Medicare Dental Coverage

Inpatient Hospital Dental Services

Under Section 1862(a)(12) of the Social Security Act and 42 CFR 411.15(i), Medicare doesn’t pay for (also called "payment exclusion") items and services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth ("dental services"), except for inpatient hospital services connected to dental services when the patient requires hospitalization because of 1 of these: 

• The patient’s underlying medical condition and clinical status 
• The severity of the dental procedure 

Dental Services Integral to Medicare Covered Services

The dental services payment exclusion doesn’t apply, and Medicare can pay under Part A and Part B, when dental services are inextricably linked to the clinical success of other Medicare-covered procedures or services.

Examples of dental services that are inextricably linked to, and substantially related and integral to the clinical success of, certain Medicare-covered services could include, but aren’t limited to: 

• Dental or oral exams as part of a comprehensive workup prior to the Medicare-covered services listed below. And, medically necessary diagnostic and treatment services to eliminate an oral or dental infection prior to or contemporaneously with these Medicare-covered services:
  • Organ transplant, including hematopoietic stem cell and bone marrow transplant
  • Cardiac valve replacement
  • Valvuloplasty procedures
  • Chemotherapy, chimeric antigen receptor (CAR) T-cell therapy, and the administration of high-dose bone-modifying agents (antiresorptive therapy) when used to treat cancer
• Dental or oral exams as part of a comprehensive workup prior to, medically necessary diagnostic and treatment services to eliminate an oral or dental infection prior to or contemporaneously with, and medically necessary diagnostic and treatment services to address dental or oral complications after, Medicare-covered treatment of head and neck cancer using radiation, chemotherapy, surgery, or any combination of these.
• Dental ridge reconstruction done as a result of and at the same time as surgery to remove a tumor.
• Services to stabilize or immobilize teeth related to reducing a jaw fracture.
• Dental splints, only when used as part of covered treatment of a covered medical condition such as dislocated jaw joints.

Medicare payment can also be made under Part A and Part B for ancillary services and supplies incident to the covered dental services, like:

• Administering anesthesia
• Diagnostic x-rays
• Operating room use
• Other related procedures

Medicare doesn’t cover items and services for the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth. Structures directly supporting the teeth are the periodontium, which includes: 

• Gingivae
• Dentogingival junction
• Periodontal membrane
• Cementum
• Alveolar bone (alveolar process and tooth sockets)

Examples of non-covered dental services include, but aren’t limited to:

• Routine dental care (services for the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth)
• Extraction of an impacted tooth
• Dental services, when performed in connection with excluded services, like to prepare the mouth for dentures, including:
  • Alveoplasty (surgical improvement of the shape and condition of the alveolar process)
  • Dental ridge reconstruction
  • Frenectomy
  • Removing the torus palatinus (a bony growth on the roof of the mouth)
• Dental services related to other non-covered services

Some dental services are so integral to other medically necessary services that the clinical success of the service is dependent upon or inextricably linked to the dental services. We provide some examples above of situations where there would be an inextricable link between dental services and other Medicare-covered services.

For dental services to be inextricably linked to other Medicare-covered services, different providers (like a doctor and a dentist) must coordinate care to provide:

• Medicare-covered services to treat the illness
• Dental services that are integral to the clinical success of the medical service

Without care coordination, health care providers won’t have the information they need to decide whether a dental service is inextricably linked to a Medicare-covered service. If there’s no documented evidence to support the exchange of information, or integration, between the health care providers furnishing the medical services and the dental services, Medicare won’t cover and pay for dental services. Examples of care coordination may include a referral or exchange of information between a medical doctor and a dentist. 

You must document coordination in the medical record. Learn more about collaborating with other providers (PDF), including what to document. 

We pay for multiple visits if it’s clinically necessary for you to provide dental services that are inextricably linked to other Medicare-covered services in more than 1 visit. For example, Medicare may pay for multiple visits for dental services to eliminate a patient’s dental infection before an organ transplant.

Medicare covers dental services provided by:

• Physicians, including a dentist or dental surgeon
• Non-physician practitioner 
• Auxiliary personnel, like a dental technician, dental hygienist, dental therapist, or registered nurse, when:
  • They’re directly supervised by a doctor, dentist, or other practitioner
  • The services meet the requirements for incident to services

Medicare covers dental services provided in inpatient (like a hospital) and outpatient (like a dentist’s office) settings.

You must be a Medicare-enrolled provider to bill and get paid for providing Medicare-covered dental services.  

If you’re not a Medicare-enrolled provider, you can provide services incident to services of a Medicare-enrolled physician or other practitioner. We’ll pay the Medicare-enrolled practitioner who bills for these services. These services must meet: 

• The requirements for incident to services
• The appropriate level of supervision
• State law and scope of practice in the state where you provide the service

To enroll in Medicare, you must be all of these:

• Doctor of Dental Surgery (DDS) or Dental Medicine (DM)
• Legally authorized to practice dental surgery or dental medicine by the State in which you’re providing services
• Acting within the scope of your license when you provide services

Medicare recognizes the following dental specialties for enrollment:

• Dental Anesthesiology
• Dental Public Health
• Endodontics
• Oral and Maxillofacial Surgery
• Oral and Maxillofacial Pathology
• Oral and Maxillofacial Radiology
• Oral Medicine
• Orofacial Pain
• Orthodontics and Dentofacial Orthopedics
• Pediatric Dentistry
• Periodontics
• Prosthodontics

You can enroll now.

1. Pre-Enrollment

• Get an NPI (PDF) if you or your organization don't already have it.
• Become a PECOS registered user. PECOS advantages are:
  • Faster enrollment
  • A tailored application process where you only give information relevant to your application
  • More control over your enrollment information and reassignments
  • Easier access to check and update your information
  • Less staff time and administrative costs to complete and submit enrollment to Medicare
• Identify your Medicare Administrative Contractors (MACs). MACs process enrollment applications and Medicare Fee-for-Service (FFS) claims. MACs also:
  • Pay providers for Medicare FFS claims 
  • Answer providers’ questions
  • Educate providers about Medicare FFS billing requirements

2. Submit Your Provider Enrollment Application(s) to Your MAC(s)

• Choose and complete an electronic or paper application
  • Electronic: Apply online through PECOS. For more information on PECOS (like technical help and FAQs), see Medicare Provider Enrollment. Or, view the PECOS Enrollment Tutorial video.
  • Paper:
    • Use CMS-855B (PDF) for clinics, group practices, and certain other suppliers
    • Use CMS-855I (PDF) for physicians and non-physician practitioners

3. What to Expect After Submitting Your Enrollment Application

• MACs take approximately 45 days to review submitted applications, but it may take longer if you use the paper application.
• Respond quickly to any requests for additional information or documents.
• If approved, your billing effective date is the later of these:
  • The date the MAC got your application
  • The date you begin providing services
• Update changes in your enrollment information in a timely manner.  You must submit most changes within 30 days of the date of the change.

After you get the enrollment approval letter from your MAC. Your MAC will send you a copy of the letter.

Before you bill, you must identify your Electronic Data Interchange (EDI) connectivity contractor for billing. Your MAC’s website has more information.

Use 1 of these claim forms to complete and submit your claim: dental (837D) (PDF), institutional (837I or CMS-1450) (PDF), or professional (837P or CMS-1500) (PDF). 

• Use the appropriate CDT or CPT codes for the services you provide. When you submit a claim for Medicare-covered dental services, you’re certifying that the dental service is inextricably linked to a Medicare-covered medical service.
• For Railroad Retirement Board patients, use the professional (837P or CMS-1500) claim form; don’t use the dental (837D) form.
• Starting July 1, 2024, you may use the KX modifier on the dental (837D) or professional (837P or CMS-1500) claim form. We encourage you to include the KX modifier to indicate: 
  • You’ve included appropriate documentation in the medical record to support the medical necessity of the dental service or item and demonstrate the inextricable link to a Medicare-covered medical service.
  • The medical and dental practitioners coordinated care for the services.
• Starting January 1, 2025, you must submit an ICD-10 code on the dental (837D) claim form.

• If you’re submitting a Medicare claim for a denial so you can get paid by a third-party payer (like Medicaid), include the appropriate HCPCS modifiers. For example, use the GY modifier to:

  • Certify that you believe Medicare shouldn’t pay for the service.
  • Submit statutorily excluded services as non-covered line items on the claim with other covered dental services (like dental services inextricably linked to the clinical success of other Medicare-covered procedures or services).
     

  Note:
  For Medicare claim denials, the dental (837D) claim form accepts the GY modifier. On the professional (837P or CMS-1500) claim form, you can still use the GA, GY, and GZ modifiers for Medicare claim denials. Learn more about when to use these modifiers (PDF).

• Don’t simultaneously submit the same claim to multiple primary payers. 
  • If Medicare pays the claim and there are costs Medicare didn’t cover (like a deductible or coinsurance), you can bill other secondary insurance for the unpaid amounts.
  • If Medicare denies the claim, you may be able to submit the claim to another primary payer (like Medicaid).
• Don’t send attachments, like x-rays or periodontal charting, with your claim. Your MAC will contact you in writing if they need additional information.

Medicare payment rates for covered dental services vary based on where you provide the services. You must be a Medicare-enrolled provider to bill and get paid for providing Medicare-covered dental services. 

Inpatient setting

For covered dental services performed in a Hospital Outpatient Department (HOPD) or Ambulatory Surgery Center (ASC), Medicare pays for both:

• The facility fee component of the service in the amount listed in the OPPS/ASC addenda 
• The professional fee/service to the practitioner under the Physician Fee Schedule (PFS)

Medicare updates the HOPD and the ASC payment rates annually. 

For covered dental services performed in an HOPD, visit OPPS Addendum A and Addendum B Updates, and find the latest Addendum B for OPPS payment rates (which includes payment rates for individual CDT and CPT codes). 

For covered dental services performed in an ASC, Medicare only pays for surgical services that are:

• Included on the ASC Covered Procedures List (CPL) 
• Covered ancillary services integral to services on the ASC CPL

Visit ASC Payment Rates – Addenda for the latest:

• ASC CPL 
• List of ASC-covered ancillary services integral to covered surgical services and their payment rates 

Outpatient setting

For covered dental services performed in the dentist’s office, Medicare pays for the professional fee/service to the practitioner under the PFS. The MAC sets the payment rates for dental services paid under the PFS.

• CR 13181 (PDF)
• CR 13190 (PDF)
• CR13649 (PDF)
• CY 2023 Physician Fee Schedule Final rule
• CY 2024 Physician Fee Schedule Final rule
• LCD A59543 Billing & Coding: Dental Services
• LCD A59447 Billing & Coding: Dental Services
• LCD A59450 Billing & Coding: Dental Services
• LCD A59449 Billing & Coding: Dental Services
• Medicaid Dental Benefits
• Physician Fee Schedule