Dental Billing vs. Medical Billing: What Dental Practices Need to Know

Dental offices increasingly treat conditions that medical insurance covers – from oral surgery after an injury to oral appliances for sleep apnea. Knowing which plan to bill, and how, can add revenue and save patients money. Here is how dental and medical billing differ, and the habits that keep dental claims paid.

The key differences

• Codes: dental claims use CDT procedure codes, maintained by the American Dental Association. Medical claims use CPT/HCPCS procedure codes plus ICD-10-CM diagnosis codes.
• Claim forms: dental plans use the ADA dental claim form (or its electronic version). Medical plans use the CMS-1500 form (837P electronically).
• Diagnosis: many dental claims need no diagnosis code, but every medical claim must show why the service was medically necessary.
• Plan design: dental plans usually have low annual maximums, frequency limits (for example, cleanings twice a year) and waiting periods. Medical plans use deductibles, copays and out-of-pocket maximums instead.

When dental offices can bill medical insurance

Medical insurance may cover dental-related care when it treats a medical condition rather than routine dental health. Common examples include:

• Oral surgery such as some extractions, biopsies and treatment of jaw lesions
• Treatment after accidents or facial trauma
• Oral appliances for obstructive sleep apnea
• TMJ/TMD evaluation and treatment, depending on the plan
• Exams and imaging needed before medical treatment, such as radiation or transplant

Coverage varies by plan, so always verify benefits and any prior authorization rules before treatment. When medical is primary, bill it first and send the remaining balance to the dental plan if it covers the service.

Common dental claim problems

1. Frequency limits: a service performed too soon after the last one is denied. Check history before scheduling.
2. Missing attachments: crowns, root canals, periodontal treatment and implants often need X-rays, charting or narratives.
3. No pre-treatment estimate: a predetermination for major work avoids surprise patient balances.
4. Eligibility not checked: waiting periods, used-up annual maximums and terminated plans cause many denials.
5. Wrong coordination of benefits: when a patient has two plans, the wrong primary payer delays payment.

A simple checklist for every visit

• Verify eligibility, remaining annual maximum and frequency history
• Decide whether dental, medical or both plans apply
• Send predeterminations or prior authorizations for major treatment
• Attach X-rays, perio charts and narratives when required
• Follow up on unpaid claims within 30 days