Determining medical necessity for dental medical billing

June 2023
Charles Blair, DDS

Dental medical billing and cross-coding can be complex, especially when you aren’t confident in establishing medical necessity. Medical and dental providers and payors use the same terminology, which means that confusion is alarmingly common when it comes to submitting dental procedures to a medical payor for reimbursement. Let’s take a closer look at tips for determining medical necessity.


What is medical necessity?

A very broad definition of medical necessity is, as explained in Practice Booster’s Medical Dental Cross Coding with Confidence 2023 guide, “the treatment or supplies provided to a patient, which are considered reasonable, necessary, and/or appropriate, based on accepted clinical standards of care.”    

Determining medical necessity for dental medical billing

There is a clear distinction made by medical payors between dental procedures considered medical in nature and those considered strictly dental in nature. For example, most medical policies consider treatment for teeth damaged due to accidental, external trauma as medical in nature. While this seems clear, confusion comes into play when choosing the correct ICD-10-CM diagnosis code for proper dental medical billing and cross-coding. More than one ICD-10-CM diagnosis code could be used to report dental treatment on a medical claim form, which means ICD-10-CM knowledge or a supporting resource is crucial to timely and efficient dental medical billing.


Here are a few common medical procedures performed by dentists:

  • Evaluation and treatment for oral cancer, including biopsies

  • Treatment for traumatic injuries, including damaged and broken teeth

  • Treatment to correct congenital abnormalities, including, but not limited to, cleft palate repair and frenectomy

  • Evaluation and treatment for temporomandibular disorders

  • Oral sleep appliances for obstructive sleep apnea (OSA)

  • Surgical extraction of teeth, especially impacted wisdom teeth 

Essential resources for dental medical billing

The adage among coding professionals is, “If it’s not documented, it didn’t happen.” While this sounds cliche, it’s absolutely true. Be certain your documentation clearly states how the treatment affects the patient’s medical condition, as well as document medical history in the patient’s chart before performing any medical or dental procedures.


If you are struggling with dental medical billing in your dental practice – or just want some additional support to keep your revenue roadblock-free – here are the resources we recommend:

  • Medical Dental Cross-Coding with Confidence – No matter your experience level, this is a must-have for every practice! This exceptional manual explains the different types of medical codes, how to complete the medical claim form, and how to submit proper claims to medical payers. 

  • Online Code Advisor – Stay in the know with the dental industry’s most comprehensive CDT coding resource, which comes with dental and medical billing and administration support from Dr. Blair and Associates.

  • Mastering Dental Documentation – Delve into the world of dental documentation and uncover the secrets to creating comprehensive and compliant patient records in this on-demand CE course from Dental Zing, taught by Practice Booster Senior Advisor, Greg Grobmyer, DDS.


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