Is your dental practice billing bone grafts to medical insurance? If not, you will want to read on! Medical insurers commonly cover services rendered in the dental practice setting. Dental practices across the country have been able to help their patients maximize their benefits and lower their out-of-pocket costs by incorporating medical billing for bone grafts.  Not all services in the dental practice qualify for medical insurance; only the services considered “medically necessary”. So, it’s important to establish medical necessity with the right diagnosis codes and documentation of medical need to send to insurers who do offer this coverage.

What makes bone grafting medically necessary?

Medical insurers view a case as medically necessary instead of dental in nature when:

  1. The services are an integral part of a covered medical procedure
  2. Disease or loss of function is present and it’s a “covered expense”

Example language from a medical policy:

Aetna’s medical policy titled “Dental Services and Oral and Maxillofacial Surgery: Coverage Under Medical Plans” addresses the criteria for bone grafting of extraction sites:

  • “Bone grafting of extraction sites will be considered for medical reimbursement when bony defects are clinically significant, and the patient is 26 years of age or older.”

Aetna’s states in another policy:

  • Coverage may be available for oral surgery procedures under either medical or dental plans.
  • Bone grafting may also be beneficial at the time of implant placement when the available volume of bone at the site is not adequate

What is needed to bill bone grafts to medical?

  1. Assign an ICD-10 (diagnosis) code, once the medically necessary condition is identified. For example, suppose a patient suffers from jaw pain due to severe atrophy of the mandible. In that case, diagnosis codes K08.23 (Severe atrophy of the mandible) and R68.84 (Jaw pain) can represent the conditions. There are also ICD-10 diagnosis codes for oral tumors, accidental injury/trauma & difficulty eating.
  2. CPT (procedure) codes are needed. The medical coding system contains two procedure codes for bone grafts of the jaws: one represents maxillary bone grafts, and the other represents mandibular bone grafts.
  3. Last, the dental practice should complete & submit the CMS 1500 medical claim form using the ICD & CPT codes. Be sure to include clinical documentation that proves medical necessity. This documentation should include the patients’ chief complaints and pertinent medical history related to qualifying conditions.

Equally as important as knowing the coverage criteria and codes is having a system documenting the chief complaints and medical need for the procedure. This system should also have a streamlined way for you to complete and submit using the CMS 1500 medical claim, whether it be submitted by the practice or submitted to a medical billing service.

Here at Nierman Practice Management, dental practices enjoy the ease of utilizing the DentalWriter Plus software to generate documentation of medical necessity and work with their patient’s medical insurance for these life-changing procedures.

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Please feel free to contact us with any questions related to this article on Bone Grafts when billing medical insurance in dentistry. Send us an email at contactus@dentalwriter.com or call 1-800-879-6468 option 1.

Article by: Rose Nierman and Courtney Snow

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