Article - Billing and Coding: Dental Services (A59449)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Title XVIII of the Social Security Act, 1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Title XVIII of the Social Security Act, 1862(a)(7) excludes routine physical examinations.Title XVIII of the Social Security Act, 1862(a)(12) states no payment may be made for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth, except that payment may be made for inpatient hospital services because of underlying medical condition and clinical status or because of the severity of the dental procedure, requires hospitalization in connection with the provision of such services.42 CFR 410.26 services and supplies incident to a physicians professional services: conditions.42 CFR 411.15(a) routine physical checkups particular services excluded from coverage, and (i) states no payment may be made for dental services in connection with care, treatment filling, removal, or replacement of teeth, or structures directly supporting teeth, except for inpatient services in connection with dental procedures when hospitalization is required because of an underlying medical condition and clinical status or the severity of the dental procedures.42 CFR 440.100 defines dental services.CMS Internet-Only Manual, Pub.100-01, Medicare General Information, Eligibility,and Entitlement Manual, Chapter4, 10.3 Certification for Hospital Admissions for Dental ServicesCMS Internet-Only Manual, Pub.100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter5, 70 Physician Defined and 70.2 DentistsCMS Internet-Only Manual, Pub.100-02, Medicare Benefit Policy Manual, Chapter 1, 30 Drugs and Biologicals and70 Inpatient Services in Connection With Dental ServicesCMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 60 Services and Supplies Furnished Incident To a Physicians/NPPs Professional Service, 120C Dentures and 150 Dental ServicesCMS Internet-Only Manual, Pub.100-02, Medicare Benefit Policy Manual, Chapter 16, 140 Dental Services ExclusionCMS Internet-Only Manual, Pub.100-03, Medicare National Coverage Determinations(NCD)Manual, Chapter 1, Part 4,260.6 Dental Examination Prior toKidneyTransplantationCMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, 3.6.2.2 Reasonable and Necessary CriteriaArticle TextThe information in this article contains billing, coding or other guidelines that support the implementation of the CY 2023 Medicare Physician Fee Schedule Final Rule on Dental Services.In addition, dental services that are inextricably linked to, and substantially related and integral to the clinical success of, a certain covered medical service are not excluded; payment may be made under Medicare Parts A and B for such 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.Ancillary services and supplies furnished incident to covered dental services are not excluded, and Medicare payment may be made under Part A or Part B, as applicable, whether the service is performed in the inpatient or outpatient setting, including, but not limited to the administration of anesthesia, diagnostic x-rays, use of operating room, and other related procedures.Medicare payment may be made for services furnished incident to the professional medical or inextricably linked dental services by auxiliary personnel, such as a dental hygienist, dental therapist, or registered nurse who is under the direct supervision of the furnishing dentist or other physician or practitioner, if they meet the requirements for incident to services as described in 42 Code of Federal Regulations (CFR) 410.26.DefinitionsAncillary Services: For the purposes of payment under this Billing and Coding article, ancillary services are services that include, but are not limited to, x-rays, administration of anesthesia, and the use of the operating room, and other related procedures.Dental Services: For the purposes of payment under this Billing and Coding article, dental services refer to dental and oral examinations and medically necessary diagnostic and treatment services, such as, but not limited to, the elimination of an oral or dental infection.Dentist: For the purposes of payment under this Billing and Coding article, a dentist refers to a Doctor of Dental Medicine or Dental Surgery, who is legally authorized to practice dentistry in the state or territory within which they perform such function, and who is acting within the scope of their license.Inextricable Linkage: For the purposes of payment under this Billing and Coding article, for a dental service to be considered inextricably linked to a covered primary medical procedure/service, evidence-based literature and/or clinical standard of care must be demonstrated such that the provision of these dental services PRIOR TO a primary covered medical procedure/service if not performed would result in a material difference in terms of clinical outcomes and success of the medical procedure/service.Claim Submission GuidanceMedicare payment for dental services is generally precluded by statute. Please refer to Title XVIII of the Social Security Act, 1862(a)(12) for non-covered services that are part of the dental exclusion. However, Medicare has paid for dental services in a limited number of circumstances, when that service is an integral part of a specific treatment of a beneficiarys primary medical condition.For dates of service January 1, 2023, and after, Medicare may pay for additional dental services that are inextricably linked to, and substantially related and integral to the clinical success of an otherwise covered medical service, such as dental exams and necessary treatments to eradicate dental infection prior to, or contemporaneously with, organ and hematopoietic stem cell transplants, cardiac valve replacements, and valvuloplasty procedures. If it is not clinically appropriate to eradicate an infection within 1 visit prior to the planned medical service, Medicare can make payment over multiple visits.To be eligible to bill and receive direct payment for professional services under Medicare Part B, the medical professional and dentist would need to be enrolled in Medicare and meet all other requirements for billing under the Physician Fee Schedule. To learn how to enroll as a Medicare provider, visit the provider enrollment page on this A/B MACs website atJurisdiction J Part B - Provider Enrollment (palmettogba.com)andJurisdiction M Part B - Provider Enrollment (palmettogba.com).Until such time that this A/B MAC can accept the American Dental Association (ADA) Dental Claim form or the 837D electronically, please submit professional claims electronically on the X12 Health Care Claim: Professional (837P).For efficient claims processing, the following information should be submitted:The name and NPI number of the medical physician treating the covered medical condition/planned procedure.The medical condition or surgical procedure linked to the dental services provided, and the estimated date of the planned procedure, if applicable.ICD-10 Diagnosis code(s) in the primary and secondary positions related to the dental service(s) provided.ICD-10 Diagnosis code(s) in the secondary positions related to the planned medical condition or surgical procedure that is considered inextricably linked.ICD-10 Diagnosis code Z01.818 should be included to notify us when the patient needs the dental service to eradicate dental infection prior to, or contemporaneously with, a covered cardiac valve surgical procedure.ICD-10 Diagnosis code Z76.82 should be included when the patient needs dental services to eradicate dental infection prior to, or contemporaneously with, organ or hematopoietic stem cell transplants.When selecting the procedure or service that accurately identifies the service performed, dentists should use the most accurate code. If the current dental terminology (CDT) code more accurately identifies the service, this should be used rather than the current procedural terminology (CPT) codes. In instances where there are overlapping CDT codes to describe durable medical equipment (DME) and supplies, we will make payment from the Medicare Durable Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS) fee schedule. If the item or supply is not on the list of codes payable by the Part B MAC, it would need to be billed to the DME MAC. To learn more about these DMEPOS coding policies please visit this A/B MACs website atJurisdiction M Part B - DMEPOS (palmettogba.com).If a dentist wants to submit a claim to produce a denial so that Medicaid or another third-party payer can make primary payment, the dentist may submit a claim with the appropriate healthcare common procedure coding system (HCPCS) modifier so that Medicare does not pay the claim. To learn more about the specific modifiers, visit this A/B MACs website atJurisdiction M Part B - Modifier Lookup: Your Resource for Correct Claim Submission (palmettogba.com).Documentation GuidanceMedicare payment may be made when a dentist provided dental services that are considered inextricably linked to and substantially related, and integral to the clinical success of an otherwise covered primary procedure or service provided by another physician or non-physician practitioner, treating the primary medical illness. If there is no exchange of information or integration between the medical professional regarding the primary medical service, and the dentist regarding the dental services, then there wouldnotbe an inextricable link between the dental and covered medical services within the Centers for Medicare and Medicaid Services (CMS) regulation 42 CFR Part 411.15(i)(3).Without the integration between the medical and dental professionals, the dental services would not be covered under the Medicare Part B benefit as stated in Title XVIII of the Social Security Act, 1862(a)(12) since they would be in connection with care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Integration between the medical and dental professionals can occur when these professionals coordinate care. This level of coordination includes, but is not limited to, a referral or exchange of information between the medical professional and the dentist. The medical record should retain documentation that this integration has occurred. Examples of integration or coordination include, but are not limited to, a notation in the medical record that a conversation between the medical professional and dentist has occurred detailing the need for dental services prior to the planned medical procedure, a copy of a written consultation between the 2 providers, or a copy of written correspondence between the 2 providers.While submission of a claim containing dental services is considered a certification by the provider of compliance with applicable payment policies and could be subject to normal post-pay review in accordance with Medicare policies, there may be instances when this A/B MAC will request documentation from the dentists to demonstrate that dental services rendered were inextricably linked to a covered medical service before payment is made. That documentation might include:Dental recordsshould be legible and signed with the appropriate name and title of the provider of the service:EvaluationsComplete, periodic, or limited dental examConsultation and coordination between the dentist and another medical professional treating the primary medical illnessEvaluation at other locations than the service billedAnesthesiaType of anesthesiaUnusual events occurring during the anesthetic monitoring periodTotal time under anesthesiaMedications provided to the patient including the dosage and time of administrationPain management prescribed post procedureRadiographsType of x-ray or other imagingResults of x-ray or other imagingTesting or diagnostic serviceDocumentation of tooth (teeth) treatedUse standard identification of teeth approved by the ADA and CMS  alpha designation for primary teeth, numeric for permanent teethTooth surface treated, if appropriateMissing teeth documented in permanent recordType of treatmentTreatment of cariesEndodontic proceduresProsthetic servicesPreventive servicesTreatment of lesions and dental diseaseLiteratureto support that the provision of certain dental services to treat a dental infection leads to improved healing, improved quality of surgery, or the reduced likelihood of readmission and/or surgical revisions. Examples of literature could include relevant peer-reviewed medical and/or dental literature and research studies, or evidence of clinical guidelines or generally accepted standards of care.Clinical evidenceto support that certain dental services would result in significant improvements in clinical, quality and safety outcomes related to the covered medical condition/procedure.If a dentist believes that Medicare will deny some or all the services or items because of medical necessity or an inextricable link may not be present, an Advance Beneficiary Notice of Noncoverage (ABN) should be issued in writing to the Medicare beneficiary. The ABN is optional when Medicare never covers a service, for example, a benefit category denial, but should be used if Medicare does cover the service for some diagnoses, but the dentist believes it will not be covered for a particular situation. To learn more about the ABN process, visit this A/B MACs website atInteractive ABN (palmettogba.com).