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Using the KX modifier for dental services inextricably linked to covered medical services
Last Modified: 10/28/2024
Location: FL, PR, USVI
Business: Part A, Part B
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.
Beginning July 1, 2024, providers are encouraged (but not currently required) to include the KX modifier on 837D claims submitted with dental services inextricably linked to covered medical services. In general, the KX modifier is submitted on a Medicare Part B claim to indicate that the service or item is medically necessary, and that the provider has included appropriate documentation in the medical record to support or justify the medical necessity of the service or item.
Providers are encouraged to include the KX modifier on the claim to indicate:
• The dental service is medically necessary
• The provider has included appropriate documentation in the medical record to support or justify the medical necessity of the service or item and demonstrates the inextricable linkage to covered medical services, and
• Coordination of care between the medical and dental practitioners has occurred for services with dates of service in 2024
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.
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.
In the CY 2023 and CY 2024 PFS final rules, CMS provided examples where dental and medical services are inextricably linked and codified such examples provided under subsection (§) 411.15(i)(3). These are examples of circumstances where CMS believes there is a clear inextricable link between the dental and medical services, but it is not an exhaustive list of instances where dental and medical services are inextricably linked.
The below information serves as examples of types of evidence that providers may submit to demonstrate that a dental service is inextricably linked to a covered medical service. The evidence submitted should include at least one of the following examples to support the linkage between the dental and covered medical services.
1. Evidence to support that the standard of care would be to not proceed with the covered medical procedure until a dental or oral exam is performed to clear the patient of an oral or dental infection, or, in instances where a known oral or dental infection is present, the standard is such that the medical professional would not proceed with the medical service until the patient received the necessary treatment to immediately eradicate the infection. We note that the dental services necessary to immediately eradicate an infection may or may not be the totality of recommended dental services for a given patient; or
2. Literature to support that the provision of certain dental services leads to improved healing, improved quality of surgery, or the reduced likelihood of readmission and/or surgical revisions, because an infection has interfered with the integration of the implant and interfered with the implant to the skeletal structure; or
3. Evidence that is clinically meaningful and demonstrates that the dental services result in a material difference in terms of the clinical outcomes and success of the medical procedure; or
4. Clinical evidence that is compelling to support that certain dental services would result in clinically significant improvements in quality and safety outcomes, for example, fewer revisions, fewer readmissions, more rapid healing, quicker discharge, and/or quicker rehabilitation for the patient.
Examples of literature could include any of the following: 1) relevant peer-reviewed medical literature and research/studies regarding the medical scenarios requiring medically necessary dental care; 2) evidence of clinical guidelines or generally accepted standards of care for the suggested clinical scenario; and/or (3) other supporting documentation to justify the inclusion of the proposed medical clinical scenario requiring dental services.
Statutorily excluded item or service
Providers should include the GY modifier on claims when the service or item does not meet the definition of a Medicare benefit or if a denial is needed to submit the claim to a secondary insurance. For these claims, bill the KX and the GY modifier on the same claim line for correct processing.
Please read our article on
dental services for more information on claim submission guidelines and medical documentation requirements.
Reference:
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