- Dental Services
- Dental Services
- Enrolling in Medicare
- Medicare Coverage Exclusion: Dental Services
- Claim Submission Guidelines
- Medical Documentation Requirements
- New Medicare Provider
- Additional Development Request Letters Guide
- Medicare Coverage Exclusion: Dental Services
- Inpatient Services in Connection With Dental Procedures
- The Utilization of the KX Modifier on Dental Claims
- Modifier GY
- Standard Companion Guide Health Care Claim: Dental (837D)
- 837D Edit Spreadsheet
- Dental Claim Cross Over
- Attention Clearinghouses and Vendors!
- Resources
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.
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’ 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.
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.
Reviewed 6/26/2024