Although it is difficult to control orthodontic billing, it serves as essential for the financial viability of any orthodontic practice. Unlike general dental billing, orthodontic billing involves unique coding, extended treatment plans, and intricate insurance policies. Providers risk delayed payments, claim denials, and revenue loss without a solid understanding of these factors.
Studies show that insurance claim denial rates in dental and orthodontic practices range from 10% to 20%, leading to significant financial setbacks.
Many dental professionals struggle with inaccurate coding, insurance issues, and claim rejections, which can delay reimbursement by 30–60 days.
Nearly 65% of dental clinics have trouble collecting insurance revenue, causing financial strain. To keep the revenue coming in and get the most revenue back, you need to learn the rules and best practices for orthodontic billing. This guide covers orthodontic billing guidelines optimization and revenue optimization tactics.
Understanding Orthodontic Billing
Orthodontic billing is the process of sending in and handling insurance claims for orthodontic treatments, making sure that the right codes are used, that proper paperwork is kept, and that patients get paid for services like braces, aligners, and other corrective procedures.
Role of Insurance Companies in Orthodontic Billing
Insurance companies have an important impact on how much orthodontic care costs, and their rules are very different. In contrast to regular dental processes, orthodontic treatments often have age, time, and lifetime limits. Benefits are usually given in stages, so you need to keep up with them.
To get the most revenue back from insurance, providers should check the benefits up front, including limits on coverage, co-pays, and the need for prior permission. For timely payouts, it’s important to be able to talk to insurers clearly about claims and appeals.
Medical Billing for Orthodontics
Medical billing for orthodontics requires a thorough understanding of insurance policies, as coverage varies between medical and dental plans. Orthodontic treatments are usually seen as optional, but there are times when they are medically necessary, like when someone was born with a birth defect or was wounded.
However, Claim processing must be done correctly, with the right use of CDT and CPT codes, previous authorizations, and detailed documentation. Working with experienced billing professionals can help orthodontic practices get the most money back from insurance claims and have fewer claims denied.
Essential Orthodontic Billing Codes
Some of the most frequently used orthodontic codes include:
D8080: Comprehensive orthodontic treatment for adolescents
D8090: Comprehensive orthodontic treatment for adults
D8670: Periodic orthodontic treatment visit
D8680: Orthodontic retention (removal of appliances and placement of retainers)
D8210: Removable appliance therapy
D8220: Fixed appliance therapy
These codes ensure that insurance providers recognize the specific orthodontic services provided, allowing for accurate claims processing and timely reimbursements.
Dental Code for Braces and Its Significance in Claims Submission
Braces are a common orthodontic treatment, billed under D8080 for adolescents and D8090 for adults. Using the correct codes is essential for:
Insurance Verification: Many plans offer lifetime orthodontic benefits with specific conditions.
Pre-Authorization: Some insurers require approval before coverage.
Preventing Denials: Accurate coding helps avoid delays and claim rejections.
Proper coding improves billing and maximizes dental practitioners’ compensation.
Medical vs. Dental Billing for Orthodontics
Medical insurance might pay for orthodontics, but it depends on what is being done. To get the most out of your patient’s insurance benefits, know when to use medical bills.
Orthodontic care for birth defects (like cleft lip and craniofacial syndromes), injuries, OSA, or TMJ problems should be covered by insurance. Instead of CDT codes, CPT codes are used, such as 21110 for orthodontics dental codes for craniofacial abnormalities, 21150 for jaw reconstruction for congenital deformities, and 20660 for TMJ manipulation.
Some health insurance plans will pay for orthodontic work if it’s medically necessary. Usually, this means getting a recommendation from a doctor, filling out paperwork about a functional impairment, and getting a full medical exam. Check the policy’s coverage standards before you file a claim to avoid being turned down.
Key Orthodontic Billing Guidelines
- Verify Insurance Coverage
Confirm patient eligibility and benefits before treatment to prevent unexpected costs.
- Use Proper Billing Codes
Apply CDT codes specific to orthodontic procedures and distinguish between comprehensive and limited treatments.
- Submit Claims Correctly
Use the correct claim form (ADA Dental Claim Form) and attach required documents like treatment plans and X-rays.
- Understand Payment Structures
Recognize that orthodontic treatment is often reimbursed in installments and track payments over time.
- Coordinate Benefits
Determine the primary and secondary payer for dual coverage to prevent duplicate billing.
- Manage Pre-Authorizations
Obtain prior authorization if required and submit necessary documents to minimize claim denials.
- Monitor Claim Denials and Appeals
Track denied claims, resolve issues promptly, and submit appeals with proper documentation when needed
Tips for Efficient Orthodontic Billing
- Verify Insurance Coverage: Confirm benefits, waiting periods, and patient co-pays before treatment.
- Use Correct CDT Codes: Stay updated on coding to prevent denials and processing delays.
- Obtain Prior Authorization: Submit required documents and follow up to ensure approval.
- Submit Accurate Claims: Double-check details and use electronic claims for faster processing.
- Maintain Proper Documentation: Keep treatment plans, X-rays, and financial agreements organized.
- Regularly Follow Up on Claims: Track outstanding claims and appeal denials promptly.
The Bottom Line
Orthodontic billing requires precision, paperwork, and insurance rules for precise compensation. Orthodontic billing is different from dental billing, so knowing the difference can help you make more revenue possible and get more people to follow the rules.
As billing and insurance laws change, it’s important to stay up to date on the company’s affairs. Not meeting current standards can cause claims to be denied, cash to be lost, and compliance issues. By using the most up-to-date payment standards, orthodontic offices can improve their processes and keep making money.
HMS Group Inc. is a leader in orthodontic billing. Our billing specialists make sure that claims are processed quickly and correctly, and they also make sure that dental providers get better financial results. HMS Group Inc. makes orthodontic bills easier so you can focus on taking care of your patients.
