What Dental Procedures Are Covered By Medical Insurance? 

Dental practices across the US know that dental plans cover many dental and oral procedural treatments. However, knowing the specific procedures likely to be paid by the insurance is quite tricky. It is essential to get familiar with the required information to save the resources and time spent in billing medical claims for procedures that are actually ‘dental’ in nature.

You may be aware that various oral procedures are covered under medical plans, and dental plans are not considered when billing for such treatments. Dental teams must know the distinctions and intricacies, as slight mistakes can result in a loss of revenue.

Difference Between Oral and Dental Procedures

To clarify the concept and help you with accurate billing, here’s the difference between oral and medical procedures.

Oral Procedure

According to AAPD, “an oral procedure is one that involves structures outside the tooth itself, namely the jaw bone, the periodontal structures, and the oral soft and hard tissues (e.g., cheek, tongue, floor of the mouth, vestibule, lips, palate, and tonsillar areas.”

Dental Procedure

According to AAPD, “dental procedure is the one that involves the tooth itself, including the crown or root portion. Some examples that fall into this category are restorative procedures (e.g., fillings, buildups, crowns, and onlays) and endodontic procedures.”

Billing Medical Insurance for Dental Procedures

Combining dental and medical care is important in the coordination of care and enhancing outcomes under the Affordable Care Act. Compared with medical plans, dental insurance plans come with a slightly low annual benefit.

So, when billing for a patient who has undergone related medical and dental procedures, you can bill the medical insurance for reimbursement. It will enhance patient’s insurance coverage and lower their financial stress.

Medical insurance policies cover treatments by dentists as medical procedures instead of dental. To enhance your practice’s revenue and minimize denials, dentists must know when a dental treatment is considered medical and billable to insurers. 

To ease it for you, we’ve explained it in the point below.

The Service Should Be Provided to Address a Diagnosed Medical Condition

Insurance companies will reimburse for a procedure only when treating a diagnosed medical condition is necessary. Dental practices and hospitals can send claims to payors for diagnostic procedures, surgical processes, and evaluations required to treat medical conditions.

When billing a dental process to medical insurance, the dentist must properly document to show how the process falls under the medical category. Simply put, it explains to the payor how an injury, disease, or surgery has affected the patient’s health and why the dental procedure is inevitable to improve their overall condition.

The Procedure Is Medically Necessary

As the name suggests, medical procedures only pay for procedures that are considered medically necessary. For instance, when the patient is suffering from a medical condition that affects the problem treated by the dentist.

When a patient is suffering from uncontrolled diabetes and requires oral surgery for acute infection, the dentist may need to adjust the dental procedures so that the claim can be submitted under the medical plan.

The Procedure Must Have a Respective Medical Code

Before sending a dental claim to medical insurance, dentists must ensure that the treatment is linked to a medical condition and should mention its code. This way, they’re guaranteeing a correct classification of the treatment under medical insurance guidelines. Documenting the corresponding code also shows the relevance of the treatment to the patient’s health.

Dental Procedures Covered by Medical Insurance

Many dental procedures belonging to specific categories can be billed for medical reimbursements. However, before proceeding, the dentist or the dental billing service provider must ensure that it fulfills multiple or any of the following categories mentioned below.

Diagnostic Procedures

Dental procedures include medical conditions like consultation, examinations, stents, x-rays, scans, etc., to discover and diagnose the sources of pain. X-rays taken of the mouth’s inside help identify the source of tooth pain and the location of disease or trauma. It falls under diagnostic procedure.

Non-Surgical Medical Treatments

Non-surgical treatments aimed at diagnosing medical conditions are billable under the medical plan. The most common scenarios are Sleep Apnea, TMD orthotics, incisions, emergency treatment for inflammation of infection, and custom fluoride trays for patients treated for cancer.

Surgical Procedures

Specific types of oral surgeries can also be billed to medical insurance. These surgeries are used to rectify a non-dental physiological condition resulting in acute functional impairment. For instance, surgery for the extraction of a wisdom tooth may include more than standard dental procedures.

In case the procedure requires general anesthesia, it can be billed to the medical plan. Soft and hard tissue biopsies, like the excision of cysts and tumors of the maxilla, mandible, and surrounding tissues, are also billable to medical plans. Extractions and tooth implants falling under tooth root replacement are also covered by a patient’s medical plan.

Treatment for Traumatic Injuries

Injuries that require urgent care are referred to as traumatic injuries. These include collisions with vehicles, injuries sustained during sports, and other physical conditions like wounds suffered during a fight, at home, or anywhere. Traumatic injuries can be billed to medical insurance.

Medical plan coverage will include reimbursement for all treatments done to restore the original look, condition, and function of the mouth, i.e., restorative care, endodontic treatments, surgery, implants, and prosthodontics.

Common Dental Procedures Billable to Medical Insurance

Here are some of the most common dental procedures that can be billed to medical insurance.

• Dental Sleep Medicine (Sleep Apnea Appliances)
• TMJ appliances and headache treatment
• Oral infections, cysts, oral inflammation
• Exams for services that are covered by medical insurance
• Panorex x-rays for services covered by medical insurance
• CBCT (cone beam) and tomography for services covered by medical insurance
• Frenectomy/tongue ties for infants and children
• Accidents to teeth
• Mucositis and stomatitis (from chemotherapy and other treatments).
• Facial pain treatment
• Dental implants and bone grafts
• 3rd molars or wisdom teeth extraction
• Biopsies
• Clearance exams before chemotherapy or surgery
• Botox Injections for bruxism and jaw pain

Dental Treatments or Procedures Not Covered Under Medical Insurance

Dentists and dental practices/facilities/offices must know which dental services aren’t covered under medical insurance.

Routine Dental Care

It includes processes like cleaning, filling, and routine checkups. They are considered dental procedures and cannot be billed to medical insurance.

Cosmetic Procedures

Beautifying treatments like teeth whitening, veneers, bonding, and Invisalign aren’t considered medically necessary by the payors. They are not paid under a medical plan.

Orthodontic Treatments

Braces and aligners are only covered under a medical plan unless they’re combined with a medical condition, i.e., jaw misalignment affecting its functionality.

Standalone Tooth Extractions

Such tooth extractions are mostly excluded from medical plans unless they’re deemed necessary and linked to infection or trauma that may affect the patient’s overall health. When it comes to traumatic injuries that fall under liability insurance, the insurance must be billed prior to medical insurance.

Periodontal Maintenance

Periodical gum care without any medical condition comes under dental insurance and not medical insurance.

Master the Codes

Knowing the relevant dental-medical codes is one of the most important aspects of getting your claims approved. The cross-coding process is based on the usage of medical codes to show dental procedures and ensure that they fulfill the medical insurance requirements. Knowing the relevant codes and ensuring cross-coding ensures claim approval and reimbursement against it.

The dentist or the dental billing service company must report the processes with precise codes to show the procedure performed. While submitting bills to a medical claim, the dentists or responsible personnel must also be aware of the insurance guidelines to ease approval.

CDT Codes

This code set is integral when it comes to submitting dental procedures to dental insurance. Most insurance companies accept CDT codes if there is no appropriate medical cross code or CPT. They’ll also accept CDT when it perfectly describes the dental procedure. Moreover, before submitting the claim, the dentist must be careful and determine whether the payor allows the submission of CDT codes.

ICD-10, CPT and HCPCS

Dentists and their in-house staff must be knowledgeable on how to report diagnoses, symptoms, and procedures using correct ICD-10 codes. They must also be smart enough to use these codes to show the insurance why a specific method is medically necessary. Using the correct procedural codes is essential to describe therapeutic/medical and surgical treatments.

HCPCS code set eases reporting durable medical equipment like oral sleep apnea appliances. Moreover, it is advised to use the most appropriate modifier where required.

Category I CPT codes

These common codes used in dentistry are separated into the following six sections.

Proper Documentation

Apart from using precise codes like ICD-10, all your claims must be sent with complete documentation that fully describes the necessity for a medical procedure or surgery in an outpatient setting. Claims without complete documentation or no proof of medical necessity may face denials.

In a situation where the dental procedure isn’t the primary procedure, the medical record should be bundled with primary procedure documentation. The documentation must be easy to read and understand, relevant, and enough to support the billed services.

Medicare Billing

When submitting a claim to Medicare, always use the CMS-1500 Health Insurance Claim Form, which is considered mandatory.

Be Aware of the Insurance Guidelines

It is essential to note that all medical plans do not cover dental benefits. However, those that do will always publish the specific procedures they cover. Dental insurance policies differ from each other based on the individual plans and the state in which they’re offered. Some plans have their own regulations for medical services offered by dentists. Getting acquainted with these rules is crucial for correct claim filing.

Stay Up to Date

You may know that medical billing is based on CPT and ICD-10 codes. What makes it different from dental billing is the usage of CDT codes. So, dentists, their in-house staff, and dental medical billing service providers must be aware of the changes.

Staying current with the medical plan of the patient lets you report and submit flawless claims. Having complete knowledge of the patient’s medical plan lets dentists administer required dental procedures and billing specialists to accurately submit claims for swift reimbursements.

Need Help? Get in Touch with the Dental Revenue Group

As a dentist, dental practice runner, or someone responsible for billing, you can reach out to DRG anytime, and we’ll help you file a medical or dental claim. We are a well-known dental billing company serving thousands of dental practices in eligibility verification to determine whether the procedures performed are billable under medical or dental plans.

We have an immensely experienced team of dental coders who take responsibility for error-free coding in claims, which sets the basis for complete and timely payments. We at DRG help you maximize revenue and minimize denials so that you don’t miss out on valuable revenue.