Dental

The Utilization of the KX Modifier on Dental Claims

National Government Services wants to bring to your attention the usage of the KX modifier for the submission of Medicare claims for dental services that are inextricably linked to covered medical services under the Medicare Physician Fee Schedule.

In general, the KX modifier is submitted on a Medicare Part B claim to indicate that the service or item is medically necessary, and the provider has included appropriate documentation in the medical record to support or justify the medical necessity of the service or item. For example, dental extractions needed before an aortic valve replacement. 

When a physician, including a dentist, believes they possess information to support the dental service(s) performed are inextricably linked to a covered medical service that demonstrates adherence to the requirements and, coordination of care between the medical and dental practitioners occurred and met the criteria of the payment policy, the provider may include the KX modifier on the claim in order to expedite determination of inextricable linkage determinations on their 837D or 837P claims. 

Note: The KX modifier is appended to the procedure code when billing the service to Medicare.

Providers are encouraged (but not currently required) to include modifier KX on dental claims.

However, claims received on or after 7/1/2025, will require the KX modifier (per line item) to indicate that a provider believes that the dental service performed is medically necessary, that the provider has included appropriate documentation in the medical record to support the inextricable link to a covered primary medical service, and that coordination of care between the medical and dental practitioners has occurred.

Beginning on 7/1/2025, MACs may deny dental claims that do not contain modifier KX as statutorily noncovered. These claims may be appealed.

Please note: the KX modifier cannot be added via a telephone reopening. 

Inextricably Linked Services

Inextricably linked services require an integrated and coordinated level of care to ensure the dental services are an integral part of the Medicare covered primary procedure or service. Integrated and coordinated care requires:

  • Exchange of information (or referral) between the medical professional (physician or other nonphysician practitioner) and the dentist regarding the need for dental services to support the primary medical service(s)

Payment under Medicare Parts A and B is only permitted for dental services that are inextricably linked to, and substantially related and integral to the clinical success of, a certain covered medical service. Payment may be made under Medicare Parts A and B for services furnished in the inpatient or outpatient setting. 

The rule also states Medicare payment may be made for ancillary services performed in the inpatient or outpatient setting that are critical to the success of dental services, such as diagnostic X-rays, administration of anesthesia, use of an operating room and other related procedures. 

For services that are not included on the fee schedule, the final rule will allow MACs to determine the amount to be paid. 

MACs will also determine on a claim-by-claim basis whether a patient's circumstances do or do not fit within the terms of the preclusion and exception specified in section 1862(a)(12) of the Act, § 411.15(i), and in accordance with the CMS manual provisions.

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.

Example scenarios (effective 2023):

  • Dental exams and necessary treatments performed as part of a comprehensive workup prior to organ transplants, cardiac valve replacements and valvuloplasty procedures.
    •     Including medically necessary diagnostic/treatment services to eliminate an oral or dental infection prior to or occurring with the above procedures.
  • Stabilization/immobilization of teeth in connection with the reduction of a jaw fracture, and dental splints only in conjunction with covered treatment of a medical condition such as dislocated jaw joints.
  • The extraction of teeth to prepare the jaw for radiation treatment of neoplastic disease.

Example scenarios (effective 2024):

  • Dental exams and necessary treatments performed as part of a comprehensive workup prior to or at the same time as Medicare-covered treatments for head and neck cancer.

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Posted 11/4/2024