Wednesday, June 15, 2022

How To Bill Medical Insurance For Dental Procedures

Don't Miss

What Are The Advantages To Dental Providers And Patients

All things considered the value of insurance coverage is how it eases the financial burden for patients. They will occasionally pay more for a certain procedure but their overall health quality is the core benefit.

Its to your advantage as a dental provider to explain what theyre allowed to bill to dental and help them maximize their annual dental insurance benefits.

When necessary some coverage allows for auxiliary services that improve their oral and general health such as tobacco and nutritional counseling. Bottom-line is helping your patients get the most benefit from their dental and medical coverage.

Summary Of Medical Billing For Dental Procedures

Outsourcing medical billing will give you immediate access to highly-trained specialists in the industry. They are well versed with all the rules, regulations, coding, and other requirements of medical billing. They will review and follow up on all your payments and see that you get paid promptly. Every outstanding dental claim is tracked until it is paid in full. You will reduce overhead when you hire a reputable medical billing service because they know exactly what theyre doing whereas your staff may require training. These are just some reasons why you need to hire a reliable medical billing service for your dental practice.

Maintaining an efficient billing system is a challenging task for many dental practices. Outsourcing the medical billing process comes with many benefits to your practice. The aforementioned article provides information on the advantages of hiring third-party medical billing for dental procedures. We hope that you have found the above insightful.

Discover How to Turn Your Practice into a Thriving Business

Can Dental Work Be Covered By Health Insurance

Health insurance providers are discerning. And for good reason.

Dental to medical cross-coding can cause administrative headaches and gridlock access to necessary dental services. All in all your patients medical plan will in many cases augment their dental benefits.

Keep in mind that dental insurance is more easily positioned to cover preventative treatment. Its essential to not raise red flags by trying to push through a procedure thats on the borderline for allowable dental or medical coverage.

Stay within the boundaries allowed by your patients dental coverage while being aware of what their medical plan will allow for dental procedures. The end result is helping assure that your patients have access to dental care.

Limitations Of Dental Insurance Plans

Every plan has a cap on what it will pay during a plan year, and for many that cap is quite low. This is the annual maximum. You pay all expenses that go beyond that amount. About half of dental PPOs offer annual maximums of less than $1,500. If thatâs your plan, youâd be responsible for all expenses above $1,500. If you need a crown, a root canal, or oral surgery, you can reach the maximum quickly.

Thereâs generally a separate lifetime maximum for orthodontics costs.

Some plans may totally exclude certain services or treatment to lower costs. Know specifically what services the plan covers and excludes.

But there are certain limitations and exclusions in most dental insurance plans that are designed to keep dentistry’s costs from going up without penalizing the patient. All plans exclude experimental procedures and services not performed by or under the supervision of a dentist, but there may be some less obvious exclusions. Sometimes, dental coverage and medical health insurance may overlap. Read and understand the conditions of your dental insurance plan. Exclusions in your dental plan may be covered by your medical insurance.

Low Reimbursement For Dental Services


While dental insurance covers standard procedures such as cleanings and fillings, even insured patients can face thousands of dollars in out-of-pocket costs for major dental work like crowns and root canalswhich are typically covered at just 50%. Most intensive procedures, such as implants, aren’t covered at all.

Medical insurance, on the other hand, usually offers more generous coverage, according to Tuller. The difference in the insurance coverage for expensive and routine procedures leaves dentists with low reimbursement rates, which Tuller writes can affect revenue.

Examples Of Dental Procedures That Can Be Medically Necessary In Certain Cases

  • Treatment of infection or inflammation
  • Repair of teeth due to other injury
  • Extraction of multiple teeth at one time
  • Specific periodontal surgery procedures
  • Consultation and treatment of temporomandibular joint issues
  • Emergency trauma procedures
  • Appliances for the treatment of sleep apnea or mandibular repositioning

How To Successfully Bill Medical Insurance For Dental Treatment: An Interview With Laurie Owens Of Devdent

We recently hosted Laurie Owens, the Director of Medical Billing at Devdent for an online webinar. Her discussion about how dentists can utilize medical billing was so impressive that we decided to revisit the topic with her for our blog. Laurie says, Medical billing for dental procedures isnt just about maximizing reimbursement for patients; its about creating more value for your practice by treating the patients whole health.

Laurie has extensive experience in the dental industry. She worked as a treatment coordinator for a dental clinic for many years. What set her apart was her expertise as a medical biller. Laurie is a Certified Professional Biller and holds certification as a Certified Professional Coder . After the owners of the clinic retired, she joined Devdent, where she now educates dental practices on medical billing while also continuing to bill medical for 6 dental practices.

Laurie says there are several compelling reasons why your practice can benefit from medical billing:

  • You decrease the amount the patient owes
  • You increase case acceptance
  • You create more value for procedures
  • Youre treating the whole patient
  • Its Not About What Procedure You Do, Its About Why It Needs to Be Done!

    Instead of focusing on what you can bill for, Laurie encourages dental practices to find out why the procedure needs to be done. If you can document medical necessity, even veneers can be a covered service, explains Laurie.

    Two Top Conditions to Bill Under Medical

    Apex Reimbursement Specialists Can Help You Increase Your Revenue

    Whether youre concerned about the potential for receiving an insurance provider audit in the new year or looking for a better way to increase your revenue, APEX Reimbursement Specialists is here to help. Contact our team today by calling 710-6005. We look forward to working with you to make your practice a more profitable place.

    Recent Posts

    The Dental Claim Form

    Just like medical and hospital claims use their own claim forms, so does dental insurance billing and coding. The dental claim form is called J400.

    This includes a space for patient demographics and identifying information, patient dental insurance information, and dental procedure codes and dates of service.

    They also include spaces for information regarding provider identification, charges, and treatment location. This is also similar to medical claims forms.

    Unlike medical claim forms, however, there is a large amount of additional information needed on dental claims forms. This includes:

    • Area of oral cavity
    • Description of procedure
    • Missing teeth information

    All of this information is included when the dental hygienist or dentist performs the necessary procedures, and as such is indicated on the claim.

    Dental Billing And Coding 101 For 2020

    April 1, 2010 by

    Billing and Coding for the dental practice continues to advance and involve the medical carrier with obtaining

    payment for certain procedures. Dentists are beginning to realize how beneficial a certified professional is to managing the billing side of their practice. With that said, the need for certified professionals educated in the following specialties are in demand; Oral and Maxillofacial Surgery, Periodontics, Endodontics, Orthodontics, and General Dentists who specialize in sleep apnea.

    While I could write a novel on the idiosyncrasies of dental billing and coding, for the purpose of this article I will explore the basics.

    What is a Dental code and where do I find it?

    Dental codes are commonly referred to as CDT-5 codes . These codes were developed by the counsel on Dental Benefit Programs and published by the ADA . When first creating these codes the council worked closely with dental office staff, claims reviewers, and third-party payers to create and publish CDT-1 beginning in 1991. Since then they have adapted and modified four revisions with CDT-5 as the newest addition beginning in 2006.

    Every payer/insurance carrier has their own guidelines as to how or if they will cover certain dental expenses. It is always a good idea to obtain a pre-authorization or pre-certification from the dental and/or medical carrier before proceeding with a procedure.

    What to do when the medical carrier should be involved.

    Description CDT code CPT code


    Do Many Dentist Offer This Payment Option

    Less than 10% of dentists currently offer financing options through your medical insurance plan because of the extra work, knowledge, and training required to provide this service, but increasingly for medically necessary dental treatments, Dr. Carlyle is able to bill through your medical insurance plan, which is a great boon to those without dental insurance, but also offers increased coverage and lower out-of-pocket costs even to those patients with dental insurance.

    Do Medical Payors Reimburse For Dental Procedures

    The good news is that, yes, medical insurance will cover dental work. Health insurance will give some latitude for a dentist billing medical insurance.

    Dental plans are equally specific about the dental procedures it will specifically cover. Knowing the overlap points between health insurance and the details of a dental claim are key.

    Reimbursement success will often come down to the insurance company, dates of service, and the dental care youre requesting payment for.

    Electronic Or Paper Claims

    Is Medical Billing for Dental Practice and Procedures Legal?

    Due to the fact that many dental claims require attachments such as radio-graphs and periodontal charts to prove medical necessity, over half of all dental claims are sent as paper claims in the mail.

    Although some dental insurance practice management programs do offer the option to scan and attach the necessary medical documents, they also come with a higher price tag.

    Not only is this type of software more expensive to buy and maintain, but it’s more expensive to send these types of claims electronically than regular medical claims, for example.

    To determine whether or not it’s in your best interest to buy this type of software and send electronic claims, you need to determine what’s more cost effective:

    • the added expense but greater ease of sending claims electronically
    • or the postage and time required to send paper claims.

    What Is Medical Insurance To Cover Dental Procedures

    Take the time out of your busy schedule to stop by one of our Happy Hour learning events so you can gather all the information you need, and to learn more about your dental procedure financing options through your medical insurance plan. Medical insurance billing for dental procedures is a complicated topic, but at the heart of it is the fact that many dental procedures are medically necessary which is being increasingly demonstrated by scientific research on the health effects of untreated dental problems. As a result, more and more dental procedures are covered by medical insurance if the dental practice has the necessary training and expertise in medical billing codes to offer this cost-saving convenience to their patients.

    Canadian Dental Code Categories

    Let’s take a look at the nitty-gritty of dental procedure codes.

    There are over 1,300 unique codes . There are also specialized sets of codes for dental hygienists, as well as dental specialists. That’s a lot of numbers.

    But don’t worry: There’s no need to get familiar with every single code. The Canadian Dental Association breaks down dental services into 10 basic categories. Each 5-digit code fits into one of these categories.

    Categories Of Dental Procedures That Are Billable To Medical

    According to medical billing expert, Christine Taxin, there are four types of common dental procedures that are billable as medical procedures.  Breaking them down to four categories helps to visualize how they should be submitted.

    • Category 1: Diagnostic proceduresThese are procedures used to diagnose a recognized medical condition. They include examinations, consultations, medical imaging, models, stents, and bacterial testing, including testing used to discover the sources of pain. For instance, an x-ray to determine the location of impacted teeth is a medical diagnostic procedure. Imaging to discover the source of jaw pain is a medical diagnostic procedure. Routine x-rays as part of preventive dental care are not considered a medical diagnostic procedure.
    • Category 2: Non-surgical medical treatmentsNon-surgical treatments unrelated to traumatic injuries can be billed as medical procedures if they treat a medical condition. This includes emergency treatments for infection or inflammation, incisions and drainage of abscesses, curettage of periodontal abscesses, appliances such as night guards, TMD orthotics and sleep apnea appliances, at-home fluoride trays for patients undergoing cancer treatments, or for patients who suffer from anorexia or bulimia.

    The key is that the treatment must be linked to a diagnosed medical condition covered by the insurance policy. Cosmetic treatments such as tooth-whitening are not covered as medical procedures.

    Dental Codes And Insurance

    When you look at the invoice your dentist’s office issues, you’ll see the services you received along with their 5-digit dental procedure code. 

    For instance, you’ll see something like:

    • 11111: 1 unit of scaling
    • 02112: 2 radiographic images

    They’ll be listed along with the amount that the dentist is charging you for each service. 

    Many insurance plans cover a fixed amount for each standardized service. Most commonly, they cover the amount that your province suggests that those standardized services are worth. That amount is determined by your province’s dental fee guide.  

    Medical Billing For Dental Procedures Is 100% Legal

    So take everything into account, medical billing for dental procedures is in fact legal, as long as the procedures performed are proven to be medical necessity. Because after all, oral health and overall health have a really tight connection.

    The California Dental Association has listed the procedures that could qualify for medical billing. Dentists just need to know the rules and follow the steps that medical coding and billing requires. These procedures include:

    • CT scans & exams
    • Consults for medically necessary procedures
    • Sleep Apnea Appliances
    • TMJ Disorder Treatment and appliances
    • Sinus Lifts and Bone Grafts
    • Mucositis
    • Tooth Loss due to trauma or systemic conditions
    • Oral Systemic Infection
    • Botox injections for painful bruxism
    • Excisions
    • Reconstruction due to trauma or conditions
    • Endodontics due to trauma or medical conditions
    • Oral Cancer Screening
    • Bone Atrophy that results in ill-fitting dentures
    • Denture Pressure ulcers
    • Many More Procedures

    Doing medical billing for dental procedures brought numerous benefits to dentists, such as a large increase in revenue, patient base, and case acceptance. In terms of income, offices doing both dental and medical billing could make 30-40% more revenue than traditional practices billing dental only. Through medical billing, dentist A in Glendale, CA, managed to get an extra $3,000 for a bone grafting surgery.

    Canadian Dental Procedure Codes Explained

    Canadian dental procedure codes are the basis for dental costs and coverage. They’re the key to understanding your dental expenses and insurance. With this guide, you’ll be able to understand your dental procedure codes and take ownership of your dental costs.

    With so many dental options, choosing an insurance plan can be overwhelming. Insurdinary compares the most comprehensive health and dental insurance quotes so that you can find the Canadian dental plan that meets your needs.

    Best of all, Insurdinary finds the best monthly rates in Canada, so you know that you’re not overpaying for your insurance. If you’re looking for affordable dental insurance in Canada, get started with Insurdinary today. 

    Dental Billing Vs Medical Billing

    When it comes to medical billing for dental offices, getting payment isnt always easy. One reason is there are differences between medical billing and dental billing. Standard dental work typically will get billed to dental insurance companies. However, services like sleep dentistry could fall under medical insurance, which is completely different than working with a dental insurance company. Medical insurance claims typically require a few more steps and specific coding to ensure timely payment. Since dental office staff members dont process claims like this every day, it can take more time and energy to do so.

    Our service for medical billing for dental offices includes doing all the work with insurance companies behind the scenes, so the office staff doesnt have to. There are many other things for a staff to work on to provide better experiences for their patients. OMS Partners can help ensure timely payments from insurance companies without requiring time and resources from the actual dentist staff.

    You can and should own your own practice

    Health Insurance 101: Get The Slide Decks

    Learn how to bill medical insurance for dental procedures ...

    Confused about the U.S. health insurance system? You’re not aloneit’s one of the most complicated systems in the world. If you missed our recent webconference series diving deep into the system, don’t worry; we’ve got you covered.

    Review the slide decks from our recent webconferences for a quick overview of each program:

    Is Oral Surgery Covered By Medical Or Dental Insurance


    If youre planning a major oral surgery you may be wondering if its possible to get your medical insurance to cover your dental treatment. For people who dont have great or any dental insurance coverage, this can be a huge factor in whether its possible to move forward with your treatment.

    The short answer to this question is that yes, medical insurance will cover some types of oral surgeries, but not all of them. In most cases, the two plans will overlap one another, picking up various aspects of the line-item expenses and expecting the other policy to pay for the ones that are not covered. 

    Who Decides if My Oral Surgery Falls Under Medical or Dental Benefits?

    Your medical insurance and dental insurance claims are filed with specific codes used to describe the service that is being rendered. Codes outline the type of oral surgery, how complicated it is, which tooth is involved, anesthesia/sedation, etc. The insurance policy will then dictate which codes are or are not covered.

    Once you have your written treatment plan in front of you, youll be able to see an estimate of which insurance plan pays for specific procedures and about how much will be left over for you to pay for out of pocket. Unfortunately, these are only estimates. Your dental or medical insurance may refuse to pay the claim, leaving you with the responsibility of covering that specific procedure. 

    When Sedation or Anesthesia is Involved

    Why are You Having the Surgery?

    Using Insurance For Dental Work

    Your medical insurance provider may only offer coverage for dental work it deems medically necessary. And what is medically necessary varies from provider to provider. Because dental health affects the rest of your body, there can be a fine line between whats considered a dental procedure and a medical procedure.

    Oral surgery could potentially be billed as a medical procedure. And while dental procedures arent typically covered by medical insurance, there may be components that are covered under certain circumstances.

    Since it can be a case-by-case basis, before you move forward with any dental procedures, its probably a smart idea to talk to your medical insurance provider to see if youre covered. That conversation alone can be a good start to understanding potential out of pocket costs that may come up.

    One important thing to note is that there is a difference between a dental office that takes your insurance vs a dental office that you are in-network with. A dentist may take your insurance even though you are out of network with them.

    When a dentist says that they take your insurance, that likely means that they will file a claim to your insurance for you. But if your insurance doesnt cover a procedure or service, the price will generally be set at your dentists discretionand you would typically be responsible for paying the costs out of pocket.

    Which Coding Books Do You Use

    Unlike medical billing and coding, however, dental coding uses a different set of data to code and send claims. Medical coding relies on three main texts: , , and .

    Dental coding, on the other hand, uses a text called Current Dental Terminology , which is published and maintained by the American Dental Association.

    This text was specifically created for dental insurance billing and coding. It has all the codes that you need to code and bill dental claims. This is because each of the dental procedure codes is specifically related to a dental diagnosis.

    For example, the code D7240 is for full bony impacted wisdom tooth removal. This means that the procedure performed was related to the patient’s dental condition, which is reflected in the procedure that was performed on the patient on the date of service. This means that a separate diagnosis code is not needed.

    We All Use One Set Of Codes In Medical Billing For Dental

    What types of procedures can be billed to medical insurance?

    A few common procedures include: sleepxTMD, trauma, surgical, systemic, evaluation/management & diagnostic.

    When it comes to filing dental claims, its not about the what, its about the why.

    How does the treatment affect your patients overall health? Can you tell a story like this one?

    Medical Billing For Dentists

    One of the many challenges of owning your own dental practice is having an efficient billing system. Still, even when the internal processes are efficient, it can be difficult working with insurance companies to receive timely payment. The back-and-forth communication with insurance companies can take up a significant amount of time. By keeping your staff attentive to patients and off the phone, theyll be able to provide a much better experience for each patient that comes through your door.

    OMS Partners specializes in medical billing for dentists, hospitals and medical practices, because we know how complex each transaction can be. Dealing with both dental and medical insurance companies can be a hassle and takes time away from patient care, so we are here to make the process much easier for dental offices.

    Single And Multiple Units

    The last digit in a code often refers to how many units of that service you received. For instance, the dental code 11111 refers to 1 unit of scaling . 

    A “unit” of scaling means the amount of scaling that the dental hygienist did in 15 minutes. If it took 30 minutes to scale your teeth, you would be charged for 2 units of scaling instead. The code for 2 units of scaling is 11112; the code for 3 units is 11113, and so on.

    Which Form Is Needed When Submitting Claims To A Medical Payor

    Accuracy in claim submission is vital whether using electronic claims submission or submitting manual claims. Required claim forms provide some primary guidance when submitting a claim to a health insurance company.

    The explanation of benefits your patient receives should outline coverage details. This information helps determine the procedures medical necessity prior to coverage approval.

    What To Do Before A Procedure

    Learn how to bill medical insurance for dental procedures ...

    Read your dental policy closely to see whether your procedure is covered. Call your insurance company if you have questions.

    If you need a major procedure, you can ask your dentist to submit a pre-treatment estimate. This will help you know what youâll likely owe after any coinsurance, , and policy maximum.

    Itâs also smart to understand how your dental plan handles emergencies. Many have provisions for urgent care or after-hours care, but you may owe a , a copay, or a larger percentage of costs.

    So Why Do Many Dentists Believe That They Cannot Bill Medically

    First of all, many dentists believe that since this procedure is not taught in dental school, it is not possible to do so. Additionally, the process hasnt been addressed by professional dentistry for decades. Therefore, dentists keep spreading the false myth to one another. 

    Secondly, there is a misconception that medical benefits are only available to physicians and oral surgeons. This misconception is not true. It is stated by medical insurance carriers that their coverage is determined by the procedures performed, not title or capacity of the service provider. In reality, a large number of procedures that dentists are performing nowadays are considered to be medical, procedures such as exams, Panos, SRPs, implants, bone grafting, and extractions.

    Legal Support: SEC.2706. NONDISCRIMINATION IN HEALTH CARE. The Federal health care law states the following: PROVIDERS. A group of health plan an a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that providers license or certification under applicable State law.

    Finally, the myth may come from the fact that the idea to bill medically for dental practices just seems wrong. There is already dental insurance for dental procedures. So obviously medical insurance is not. 

    More articles

    Popular Articles