Dental vs. Medical Billing

For many practices, especially those offering both dental and medical services, understanding the billing differences between the two systems is essential. While they may seem similar on the surface—both involve coding, insurance claims, and reimbursements—their rules, workflows, and payer expectations can vary dramatically.

In this article, we break down the key differences between dental and medical billing, identify where they overlap, and explain how understanding both can streamline your practice and maximize revenue.

1. Insurance Coverage: Who’s Paying?

Dental Billing:
Dental billing typically involves submitting claims to dental insurance providers, who cover preventive care (cleanings, X-rays), restorative procedures (fillings, crowns), and sometimes orthodontics.

Medical Billing:
Medical claims go to health insurance providers and are based on medical necessity. If a dental service has a systemic health connection (like an abscess affecting overall health), it might be billed medically.

➡ Key Difference: Dental plans have annual maximums, while medical insurance has deductibles and out-of-pocket maximums.

2. Coding Systems

Dental Billing:
Uses CDT (Current Dental Terminology) codes, maintained by the American Dental Association (ADA). These codes are specific to dental services like D1110 (adult cleaning) or D2740 (crown).

Medical Billing:
Uses ICD-10-CM (diagnosis codes), CPT/HCPCS (procedure codes). These systems are far more extensive and required for almost all payer types.

➡ Key Difference: Medical billing requires diagnosis codes and procedural justification; dental does not always require a diagnosis.

3. Documentation Requirements

Dental Billing:
Documentation may be lighter and often focuses on X-rays, chart notes, and treatment plans.

Medical Billing:
Requires thorough charting with SOAP notes (Subjective, Objective, Assessment, Plan), including clear medical necessity for the procedure.

➡ Key Difference: Medical payers demand more detailed documentation to justify reimbursement.

4. Claim Submission Process

Dental Billing:
Claims are submitted using the ADA claim form and usually electronically through a dental clearinghouse. Many dental plans also accept paper claims.

Medical Billing:
Claims use the CMS-1500 form (or UB-04 for facilities), submitted electronically to medical payers via a medical billing clearinghouse.

➡ Overlap: Practices may use clearinghouses for both, but the forms and formatting are different.

5. Coordination of Benefits (COB)

In integrated treatment, a service may be billable to both medical and dental plans—but not simultaneously.

Example:

• Sleep apnea appliances or oral surgeries may qualify for medical billing if medically necessary.

• Submit first to the medical insurer, then use the EOB (Explanation of Benefits) for secondary dental billing.

➡ Pro Tip: Always confirm primary vs. secondary coverage before submitting dual claims.

6. Provider Credentialing and Network Participation

Dental:
Dentists typically credential directly with dental payers and may not be recognized by medical plans unless they offer medically necessary services.

Medical:
Providers must go through a more complex credentialing process with medical payers, often including NPI, licensure, specialty, and board certifications.

➡ Important Note: If you want to bill medically as a dental provider, check if your NPI is recognized by the payer for the service rendered.

When Dental and Medical Billing Work Together

There are several procedures where medical billing for dental services makes sense:

• Trauma (facial injury, lacerations)

• Oral surgery (extractions, biopsies)

• Sleep apnea appliances

• TMD (temporomandibular disorder) treatment

• Pre-transplant dental clearance

• Congenital conditions like cleft palate

In these cases, proper documentation, correct medical codes, and payer preauthorization are crucial.

Final Thoughts

Understanding the key differences between dental and medical billing is more than just academic—it’s a financial advantage. Practices that know how to bill correctly and compliantly across both systems can:

• Expand services

• Improve patient access

• Maximize reimbursements

• Reduce billing errors and denials

If your practice handles or is considering integrated care, now is the time to ensure your billing workflows and staff are trained in both systems.

Need help navigating dental-medical billing integration? Our team of specialists can help set up compliant processes, train your staff, and ensure you’re getting paid for every eligible service. Contact us at admin@triumphmps.com.