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June 8, 2023

Medicare Dental Service Coverage Update

Calendar Year (CY) 2023 Medicare Physician Fee Schedule (PFS) Final Rule

Medicare coverage of dental services is very restrictive except under limited circumstances as described in the Social Security Act Section 1862(a)(12)External website. The CY 2023 PFS Final RuleExternal website, published in November 2022, defines new dental service coverage expansions and outlines changes to Medicare payment and policies for certain dental services. The final rule provides clarification of medically necessary dental services covered under Medicare Part A or Part B and lists new scenarios where payment can be made for dental services.

Statutory Dental Exclusion

Section 1862(a)(12) of the Social Security Act generally precludes payment under Medicare Part A or Part B for any expenses incurred for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth.

Example scenarios:

  • Reconstruction of a ridge performed primarily to prepare the mouth for dentures
  • Cometic procedures such as veneers or dental implants
  • Oral surgery or tooth extraction
  • Oral exams or teeth cleaning

Medicare Payment Exception

However, payment is permitted for inpatient hospital services in connection with the provision of such dental services (care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth) if the individual’s underlying medical condition/clinical status and severity of the dental procedure, requires hospitalization to perform the services. These circumstances exist when a dental service is an integral part of specific treatment of a beneficiary's primary medical condition.

Example scenarios:

  • Reconstruction of the jaw following fracture or injury
  • Tooth extractions done in preparation for radiation treatment for cancer involving the jaw
  • Oral exams preceding kidney transplantation

New Clinical Scenarios – Inextricable Linkage

The final rule defines new clinical scenarios for which Medicare Part A or Part B payment can be made for dental services in either the inpatient or outpatient setting (as clinically appropriate) that are inextricably linked to, and substantially related and integral to the clinical success of other certain covered medical services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth.

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
  • Reconstruction of a dental ridge performed as a result of and concurrently with the surgical removal of a tumor
  • 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

Integrated Dental and Medical Services

Medicare Part A or Part B payment for dental services is only permitted when dental and medical services are integrated, meaning medical and dental professionals must coordinate care. 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 Medicare Administrative Contractors (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.

Claim Submission

All dental claims submitted for Medicare Part A or Part B payment provide certification that the dental service is inextricably linked to a Medicare-covered medical service as specified under § 411.15(i)External website. These claims may be subject to normal medical review in accordance with Medicare policies. The Centers for Medicare and Medicaid Services (CMS) established a new HCPCS code (G0330) and assigned Ambulatory Payment Classification (APC) 5871 (Dental Procedures). HCPCS code G0330 describes dental rehabilitation services that require monitored anesthesia and the use of an operating room (OR) and can be used to bill for covered services furnished to patients with special health needs that require general anesthesia in an OR to receive dental care. The existing unlisted CPT code 41899 should be used to bill for covered, non-surgical dental services, or surgical dental services not performed under monitored anesthesia in an OR, not otherwise described by existing dental codes already assigned to an APC. Medicare coverage requirements for dental services (as finalized in the CY 2023 PFS Final RuleExternal website ) must be met when billing dental services. When a Medicare claim denial is required so third-party payers can pay as primary, continue to submit claims with the appropriate HCPCS modifiers as usual. Using the modifier serves as certification that the provider believes Medicare should not pay the claim.

Advance Beneficiary Notice of Noncoverage (ABN)

The ABN processExternal website for this payment policy is consistent with the process that applies to any other Medicare payment policy. Report the appropriate ABN modifier (i.e., mandatory, voluntary, etc.) on the claim when applicable.

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