What makes it medical? A basic guide to medical vs. dental procedures
Editor's note: This article was originally published in 2016 and is updated regularly.
Just because a procedure happens in a dental office doesn't mean it isn’t a medical procedure. Most states and the federal government understand that dentists also provide necessary medical care, not simply dental care. Whenever you perform a procedure that is medical rather than purely dental in nature, you have the option of billing medical insurance for the claim.
Most dental insurance covers routine cleanings at 100% but only pays a small fraction of the cost of other treatments. Dental insurance also tends to have a low annual maximum benefit, so patients with complex issues can quickly exhaust their dental benefits for the year. If you have patients whose medical and dental issues are related, billing medical insurance for procedures can help them afford necessary care.
When is a procedure medical? When it is used to diagnose or treat a medical condition. For instance, “overbite” is a dental condition but not a medical condition. “Abscessed tooth” is a medical condition and a dental condition. “Diabetes” is a medical condition. It may seem a bit confusing at first, but with practice and training, you can learn to identify which of your procedures are being used to treat medical conditions.
The basics of medical conditions and necessary treatment
Medical insurance will pay for a procedure if it’s a necessary treatment for a diagnosed medical condition. You treat medical conditions in your office every day, though you probably don’t even realize it. For instance, are you dealing with the after effects of a traumatic injury? This is a medical treatment. Anytime you diagnose or treat inflammation or infection in the office, such as any disease of the gums, you’re actually treating a medical condition.
Surgery is always considered a medical treatment, as is imaging and other procedures that diagnose medical conditions. Finally, if you’re treating pain or other issues that result in the loss of function in a patient’s daily life, you’re treating a medical condition. For instance, if tooth problems have made it impossible for a patient to eat solid food, that person has stepped over the line from a dental to a medical issue. As insurers become more concerned with systemic illnesses and whole-body health, they’re more likely to understand that dental practices play an important roll on a patient’s medical team.
The four basic types of billable procedures
There are four basic types of common dental procedures that are billable as medical procedures. When you’re deciding which insurance to bill, you should see if the planned procedure falls into one of these categories.
Category 1: Diagnostic procedures—These 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 treatments—Non-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.
Category 3: Surgical treatments—Surgery is usually billable as a medical treatment. For instance, medically necessary tooth removal, the removal of impacted teeth, and the removal of teeth before radiation therapy or an organ transplant can be billed to medical insurance. However, in the case of preventive removal, the patient may need to obtain a referral from a physician. Soft and hard tissue biopsies and extractions are also covered, as is the surgical placement of dental implants.
Category 4: Treatment for traumatic injuries—Treatment for traumatic injuries that are covered by medical insurance can also be billed to medical insurers. However, you must first check to make sure the injury isn’t covered by auto, homeowners, or some other type of liability insurance. If an injury is covered by liability insurance, you must bill that insurance before you bill medical insurance. When an injury is covered, all treatments that restore original look and function of the mouth are covered, including restorative care, endodontic treatments, surgery, implants, and prosthodontics.
You’ll see that many of the treatments you perform each day are actually medical treatments in certain circumstances. Educate yourself and your staff about medical billing for dental procedures, and help more of your patients afford their necessary treatments.
