Dental

Dental Services

If you're a new or seasoned provider billing dental services to Fee-for-Service Medicare or Original Medicare, this article guides you through recently clarified payment provisions for dental services in 2023, the provider enrollment process and how to bill and document your claims.

2023 provisions related to dental services:

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What's New? 2023 Provisions Related to Dental Services

Medicare generally precludes payment under Medicare Parts A or B for any expenses incurred for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth. Prior to 2023, there were a limited number of circumstances listed as examples in regulations for when Medicare payment could be made for dental services.

The 2023 PFS Final Rule issued guidance to clarify Medicare should make payment in circumstances where the dental services are so integral to other medically necessary services that they are inextricably linked to the clinical success of that medical service(s). As such, Medicare will provide payment for more types of dental services associated with a broader set of medical services than before 2023.

CMS finalized the following provisions in the final rule related to dental services:

  • Clarification and codification of certain aspects of the current Medicare FFS payment policies for dental services when that service is an integral part of specific treatment of a beneficiary's primary medical condition
  • Medicare Parts A and B payment for dental services, such as dental examinations, including necessary treatment, performed as part of a comprehensive workup prior to organ transplant, or prior to a cardiac valve replacement or valvuloplasty procedures
  • Effective for CY 2024, Medicare Parts A and B payment for dental services, such as dental examinations, including necessary treatments, performed as part of a comprehensive workup prior to the treatment for head and neck cancers
  • A process to identify for CMS’s consideration and review submissions of additional dental services that are inextricably linked and substantially related and integral to the clinical success of other covered medical services

Additionally, effective for CY 2023, payment can be made under Medicare Parts A and B, under the applicable payment system, for such dental services that occur within the inpatient hospital and outpatient setting, as clinically appropriate.

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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 can be made 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. 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

It may not be clinically appropriate to receive the totality of dental services, which are necessary to immediately eradicate an infection that is inextricably linked to the covered medical services, within one visit. As such, Medicare can make payment, for the dental services immediately necessary to eradicate the infection if such services require multiple dental services and if it is clinically advisable for those services to occur over multiple visits prior to medical services such as an organ transplant, cardiac valve replacement, or valvuloplasty procedures.

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Enrolling in Original Medicare

To be eligible to bill and receive direct payment for professional services under Medicare Part B, the medical professional and dentist must be enrolled in Medicare and meet all other requirements for billing under the PFS.

To enroll in the Medicare Program, medical professionals and dentists must complete the CMS-855I application for physicians and nonphysician practitioners. You can conveniently enroll through the Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or submit a paper application to National Government Services.

NGS encourages dentists who have not yet enrolled, to enroll as a Medicare provider. Instructions about the Initial Provider Enrollment Process are available on our website. PECOS is the most efficient way to enroll.

Additional Clarifying Information

Definition of the NPI Type I and 2 profile that is set up in the NPPES (hhs.gov) system:

  • NPI Type 1 is an Individual provider
  • NPI Type 2 is an Organization (clinics/group practices) entity that has a TIN

First time enrolling, understand how you will be billing Medicare to enroll correctly.

  • An individual provider that will be billing as a sole proprietor will need to either enroll on PECOS or submit the CMS-855I and CMS-588. The CMS-460 is optional.
  • An individual provider that will be billing as a sole owner will need to either enroll on PECOS or submit the CMS-855I and CMS-588. The CMS-460 is optional.
  • An individual provider that reassigns benefits to an organization (clinic/group practice) entity, will need to either enroll in PECOS or submit the CMS-855I for the individual Medicare Provider Enrollment but also verify that the organization (clinic/group practice) entity has a Medicare Provider Enrollment that the individual provider will be associated as a reassignment.
  • An organization (clinic/group practice) entity that is owned by more than one individual will need to either enroll in PECOS or submit the CMS-855B and CMS-588, the CMS-460 (optional) and will need to verify the individuals that will be reassigning benefits to the entity are set up with a Medicare Provider Enrollment and submit the CMS-855I to associate each as a reassignment.

More information can be found in the following articles:

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Advanced Beneficiary Notice

The ABN, Form CMS-R-131, is issued by providers (including independent laboratories, home health agencies, and hospices), physicians, practitioners, and suppliers to Original Medicare beneficiaries in situations where Medicare payment is expected to be denied. The ABN is issued to transfer potential financial liability to the Medicare beneficiary in certain instances. Guidelines for issuing the ABN can be found beginning in Section 50 in the CMS Publication. 100-04 Medicare Claims Processing Manual, Chapter 30.

  • Modifier GA: Used when physicians, practitioners, or suppliers want to indicate they expect Medicare will deny a service as not reasonable and necessary, and they do have an ABN signed by the beneficiary on file.
  • Modifier GZ: Used when physicians, practitioners, or suppliers want to indicate they expect Medicare will deny an item or service as not reasonable and necessary, and they do not have an ABN signed by the beneficiary.

Using the modifier serves as certification the provider believes Medicare should not pay the claim. If providers submit the dental claim without one of more of the HCPCS modifiers, they certify the applicable payment policies, and the dental service is inextricably linked to a Medicare covered medical service as described.

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Medical Documentation Requirements

When filing a claim to Medicare for payment, please include all applicable diagnosis codes to the highest level of specificity to establish the medical necessity of the services provided. NGS may issue an ADR. When responding to an ADR, or if you’re using the PWK segment to submit your claim documentation electronically, make sure you include the documentation outlined below:

  • Lab report/results, including laboratory name, test name, and details of test methodology
  • Office notes that support medical necessity, specifically explaining how the test will be used in the treatment and/or management of the patient
  • Patient history and physical
  • Procedure or operative report
  • Progress or office notes
  • Invoice, when applicable
  • Referral information showing the service is inextricably linked to, and substantially related and integral to the clinical success of, a certain covered medical service

We encourage you to review your documentation prior to submission to ensure that all requested documentation is included in your response, and that the medical records are appropriately authenticated. View the MLN® Fact Sheet: Complying with Medicare Signature Requirements to learn more.

Additional Education

To assist you in understanding the Medicare Program, we have a manual on our web site, Medicare Part B 101 Manual, which will provide you with an overview.

The Part B Provider Outreach and Education Team offers regularly scheduled webinars on Introduction to Medicare. You can find this webinar and other training topics in the Schedule of Events section of our website.

Revised 7/8/2024