Does your dental practice ever bill to medical insurance? Depending on the suite of services that you offer, not billing dental procedures to medical insurance could mean missing out on higher reimbursements or leaving your patients paying more for their procedures out of pocket. You might be surprised to learn that medical insurance can reimburse for many procedures that oral surgeons and endodontists perform regularly. Should you bill to medical or dental?


To Bill or Not to Bill

It is not always easy to have medical insurance cover dental procedures immediately, which is why some dentists, oral surgeons and endodontists, become discouraged too soon into the process and don’t attempt to appeal or try again. Medical billing for dental procedures can help your patients to afford treatment in many cases, as dental insurance often has a lower benefit cap. While things like teeth cleanings and cavity fillings would not necessarily be considered medically necessary, surgeries that are medically necessary can often be billed to medical insurance.

What Is Medically Necessary When Billing Dental Procedures?

The key part of getting reimbursement from a medical insurance company is demonstrating that the dental surgery was medically necessary for the patient. That means that medical insurers want to typically see ICD-10 codes, not CDT codes. Insurance companies expect to see documentation explaining:

  • The primary presenting situation
  • Secondary, supporting diagnoses (if present)
  • The appropriate codes for the treatment
  • Surgical pre-authorization
  • A letter of medical necessity
  • A supporting letter from the patient’s Primary Care Physician (if possible to strengthen the medical necessity argument)
  • All procedures performed

This helps to paint a comprehensive picture of the care that you provided and why it was needed and medically necessary, therefore it should be eligible for at least partial reimbursement by the insurance company. In general, the dental professionals who perform procedures that are eligible for medical reimbursement are endodontists or oral surgeons.

Pre-Authorization Helps

Pre-authorization can be a hassle, but it can often mean the difference between reimbursement and denial. Most medically necessary dental procedures are scheduled, which means that the insurance company believes you or the patient have time to call ahead and receive pre-authorization. Calling ahead makes a big difference when billing dental procedures to medical insurance.

Letter of Medical Necessity

A Letter of Medical Necessity, also known as an LMN, gives you the opportunity to show your case for the medical necessity of the surgery. Again, you should use ICD-10 codes and explain your diagnosis or diagnoses clearly.

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

APEX Reimbursement Specialists Can Help You Increase Your Revenue

Whether you’re 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 (410) 710-6005. We look forward to working with you to make your practice a more profitable place.