims processing. Reliable dental billing services provided by experienced companies can help dental practices report services correctly on claims.
Nearly 47.2 percent of Americans over 30 have some form of gum disease or periodontal disease, according to the American Dental Association. If left untreated, periodontal disease can infect the roots of the teeth. In a worst-case scenario, the teeth will become loose or uncomfortable. To correct the condition, dentists will advise gingivectomy, the surgical removal of gingival or gum tissue. Getting reimbursed for different types of gingivectomy procedures can be challenging. Dental offices can rely on outsourced dental billing services to submit claims with the correct CDT codes in compliance with payer guidelines to ensure accurate claim submission.
Periodontal Disease and Gingivectomy
Periodontal disease develops when bacteria present in the mouth attaches to the teeth and forms a biofilm called plaque. If oral hygiene is not maintained properly, leaving the plaque and food debris in the mouth, gingivitis will get worse. As the plaque continues to accumulate and moves below the gum line, the gum tissue becomes more inflamed. Bleeding can occur and the area between the tooth and gum tissue can deepen to form a periodontal pocket. Symptoms can also include bone loss that shows up on an x-ray, excessive tooth instability, gum recession, or the existence of exudate along or under the gumline.
Good dental hygiene can prevent periodontal disease. Getting a comprehensive annual periodontal evaluation (CPE) by a dentist is also important. A CPE involves assessing the teeth, plaque level, gums, bite, bone structure and other risk factors for periodontal disease. Identifying symptoms of gum disease early, which is key protecting the teeth and gums.
If periodontal disease is left untreated, the plaque will continue to spread below the gum line and infect the inside of the pocket, resulting in loose or uncomfortable tooth that require gum surgery or gingivectomy. The procedure involves removing a portion of the gums from in and around a tooth or teeth to treat gum disease or to lengthen the height or width of a tooth or a section of teeth. Gingivectomy may be also considered to remove extra gum tissue for cosmetic reasons, such as to modify a smile.
Dental practices can ensure correct coding and claims submission by outsourcing these tasks to an experienced dental billing company.
The teeth in the mouth are divided into four quarters or sections. Let’s take a look at the CDT codes that describe gingivectomy procedures and when each CDT code should be used.
- D4210 Gingivectomy or Gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant
- D4211 Gingivectomy or Gingivoplasty – one or three contiguous teeth or tooth bounded spaces per quadrant (Involves the excision of the soft tissue wall of the periodontal pocket by either an external or an internal bevel. It is performed to eliminate suprabony pocketsafter adequate initial preparation, to allow access for restorative dentistry in the presence of suprabony pockets, or to restore normal architecture when gingival enlargements or asymmetrical or unaesthetic topography is evident with normal bony configuration).
These procedures are performed to eliminate suprabony pockets or to restore normal architecture when gingival enlargements or asymmetrical or unaesthetic topography is evident with normal bony configuration. D4210 is covered when four or more teeth within a section meet the allowable criteria. D4211 is covered when one to three teeth within a section meet the allowable criteria. For instance, Cigna Dental’s policies for coverage of D4210 and D4211 are as follows —
- Allowable under the following conditions:
- When periodontal pocket depths are 5mm (13/64 inch) or more.
- When it is clinically necessary to improve the shape of the gum tissue by correcting irregularities in the gum tissue around the teeth.
- When performed to remove overgrown gum tissue.
- Not allowable under the following conditions:
- When the procedure is being performed only to improve appearance and there is no disease present.
- When performed in conjunction with, and is considered incidental to, another surgical procedure.
- When a more extensive procedure is needed to gain access to and/or to treat the supporting bone.
- When this procedure is being performed at the same site on the same date of service, or within 30 days of, crown, bridge, and/or implant prosthesis preparations, impressions, and/or delivery.
- D4212 Gingivectomy or Gingivoplasty to allow access for restorative procedure, per tooth
- D4240 gingival flap procedure, including root planning – four or more contiguous teeth or tooth bounded spaces per quadrant
- D4241 gingival flap procedure, including root planning – one to three contiguous teeth or tooth bounded spaces per quadrant
- D4346 scaling in presence of generalized moderate or severe gingival inflammation- full mouth, after oral evaluation
- D4921 gingival irrigation- per quadrant
- D7971 excision of per coronal gingival
D7971 is used when inflammatory or hypertrophied tissue is being removed on a partially erupted or impacted tooth (i.e. operculectomy). D4274 can also be used for this procedure. This code does not include any osseous recontouring or removal and is used when the procedure is performed in an edentulous area adjacent to a tooth allowing removal of a tissue wedge to gain access for debridement and to reduce pocket depth. However, any benefit for this procedure will be disallowed when performed in conjunction with another surgical procedure in the same area. For instance, if bone removal is indicated or performed, D4261 should be used instead of D4274.
As medical billing and coding for dental procedures can be complex, relying on dental billing services offered by companies that have AAPC-certified coding specialists on board is an ideal option to ensure accurate coding, billing and claims submission. Dental billing companies also provide comprehensive dental eligibility verification services to verify the patient’s coverage before procedures are performed.