Skip to Main Content
LICENSES AND NOTICES

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA websiteExternal Website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "I DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

  1. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
  2. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association websiteExternal Website.
  3. Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. Please click here to see all U.S. Government Rights Provisions.
  4. ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT-4 is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT-4. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT-4 and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third-party beneficiary to this Agreement.
  5. CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT-4 should be addressed to the ADA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT-4. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must click below on the button labeled "I DO NOT ACCEPT" and exit from this computer screen.


Impact

Print | Bookmark | Email | Font Size: + |

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
  • Cosmetic 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.

Resources

spacer

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © 2025 CGS Administrators, LLC. All Rights Reserved