Billing Dental Implants under Medical Coverage

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Aug 12th, 2021

Implants can be costly to the patient and the provider, and it is crucial to understand how to bill a patient’s medical insurance to ensure there is adequate coverage for the best treatment. Implants are commonly billed in a dental office under a patient’s medical benefits.   

Implants could be considered dental but will be covered by most payers if the prosthesis is used secondary to maxillofacial surgery or repair to a traumatic injury. Be sure to note the intended use on the claim form, as well as in your documentation notes. For example, note the date of trauma, tumor, biopsy, resection, any dates of radiation treatment, and all other necessary medical history pertaining to the implants.   

Billing for Prosthesis Designed and Prepared by the Dentist

If billing for maxillofacial services providing a prosthesis and a prosthesis is provided, designed, and prepared by the dentist, it is billed with CPT codes 21076 through 21089. If an outside laboratory prepares the prosthesis, it is billed under durable medical with a HCPCS code. The outside laboratory charge and payment should be supplied in Item 19 of the CMS-1500 form. Medicare Part B will then pay CPT code 21299. 

Be sure to adequately describe any revision, relining, or any adjustment to the prosthesis. It is also essential to document the time interval since fabrication or previous modification. Due to using the unlisted code, it is necessary to give very descriptive documentation and attach the documentation to the claim anytime you are using an unlisted code. 

According to Medicare, under Medicare policy, care, treatment, removal, replacement of teeth, or structures directly supporting the teeth are not covered. Medical insurance may also cover teeth extraction to prepare the jaw for radiation treatment of neoplastic disease. If a service, otherwise non-covered, is an integral part of a covered procedure, e.g., associated with the surgical removal of a tumor (for other than dental purposes), it can be covered. X-rays related to a covered procedure can also be covered.