At Victorian Maxillofacial Surgeons (VMS), we understand that navigating health insurance for your oral and maxillofacial surgical care can sometimes feel complex. As our surgeons hold dual qualifications as both dental practitioners and medical doctors, the procedures we offer may be categorised under either dental codes or medical codes. The following aims to provide clarity on this distinction and how it relates to your private health insurance, although we always recommend you confirm the specifics of your coverage directly with your insurer.

Categorisation of Procedural Codes

To help you identify the type of code being used, it’s useful to know a general rule of thumb:

• Medical Item Numbers: These are generally 5 digits long. We employ medical codes at VMS for procedures of a more complex medical focus, addressing the skeletal structures of the face and jaws. Illustrative examples of procedures we perform under medical codes are:

  • Fracture Management of the Mandible and Maxilla (following trauma)

  • Orthognathic Surgery (corrective jaw surgery for malocclusion and skeletal discrepancies)

  • Bone Grafting Procedures (beyond the scope of implantology)

  • Sinus Lift Procedures (often prerequisite to implant placement)

• Dental Item Numbers: These are generally 3 digits long. At VMS, we utilise dental codes for procedures primarily considered to be of a dental nature, even when surgical intervention is involved. Examples of such procedures at our practice include:

  • Surgical Extraction of Teeth (including wisdom teeth)

  • Dental Implant Placement

• Consultation Item Numbers: It's important to note that whether for your initial visit or for follow-up appointments, your consultation item number will always be a medical code and will be 3 digits long. The specific medical codes used for consultations at VMS are: 104 for an initial consultation, and 105 for a subsequent consultation.

Private Health Insurance Coverage Framework

Private health insurance typically offers two primary categories of coverage pertinent to services you may receive at VMS:

• "Extras" Cover: This form of coverage generally encompasses ancillary health services, such as dental, optical, and physiotherapy. It's important to understand that "Extras" cover is designed to provide benefits for "outpatient" procedures coded as dental.

• "Hospital" Cover: This coverage is applicable when formal admission to a hospital as an "inpatient" for medical treatment becomes necessary.

Outpatient vs. Inpatient Procedures & Insurance

It's important to understand the difference between "outpatient" and "inpatient" procedures for insurance purposes. Private health insurance typically does not cover "outpatient" procedures using medical codes performed in our clinic. In these cases, Medicare rebates are usually available. However, "Extras" cover generally does apply to "outpatient" procedures using dental codes, whether performed in our clinic or a hospital outpatient department. This means procedures like tooth extractions and implants may be eligible for "Extras" rebates.

Hospital vs Clinic Fees

When considering where to have your procedure, it’s important to understand the cost implications of clinic versus hospital settings. Certain procedures at VMS, such as some bone grafting and sinus lifts, may be suitable for our clinic. However, if these clinic-based procedures are coded medically, it's crucial to remember that only Medicare rebates will likely apply; private health insurance generally won't provide any rebates for these "outpatient" medical procedures in a clinic. Conversely, for procedures requiring a hospital setting, it's often surprising to learn that hospital-based treatment can actually be more financially advantageous. This is because private health insurance rebate structures are designed to offer significantly higher rebates for hospital treatments, especially when general anaesthesia is used. Due to these enhanced hospital rebates, VMS may offer reduced professional fees for procedures performed in a hospital compared to our clinic. This is because the larger insurance rebates in hospitals can help offset costs. This system is partly designed to encourage more complex medical treatments to be carried out in the comprehensive and well-resourced environment of a hospital. Therefore, while you might expect clinic procedures to be less expensive, undergoing your procedure in a hospital may, in some instances, be a more financially viable option due to the increased overall insurance benefits and potentially lower surgeon's fees in that setting.

Simplified Summary

• Dental Code Procedures (Tooth Extraction, Implants): "Extras" cover may assist, in both clinic and hospital settings.

• Medical Code Procedures (Jaw Surgery, Bone Grafting, Sinus Lifts):

  • Clinic Setting: Medicare rebates only, no private health insurance rebate

  • Hospital Setting: "Hospital" cover may provide significant rebates through private health insurance

At VMS, we are here to support you in understanding your financial aspects of care. Please discuss these details with your surgeon and our staff during your consultation. However, remember to confirm your private health insurance coverage directly with your insurer.