One of the biggest hurdles in dentistry is the age-old question “will my insurance pay for this?”. As much as we would aspire to have a fee for service, money is no object practice, the reality is that is a unicorn in our industry.

Dental insurance provides little or no reimbursement for implants. Implant procedures are eligible for medical billing when they meet the threshold of medical necessity. Examples are cases that restore function by resolving compromised ability to chew. Another example are cases where oral disease complicates or causes other medical conditions such as digestive or nutritional problems from impaired chewing function.

Any licensed professional DDS, DMD, MD, DO can perform any medical procedure that falls under the scope of their license – state and federal guidelines apply. A dentist performing a bone graft for instance bills the exact same procedure code as a plastic surgeon performing a bone graft. Similarly, in dentistry, an oral surgeon uses the exact same code as a general dentist.

Why bill medical insurance? You will be able to increase case acceptance by decreasing the patient’s portion. It leaves dental benefits for future dental procedures and you get paid for exactly what you are doing every procedure. Medical has no maximums or frequency limitations as well and you will be able to separate your practice from others. Do not be afraid of medical billing. Software such as Dentrix, are adding it into their systems to help ease the process.

Dental offices typically need to upgrade and modify patient assessment and documentation to uncover medical conditions and establish medical necessity. The accepted process for documentation of patient encounters that has been widely adopted for communication between interdisciplinary healthcare providers goes by the acronym SOAP (as in SOAP notes)

Subjective: Include patient’s chief complaint, review of systems, gender, height, weight, symptoms and conditions, social history and medical history.

Objective: Facts that can be verified or observed during the exam. Include doctors’ findings and observations. Such as intra and extra oral exam, imaging and medical/dental findings. Things that are measurable.

Assessment: The providers initial clinical impression or diagnosis. The dentist’s conclusions, diagnosis, or prognosis based on the exam and/or diagnostic tests. May include theories of causation and severity.

Plan/Procedure: The provider’s plan for testing, treatment or referral of the patient.

SOAP notes will be of tremendous assistance to your insurance specialist in identifying the proper disease-diagnosis codes (ICD-10) and procedural (CPT) billing codes.

What not to say in SOAP notes:

• Teeth: Use reconstruction of mandible/maxilla or treatment on upper right quadrant. We are looking at treating the supporting structures.
• Super-Erupt: An unknown term in medicine and should be avoided
• Tipped Teeth: Use horizontal displacement
• Bite: Correcting malocclusion

Categories: 

• Exams and Radiographs: Exams, after hour exams, CBCT – 3D Images, panoramic, bitewing or periapical x-rays. There are CPT codes for all types of exams and they based upon time. 10, 20 and 30 minute increments for new patients. Typically, your existing patients will be coded in the following time increments of 5, 10 and 15 minutes. There are palliative treatment exams, consultations and even after hour service codes. When billing in medical systems the HIGHEST service should be listed first.
• Screening and Diagnostic: Periodontal maintenance for preventive services, scaling and root planning, oral cancer screenings, blood sugar and PH tests, DNA and saliva testing, nutritional counseling, smoking cessation and Botox.
• Sleep and TMD: Oral appliances for obstructive sleep apnea, occlusal guards, palatal expanders, habit correcting devices and clear aligners
• Trauma: exams, radiographs, diagnostic procedures, anesthesia, restorative treatment, surgical treatment, interim treatment, after hours or emergency care.
• Surgical and Laser Treatment: surgical extractions,, 3^rd molar extractions, implant placement, bone and tissue grafting, all on four/FM reconstruction, periodontal surgery, anesthesia, and LANAP (laser assisted new attachment procedure)
• Systemic Relation: Procedures related to medication use or medical treatments, treatment on patients with diabetes, or immune system disorders. Tooth replacement on edentulous patients with GERD or other gastrointestinal disease or epilepsy.

Specifically billing for implants

Class level is used to determine the severity of the patients’ tooth loss and how easily the patient can be treated with prosthodontic techniques, e.g., dentures. Class 1 are patients that have a fully or almost fully intact dental structure and are the most apt to respond well to prosthetic treatment. Class II patients suffer from some degradation of the supporting dental structures or present with early onset of a disease process which is expected to damage those structures. They may require special modifications to fit properly.  Class III patients require surgical revision of the dental supporting structures of the jaw in order to be fitted with dentures due to severe deterioration and or an ongoing disease process. Class II and III are primarily your all on 4 cases.

Procedure codes – CPT/CDT

70486 – Computerized tomography, maxillofacial area

21210-52 Graft, bone: nasal, maxillary or molar areas (includes obtaining graft)

21248 – Reconstruction of mandible or maxilla, endosteal implant: partial 1-3 per jaw

21249 – Reconstruction of mandible or maxilla, endosteal implant 4 or more per jaw

20670 – Implant removal superficial

Diagnostic code examples:

K08.401 -  Partial loss of teeth due to …

K08.24 -  Minimally atrophy of maxilla (always bone graft)

Back in 2018 an EOB from Blue Cross Blue Shield had a claim issued for a bone graft and the allowed amount was $1067.00 the claim was paid at 90%. $960.30. That same year another claim was billed for bone graft and an implant for a total of $4001 that was allowed. The claim was paid to the tune of $2471. Coding for all on 4 or full mouth reconstruction is of course more detailed between the extractions, implants, grafts, sinus augmentations and such but another claim from 2019 was filled for $23,745 allowable and was paid at 90% or $21,282. 

Medical billing is not mandatory but can be extremely beneficial to your dental practice. Considering that a typical dental plan has annual maximum benefit limits of $1,000 to $2,000 having an opportunity for your patients to reduce their out of pocket expense will set you apart and create a better environment for case acceptance.

Implementing medical billing is not just for one employee to tackle. Your practice is a team effort and when medical billing it works the same way. The front desk is not the sole person responsible for the billing process. Clinical assistants and Dr.’s equally work together in a systematic workflow for optimal results. In order to submit a clean claim SOAP notes must be documented properly, establish the medical necessity by the Dr’s, front office verifies benefits and payer information requirements then the selection of appropriate ICD-10 and CPT codes, and finally submitting all required documentation.  Many teams hire a specific implant coordinator for seamless start to finish efficiency or hire a separate billing company.

I would like to thank Laurie Owens, medical billing consultant who helped me collect some of data for this article. You may visit her website for free webinars or to register for a medical billing course @www.devdent.com.