Is medical billing the same as dental billing?

No. Medical billing and dental billing both send claims to an insurer for payment, but they use different procedure codes, different claim forms and different plan rules. A dental practice mostly bills dental plans, and sometimes bills a medical plan for a procedure that is medical in nature. This guide covers each difference and what to ask a billing company about both.

Procedure codes: CDT and CPT

Dental procedures are reported with the Code on Dental Procedures and Nomenclature, known as the CDT Code, which the American Dental Association maintains. Medical procedures are reported with Current Procedural Terminology (CPT) codes and the Healthcare Common Procedure Coding System (HCPCS). Diagnoses on medical claims are reported with ICD-10 codes.

All four are code sets adopted under HIPAA for electronic health care transactions. Source: CMS overview of HIPAA code sets. A procedure code from one set cannot simply be swapped for a code from another, so a team that bills dental claims needs to know the CDT Code, and a team that sends a dental practice’s medical claims needs to know CPT and ICD-10 as well.

Claim forms

The ADA Dental Claim Form provides a common format for reporting dental services to a patient’s dental benefit plan. The ADA publishes the current form and completion instructions.

Medical claims from a professional office use a different form. The CMS-1500 is the standard paper claim form that non-institutional providers use to bill Medicare, and some state Medicaid agencies use it too. Source: CMS on the CMS-1500 form. Claims of either kind can also be sent electronically, using the 837 health care claim transaction adopted under HIPAA. Source: CMS overview of HIPAA transactions.

For a broader introduction, read our guide to dental billing and the billing process, including links to ADA claim-form instructions.

Dental claim details

A dental billing company also works with claim details that a medical claim does not ask for. The dental claim form has fields for:

• the tooth number or letter;
• the tooth surface;
• the area of the oral cavity;
• missing teeth;
• the tooth numbering system used.

A claim with one of these left blank or filled in wrongly may be returned or denied, so the person preparing it has to read the clinical note and chart, not only the procedure code.

Coverage and reimbursement

Coverage, frequency limits, deductibles, annual maximums and payment timing depend on the patient’s plan and the claim. Because these limits differ from plan to plan, checking the patient’s benefits before treatment matters as much as coding the claim correctly.

When a dental practice bills medical insurance

Some procedures done in a dental office may be covered by the patient’s medical plan, in full or in part. Whether they are depends on the plan, the patient’s medical condition and the procedure.

For oral surgery involving both medical and dental insurance, confirm the claim-submission order with the applicable plans rather than assuming medical insurance must always be billed first. Delta Dental’s consumer guidance notes that some medical policies require the dental claim to be processed first. Check the patient’s specific plan requirements; this example is not a universal billing sequence or a promise of coverage.

Medicare is a separate case. Medicare does not pay for most dental services, such as the care, filling, removal or replacement of teeth. It can pay when a dental service is closely tied to the success of a covered medical treatment; CMS gives examples such as a dental exam and treatment of an oral infection before an organ transplant or cardiac valve replacement. Source: CMS on Medicare dental coverage.

Choosing billing support

A company that bills medical claims does not necessarily handle dental claims, and the reverse is also true. Confirm what a billing company actually does rather than assuming both are included. Questions to ask:

• Does the team that would handle our account work with CDT codes and the ADA Dental Claim Form every day?
• Do you also send medical claims for dental procedures, and who codes them?
• Which dental plans that we bill do you already work with?
• What is the fee, what does it include, and is there a trial period?
• Can we see a sample report with patient details removed?

Related guides: compare providers with our dental billing company checklist, review what dental claim denials are and how to avoid them, read when outsourcing dental billing makes sense, or see the benefits of outsourcing dental billing. Explore our dental insurance billing services (2.75% rate, $250 monthly minimum, 30-day free trial) for claims follow-up, payment posting and accounts receivable support. Contact eDental Billing to discuss your practice’s billing needs.