Dental - JE Part A
Dental services for the majority are not covered by Medicare. Items and services in connection with the care, treatment, filling, removal, or replacement of teeth, or structures directly supporting the teeth are not covered. These structures are defined as those directly supporting the teeth meaning the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum, and alveolar process.
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 one visit prior to the planned medical service, Medicare can make payment over multiple visits.
Access the below dental related information from this page.
- Dental Splints
- Temporomandibular Joint (TMJ) Syndrome Treatment
- Oral Devices
The hospitalization or nonhospitalization of a patient has no direct bearing on the coverage or exclusion of a given dental procedure.
When an excluded service is the primary procedure involved, it is not covered regardless of its complexity or difficulty. For example, the extraction of an impacted tooth is not covered. Similarly, an alveoplasty (the surgical improvement of the shape and condition of the alveolar process) and a frenectomy are excluded from coverage when either of these procedures is performed in conjunction with an excluded service, such as the preparation of the mouth for dentures.
Similarly, the removal of the torus palatinus (a bony protuberance of the hard palate) could be a covered service. However, with rare exception, this surgery is performed in conjunction with an excluded service, as the preparation of the mouth for dentures. Under such circumstances, reimbursement is not made for this purpose.
Payment may be made for other certain services of a dentist. The following are examples of possible coverage situations listed by CMS in the Internet-Only Manual (IOM) Publication 100-02, Chapter 15, Section 150 - Dental Services:
Example 1 - 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.
Example 2 - The reconstruction of a ridge performed primarily to prepare the mouth for dentures is a noncovered procedure. However, when the reconstruction of a ridge is performed as a result of and at the same time as the surgical removal of a tumor (for other than dental purposes), the entirety of the surgical procedures is a covered service.
Example 3 - Medicare makes payment for the wiring of teeth when this is done in conjunction with the reduction of a jaw fracture. Whether such services as the administration of anesthesia, diagnostic x-rays, and other related procedures are covered depends upon whether the primary procedure being performed by the dentist is covered. Thus, an x-ray taken in conjunction with the reduction of a fracture of the jaw or facial bone is covered. However, a single x-ray or x-ray survey taken in conjunction with the care or treatment of teeth, or the periodontium is not covered.
Example 4 - The extraction of teeth to prepare the jaw for radiation treatments of neoplastic disease is covered. This is an exception to the requirement that to be covered, a noncovered procedure or service performed by a dentist must be incident to and an integral part of a covered procedure or service performed by the dentist. Ordinarily, the dentist extracts the patient's teeth, but another physician, e.g., a radiologist, administers the radiation treatments.
Dental splints used to treat a dental condition are excluded from coverage under 1862(a) (12) of the Act. On the other hand, if the treatment is determined to be a covered medical condition (i.e., dislocated upper/lower jaw joints), then the splint maybe covered.
Whether services such as the administration of anesthesia, diagnostic x-rays, and other related procedures are covered depends upon whether the primary procedure being performed by the dentist is itself covered. Thus, an x-ray taken in conjunction with the care or treatment of teeth or the periodontium is not covered.
Temporomandibular Joint (TMJ) Syndrome Treatment
There are a wide variety of conditions that can be characterized as TMJ, and an equally wide variety of methods for treating these conditions. Many of the procedures fall within the Medicare program's statutory exclusion that prohibits payment for items and services that have not been demonstrated to be reasonable and necessary for the diagnosis and treatment of illness or injury (§1862(a)(1) of the Act). Other services and appliances used to treat TMJ fall within the Medicare program's statutory exclusion at 1862(a) (12), which prohibits payment "for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth...." For these reasons, a diagnosis of TMJ on a claim is insufficient. The actual condition or symptom must be determined.
Noridian has a policy covering oral appliances for Obstructive Sleep Apnea (OSA) which is administered through the Durable Medicare Contract (DME). View the Oral Device Local Coverage Determination (LCD) on the JA or JD DME website.
Current Dental Terminology (CDT) Codes
CDT codes may be billed on UB-04, or CMS-1450; however, codes may deny as routine dental service, depending on what is billed, and may require a redetermination to support medical necessity of dental services. Noridian cannot state if it is or is not appropriate to use a D code, or if it would, or would not, be more appropriate to use a CPT/HCPCS code, as Noridian may correct the D-code if it's supported by the medical record to an unlisted CPT code to pay.
Anything pertaining to the dental charges, if now allowed, will be denied. This may differ on a claim-by-claim basis.
Examples - These come from the Office of Inspector General (OIG) March 2017 Medicare Contractors' Payments to Providers for Hospital Outpatient Dental Services Generally did not Comply with Medicare Requirements, March 2017 report and from upheld redeterminations. Not an all-inclusive list.
- Extraction of teeth occurred after radiation treatment began
- Beneficiary with cognitive and/or neurological impairment received dental treatment not in conjunction with a covered service
- Anesthesia alone doesn't substantiate payment from Medicare
- Beneficiary presented with routine dental needs, which are statutorily excluded
- Tooth socket repaired in preparation for dentures
- Tooth extraction in preparation for dentures
- Periodontal osseous surgery when treating gum disease
- Gum repair
- Removing inflamed gums
- Reshaping gums for cosmetic or functional purpose
- Documentation didn't support medical necessity
Dentists, if he/she is an oral surgeon, may bill an Evaluation and Management (E/M) code; however, if a consultation is performed with the beneficiary before services are rendered, this is considered part of the surgery and is not separately billable. Because the dentist is a physician (of dentistry), an order is not needed for the services he/she performs. Dentists who perform maxillofacial and/or oral surgery may enroll as a Medicare physician if he/she chooses, and thus be reimbursed by Medicare for his/her services.
Liability Modifiers - Medicare clearly indicates that routine dental services are not covered. These would be statutorily excluded and therefore would not require the use of an ABN. Unless billing for denial, there would be no need to bill for these services. The service may be billed as patient responsibility, and a voluntary ABN, if desired, may be issued.
Providers are reminded to bill with appropriate liability modifier, such as: GX when a voluntary ABN has been issued; or GY when the service is statutorily excluded or does not meet the definition of any Medicare benefit. If expecting to receive denial for the service not being reasonable or necessary, and an ABN was not issued, the GZ modifier may be billed to make line item provider-liable.
Skilled Nursing Facilities (SNFs)
SNFs are required to provide emergency and routine dental care to their clients, per 42 CFR, Section 483.55; however, they can charge a Medicare resident an additional amount for these services.
- CMS Internet Only Manual (IOM), Publication 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 5 - Definitions, Section 70 - Physician Defined and 70.2 - Dentists
- CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1 - Inpatient Hospital Services, Section 70 - Inpatient Services in Connection with Dental Services
- CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15 - Covered Medical and Other Health Services Section 150 - Dental Services
- CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16 - General Exclusions from Coverage, Section 140 - Dental Services Exclusion