Understanding the Potential of Medical Billing in Dentistry

Discover six categories of procedures that can potentially be billed to medical insurance.

We’ve all been there. Sue is a new patient who presents with tooth pain. After an exam and X-rays, the doctor prepares a comprehensive treatment plan to restore function and resolve her pain. She’s excited by the doctor’s recommended treatment and is eager to get started and get relief from her pain. However, you can see the fear in Sue’s eyes as she is anticipating the dreaded four-letter word, COST. Her eyes focus on that grand total, and tears start to form. It is nearly $15,000. She desperately wants this treatment, she wants a healthy mouth and she wants to be pain-free, but Sue doesn’t have $15,000. Even with dental insurance coverage, she is looking at nearly $13,500 out of pocket.

In comes medical billing. “It’s OK, Sue. Don’t worry. If you remember, we collected your medical insurance information when you scheduled this appointment, and my team has already verified your medical insurance benefits. I’m happy to say that after you satisfy your $5000 deductible, you have 80% coverage on medically necessary dental treatment. We can also still utilize your dental insurance. That means, because you came to an office that bills medical insurance, your total out-of-pocket for this comprehensive treatment plan will cost you closer to $5500.” Tears are falling down Sue’s cheeks because she can now afford to get the treatment that she desperately needs. Talk about a win-win situation. Patients get the care that they need, and your office just scheduled a $15,000 treatment plan.

Everyone can see the value of adding medical billing to a practice. But very few dental professionals understand the full potential. To make it easier, I’ve created six categories of procedures that can potentially be billed to medical insurance. Within the six categories, you will see that every dentist in the country is doing some procedure that could be billed to medical insurance. So, let’s dive in and see just some of the potential of medical billing in dentistry.

Category 1: Exams and Radiographs

This category encompasses office visits or exams when you’re seeing a patient for a medical reason. An example might be a patient who was referred to you for evaluation before surgery or a medical procedure or who needs to be seen more regularly because of a health condition, such as diabetes or heart failure. This could also be seeing a patient for an exam because the patient is in pain or has an abscess or infection. The easiest way to describe this is, if you are seeing a patient for any medical condition or medically billable procedure, chances are the exam could be billed to medical insurance.

When it comes to billing radiographs, many dentists already know that 3-D imaging, like CBCT, can be billed to medical insurance. But did you know that PAs, bitewings and panos can as well? Similar to exams, you just need to be taking an X-ray for a medically related purpose, such as an abscess, infection, pain or even planning for a medically covered procedure such as an implant.

Category 2: Screening and Preventative Services

This category includes screening for any medical condition. A few examples include HbA1c testing, oral cancer screening or DNA testing. I also include periodontal treatment in this category. Yes, you read that right, periodontal treatment may be billable to medical insurance. If you are treating a patient with periodontal disease and they also have an underlying medical condition that is being affected by the perio infection, such as pregnancy, diabetes or heart disease, you have an argument for medically necessary dental treatment. This could include scaling and root planing, antibiotic and laser treatment, and even periodontal maintenance.

Category 3: Sleep Apnea and TMD Appliances

Within this category are all appliances, including sleep apnea treatment, TMD treatment, pediatric appliances, palatal expanders and ortho. Most of these procedures are not billable to dental insurance, so the only coverage your patient may have is medical coverage, which makes this category one of the most popular. Additionally, if you happen to be treating sleep with the expectation of getting referrals from medical doctors, there is no faster way to build rapport and legitimacy than offering medical billing for these services.

Category 4: Trauma

This category encompasses everything related to trauma or accidents. I can say with almost complete certainty that everyone has seen a trauma case that could’ve been billed to medical. Often when we think about accidents or trauma, we think there must be an ER report, police report or some sort of specific documentation about the accident. That is not the case. Your patient simply needs to complete an accident form within your office explaining exactly what happened. If the provider concurs that the damage is consistent with the patient’s recollection of the incident, you have a case for medical billing. The thing I want you to remember about billing for trauma is that all treatment related to restoring this patient to pre-accident function is billable to insurance. That means you can bill for the exam, X-rays, implant, bone, membrane, final restoration and fillings if that’s what it takes to restore the patient to pre-accident functionality.

Category 5: Surgical and Laser Treatment

This category is broad and includes all treatments related to laser treatment, hard and soft tissue, and all surgical procedures. This can range from third molar extractions to basic single tooth implants to full mouth reconstruction. The reason this category gets so much attention is these cases often have higher costs associated with them, and more patients need financial assistance from their medical insurance. Nearly all practices provide some services within this category.

Category 6: Systemic Related Procedures

While this category is often the most challenging, I find it the most rewarding. This is where we prove that a medical condition or medication is either affecting the oral cavity or being affected by the health of the oral cavity. Examples of this would include patients that suffer from severe dry mouth due to medication use or patients with acid reflux or GERD that is causing acid erosion of the teeth. This could also include congenital conditions like missing teeth, or other health conditions such as diabetes and immune disorders. The list of health conditions that are affecting the oral cavity and health conditions that are being affected by the oral cavity is constantly growing, as is the list of side effects caused by medication use. While helping these patients get the treatment they need is very rewarding, the challenge can come from documentation and working with their medical doctors to confirm the diagnosis of these medical conditions.

Now that you know just some of the potential with medical billing, I challenge you to ask yourself these questions:

  • Would more of your patients accept the care that you recommend if you could reduce their out-of-pocket portion?
  • Would more of your patients stop looking at dentistry as an elective procedure if you could show them that medical insurance is acknowledging the need for this treatment?
  • Would you like to receive referrals from hospitals, ERs and medical professionals because you were known as a provider who bills medical insurance?

If you answered yes to any of these questions, the next question is this: What are you waiting for?


Learn More

Find out how to make medical billing work for you with Imagn and Dentrix.


By Crystal May, COO, Devdent

Crystal May is dedicated to helping dental practices be successful in dental sleep medicine and medical billing. With over 17 years of medical billing experience, 10 with an emphasis on dentistry, she is a leading educator on these topics. Having owned and managed multiple dental practices, she mastered the process of efficient implementation. She enjoys sharing her passion and knowledge with dental practices throughout the country.