Purpose: The information in this article contains billing, coding or other guidelines that support the implementation of the CY 2023 Medicare Physician Fee Schedule Final Rule on Dental Services.
Title XVIII of the Social Security Act, §1862(a)(12) states no payment may be made for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth, except that payment may be made for inpatient hospital services because of underlying medical condition and clinical status or because of the severity of the dental procedure, requires hospitalization in connection with the provision of such services.
Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
42 CFR Part 411.15(i) states no payment may be made for dental services in connection with care, treatment filling, removal, or replacement of teeth, or structures directly supporting teeth, except for inpatient services in connection with dental procedures when hospitalization is required because of an underlying medical condition and clinical status or the severity of the dental procedures.
Accordingly, dental services that are inextricably linked to, and substantially related and integral to the clinical success of, a certain covered medical service are not excluded; payment may be made under Medicare Parts A and B for such services furnished in the inpatient or outpatient setting. Such services include, but are not limited to:
- Dental or oral examination performed as part of a comprehensive workup in either the inpatient or outpatient setting prior to Medicare-covered organ transplant, cardiac valve replacement, or valvuloplasty procedures; and medically necessary diagnostic and treatment services to eliminate an oral or dental infection prior to, or contemporaneously with, the organ transplant, cardiac valve replacement, or valvuloplasty procedure.
- The reconstruction of a dental ridge performed because of and at the same time as the surgical removal of a tumor.
- The stabilization or immobilization of teeth in connection with the reduction of a jaw fracture, and dental splints only when used in conjunction with covered treatment of a covered medical condition such as dislocated jaw joints.
- The extraction of teeth to prepare the jaw for radiation treatment of neoplastic disease.
Ancillary services and supplies furnished incident to covered dental services are not excluded, and Medicare payment may be made under Part A or Part B, as applicable, whether the service is performed in the inpatient or outpatient setting, including, but not limited to the administration of anesthesia, diagnostic x-rays, use of operating room, and other related procedures.
Medicare payment may also be made for services furnished incident to the professional medical or “inextricably linked” dental services by auxiliary personnel, such as a dental hygienist, dental therapist, or registered nurse who is under the direct supervision of the furnishing dentist or other physician or practitioner, if they meet the requirements for “incident to” services as described in 42 Code of Federal Regulations (CFR) §410.26.
Definitions
Ancillary Services: For the purposes of payment under this Billing and Coding article, “ancillary services” are services that include, but are not limited to, x-rays, administration of anesthesia, and the use of the operating room, and other related procedures.
Dental Services: For the purposes of payment under this Billing and Coding article, “dental services” refer to dental and oral examinations and medically necessary diagnostic and treatment services, such as, but not limited to, the elimination of an oral or dental infection.
Dentist: For the purposes of payment under this Billing and Coding article, a “dentist” refers to a Doctor of Dental Medicine or Dental Surgery, who is legally authorized to practice dentistry in the state or territory within which they perform such function, and who is acting within the scope of their license.
Inextricable Linkage: For the purposes of payment under this Billing and Coding article, for a dental service to be considered “inextricably linked” to a covered primary medical procedure/service, evidence-based literature and/or clinical standard of care must be demonstrated such that the provision of these dental services PRIOR TO a primary covered medical procedure/service if not performed would result in a material difference in terms of clinical outcomes and success of the medical procedure/service.
Claim Submission Guidance
Medicare payment for dental services is generally precluded by statute. Please refer to Title XVIII of the Social Security Act, §1862(a)(12) for non-covered services that are part of the dental exclusion. However, Medicare has paid for dental services in a limited number of circumstances, when that service is an integral part of a specific treatment of a beneficiary’s primary medical condition.
For dates of service January 1, 2023, and after, Medicare may pay for additional dental services that are “inextricably linked” to, and substantially related and integral to the clinical success of an otherwise covered medical service, such as dental exams and necessary treatments to eradicate dental infection prior to, or contemporaneously with, organ and hematopoietic stem cell transplants, cardiac valve replacements, and valvuloplasty procedures. If it is not clinically appropriate to eradicate an infection within 1 visit prior to the planned medical service, Medicare can make payment over multiple visits.
To be eligible to bill and receive direct payment for professional services under Medicare Part B, the medical professional and dentist would need to be enrolled in Medicare and meet all other requirements for billing under the Physician Fee Schedule. The initial provider enrollment process can be found at Jurisdiction 6 - Provider Enrollment or Jurisdiction K - Provider Enrollment.
Until such time that National Government Services can accept the American Dental Association (ADA) Dental Claim form or the 837D electronically, please submit professional claims electronically on the X12 Health Care Claim: Professional (837P).
For efficient claims processing, the following information should be submitted:
- The name and NPI number of the medical physician treating the covered medical condition/planned procedure.
- The medical condition or surgical procedure linked to the dental services provided, and the estimated date of the planned procedure, if applicable.
- The accompanying documentation should be provided to support or refute the link between certain medical and dental services and provide the medical rational with supporting documentation regarding why the medical services should be further considered as not subject to the general preclusion on payment for dental services.
- ICD-10 Diagnosis code(s) in the primary and secondary positions related to the dental service(s) provided.
- ICD-10 Diagnosis code(s) in the secondary positions related to the planned medical condition or surgical procedure that is considered “inextricably linked.”
- ICD-10 Diagnosis code Z01.818 should be included to notify us when the patient needs the dental service to eradicate dental infection prior to, or contemporaneously with, a covered cardiac valve surgical procedure.
- ICD-10 Diagnosis code Z76.82 should be included when the patient needs dental services to eradicate dental infection prior to, or contemporaneously with, organ or hematopoietic stem cell transplants.
When selecting the procedure or service that accurately identifies the service performed, dentists should use the most accurate code. If the current dental terminology (CDT) code more accurately identifies the service, this should be used rather than the current procedural terminology (CPT) codes. In instances where there are overlapping CDT codes to describe durable medical equipment (DME) and supplies, Medicare will make payment from the Medicare Durable Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS) fee schedule. If the item or supply is not on the list of codes payable by the Part B MAC, it would need to be billed to the DME MAC. To learn more about these DMEPOS coding policies please visit the NGS web page for Durable Medical Equipment, Prosthetics, Orthotics and Supplies.
If a dentist wants to submit a claim to produce a denial so that Medicaid or another third-party payer can make primary payment, the dentist may submit a claim with the appropriate healthcare common procedure coding system (HCPCS) modifier so that Medicare does not pay the claim. To learn more about the specific modifiers, visit National Government Services website page for ABN Modifiers.
Documentation Guidance
We expect accompanying documentation to be provided. Medicare payment may be made when the medical evidence supports or refutes whether the provision of certain dental services submitted by a dentist are considered “inextricably linked” to and substantially related, and integral to the clinical success of an otherwise covered primary procedure or service provided by another physician or non-physician practitioner, treating the primary medical illness. If there is no exchange of information or integration between the medical professional regarding the primary medical service, and the dentist regarding the dental services, then there would not be an inextricable link between the dental and covered medical services within the Centers for Medicare and Medicaid Services (CMS) regulation 42 CFR Part 411.15(i)(3).
Without the integration between the medical and dental professionals, the dental services would not be covered under the Medicare Part B benefit as stated in Title XVIII of the Social Security Act, §1862(a)(12) since they would be in connection with care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Integration between the medical and dental professionals can occur when these professionals coordinate care. This level of coordination includes, but is not limited to, a referral or exchange of information between the medical professional and the dentist. The medical record should retain documentation that this integration has occurred. Examples of integration or coordination include, but are not limited to, a notation in the medical record that a conversation between the medical professional and dentist has occurred detailing the need for dental services prior to the planned medical procedure, a copy of a written consultation between the 2 providers, or a copy of written correspondence between the 2 providers.
While submission of a claim containing dental services is considered a certification by the provider of compliance with applicable payment policies and could be subject to normal post-pay review in accordance with Medicare policies, there may be instances when National Government Services will request documentation from the dentists to demonstrate that dental services rendered were “inextricably linked” to a covered medical service before payment is made.
1. That documentation might include:
Complete, periodic, or limited dental exam
Consultation and coordination between the dentist and another medical professional treating the primary medical illness
Evaluations at other locations than the service billed
Type of anesthesia
Unusual events occurring during the anesthetic monitoring period
Total time under anesthesia
Medications provided to the patient including the dosage and time of administration
Pain management prescribed post procedure
Type of x-ray or other imaging
Results of x-ray or other imaging
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- Testing or diagnostic service
Documentation of tooth (teeth) treated
Use standard identification of teeth approved by the ADA and CMS – alpha designation for primary teeth, numeric for permanent teeth
Tooth surface treated if appropriate
Missing teeth documented in permanent record
Treatment of caries
Endodontic procedures
Prosthetic services
Preventive services
Treatment of lesions and dental disease
2. Literature to aid National Government Services in conducting a thorough review
3. Clinical evidence containing supporting documentation to justify the inclusion of the proposed medical clinical scenario requiring dental services to support that certain dental services would result in significant improvements in clinical, quality and safety outcomes related to the covered medical condition/procedure.
4. Other supporting documentation to justify the inclusion of the proposed medical clinical scenario requiring dental services.
Dental records should be legible and signed with the appropriate name and title of the provider of the service.
If a dentist believes that Medicare will deny some or all the services or items because of medical necessity or an “inextricable link” may not be present, an Advance Beneficiary Notice of Noncoverage (ABN) should be issued in writing to the Medicare beneficiary. The ABN is optional when Medicare never covers a service, for example, a benefit category denial, but should be used if Medicare does cover the service for some diagnoses, but the dentist believes it will not be covered for a particular situation. To learn more about the ABN process, visit National Government Services website page for Limitation of Liability (Advance Beneficiary Notice).
This billing and coding article is not to be construed nor imply coverage of dental screening services, dental prophylaxis, treatment of simple dental caries, routine tooth extractions, dental prosthetics/splints/dentures/oral appliances, nor definitive reconstruction or restoration of dental structures because of the removal of identified infection and/or the source.
The expansion of potentially payable dental services does NOT apply to dental services performed AFTER the respective “inextricably linked” medical procedure/service. When an excluded service is the primary procedure involved, it is not covered regardless of its complexity or difficulty. The hospitalization or non-hospitalization of a patient has no direct bearing on the coverage or exclusion of a given dental procedure. Should the dental services provided fail to demonstrate inextricable linkage and thus fall under the Medicare Dental Exclusion, the claim may be denied as a benefit category denial subject to beneficiary liability.
