Last Modified: 6/21/2024
Location: FL, PR, USVI
Business: Part A, Part B
If you’re a new or seasoned provider billing dental services to Fee-For-Service (FFS) Medicare, or Original Medicare, this article guides you through recently clarified payment provisions for dental services in 2023, the provider enrollment process, as well as how to bill and document your claims.
2023 provisions related to dental services:
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 Physician Fee Schedule (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.
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 non-physician 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.
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.
Alternatively, a dentist not enrolled in Medicare could perform services incident-to the professional services of a Medicare enrolled physician. In that case, the services must meet the requirements for incident-to services. If you are considering incident-to billing, please see our
incident-to FAQs and use the
incident-to tool to help verify if your billing situation meets incident-to guidelines.
Claim submission guidelines CMS developed and transmitted HCPCS and PFS payment and coding files to include revisions to add other Current Dental Terminology (CDT) codes and indicated parameters for payment to implement the finalized Medicare Parts A and B payment for dental services provisions of the 2023 PFS Final Rule. Medical and dental providers should bill using CDT or CPT codes where applicable and must submit claims using the professional (Part B CMS-1500 claim form) or institutional claim forms (Part A CMS-UB04 claim form) or electronic equivalents.
Currently, First Coast is not able to accept the CDT dental claim form or its electronic equivalent. Please submit your paper dental claims using the CMS-1500 for Part B or the CMS-1450 (UB-04) for Part A or submit them electronically. We have resources available to assist you in identifying the claim form fields and understanding how to properly bill.
First Coast claim resources:
• Part B paper claims:
• Interactive CMS-1500 form tutorial: This interactive tool provides the basic guidelines for completing the data element requirements for the CMS-1500 (02/12) claim form.
• Part A paper claims:
• Electronic claim submissions:
• To submit claims via Electronic Data Interchange (EDI), you must complete one of the EDI forms to connect directly to First Coast or register for SPOT, our free web-based application which provides access to an abundance of Medicare data.
• Electronic services – getting started: This webpage provides links to the instructions and resources providers and third-party entities need to enroll for direct electronic billing with First Coast.
• EDI forms: This webpage offers links to forms providers need to bill electronic dental claims.
• SPOT: This webpage provides a link to register for SPOT and the necessary enrollment forms and instructions.
Here’s a few tips to facilitate prompt and accurate claims processing:
• Submit ICD-10 diagnosis code(s) to the highest level of specificity in the primary and secondary positions related to the dental service(s) provided
• Submit ICD-10 diagnosis code(s) to the highest level of specificity in the secondary positions related to the planned medical condition or surgical procedure that is considered “inextricably linked”
Both Medicare beneficiaries and providers have certain rights and protections related to financial liability and appeals under Original Medicare and the Medicare Advantage (MA) Programs. These financial liability and appeal rights and protections are communicated to beneficiaries through notices given by providers.
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 Pub. 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.
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. First Coast may issue an
additional documentation request (ADR). When responding to an ADR, or if you’re using the paperwork segment (PWK) 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
First Coast encourages 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. Learn more about
Medicare’s signature requirements.
• CMS IOM Pub. 100-02
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.
, our Provider Enrollment Gateway, or submit a paper application. First Coast offers several resources and articles to help you with completing the application.
