Dental - JE Part B
The dental exclusion was included as part of the initial Medicare program. In establishing the dental exclusion, Congress did not limit the exclusion to routine dental services, as it did for routine physical checkups or routine foot care, but instead it included a blanket exclusion of dental services.
The Congress has not amended the dental exclusion since 1980 when it made an exception for inpatient hospital services when the dental procedure itself made hospitalization necessary.
CMS has made an exception(s) to the exclusion. Medicare may pay for dental services generally precluded by statute in a limited number of circumstances, when that service is an integral part of a specific treatment of a beneficiary's primary covered 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 one visit prior to the planned medical service, Medicare can make payment over multiple visits.
- Billing and Coding
- Dental Splints
- Temporomandibular Joint (TMJ) Syndrome Treatment
- Oral Devices
To be eligible to bill and receive direct payment for professional services under Medicare Part B, the medical generally precluded by statute. Please refer to Title XVIII of the Social Security Act, Section 1862(a)(12) for non-covered services that are part of the dental exclusion. However 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 our website at provider enrollment.
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 Section 410.26 of our regulations.
Ancillary 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.
Billing and Coding
Dentists have traditionally not been required to report diagnostic codes to substantiate dental procedures and services.
Until such time that Noridian can accept the ADA Dental Claim form or the 837D electronically, please submit professional claims on a CMS 1500 form.
For efficient claims processing, the following information is required:
- Item 17 - The name and NPI number of the medical physician treating the covered inextricably linked medical condition/planned procedure
- Place the qualifier "DN" to the left of the dotted vertical line in Item #17a to identify the physician who referred the patient.
- Item 17b - Enter the referring physician's NPI
- Item 19 - Medical condition or surgical procedure linked to the dental services provided, and the estimated date of the planned procedure, if applicable.
- Item 21 - 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.
- Item 24D - CPT/HCPCs/CDT procedure code(s). When selecting the procedure or service that accurately identifies the service performed, dentists should use the most accurate code. If the CDT code more accurately identifies the service, this should be used rather than the CPT codes.
Noridian Claims Submission page provides information on how to complete the CMS 1500 form
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 two providers, or a copy of written correspondence between the two 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 Medical Review in accordance with Medicare policies, there may be instances when Noridian 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 records should be legible and signed with the appropriate name and title of the provider of the service:
- Complete, periodic, or limited dental exam
- Consultation and coordination between the dentist and another medical professional treating the primary medical illness
- Evaluations at other locations than the service billed
- Type of anesthesia
- Unusual events occurring during the anesthetic monitoring period
- Total time under anesthesia
- Medications provided to the patient including the dosage and time of administration
- Pain management prescribed post procedure
- Type of x-ray or other imaging
- Results of x-ray or other imaging
- Testing or diagnostic service
- Documentation of tooth (teeth) treated
- Use standard identification of teeth approved by the ADA and CMS – alpha designation for primary teeth, numeric for permanent teeth
- Tooth surface treated if appropriate
- Missing teeth documented in permanent record
- Type of treatment
- Treatment of caries
- Endodontic procedures
- Prosthetic services
- Preventive services
- Treatment of lesions and dental disease
Literature to 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 Evidence to 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 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 HCPCS modifier so that Medicare does not pay the claim. To learn more about the specific modifiers, visit our website at modifiers.
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 our website at ABN.
The expansion is not meant to construed nor imply coverage of dental screening services, dental prophylaxis, treatment of simple dental caries, routine tooth extractions, dental prosthetics/splints/dentures/oral appliances, nor definitive reconstruction or restoration of dental structures because of the removal of identified infection and/or the source. Nor does the expansion of potentially payable dental services apply to dental services performed AFTER the respective "inextricably linked" medical procedure/service. When an excluded service is the primary procedure involved, it is not covered regardless of its complexity or difficulty.
The hospitalization or non-hospitalization of a patient has no direct bearing on the coverage or exclusion of a given dental procedure. Should the dental services provided fail to demonstrate inextricable linkage and thus fall under the Medicare Dental Exclusion, the claim may be denied as a benefit category denial subject to beneficiary liability.
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 (Section 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.
- CMS Internet-Only Manual, Publication 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, Section 10.3 Certification for Hospital Admissions for Dental Services
- CMS IOM, Publication 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, Section 70 Physician Defined and Section 70.2 Dentists
- CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 30 Drugs and Biologicals and Section 70 Inpatient Services in Connection With Dental Services
- CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 120C Dentures and Section 150 Dental Services
- CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 60 - Services and Supplies Furnished Incident To a Physician's/NPP's Professional Service
- CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 140 Dental Services Exclusion
- CMS IOM, Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Section 260.6 Dental Examination Prior to Kidney Transplantation
- CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 188.8.131.52
- Code of Federal Regulations - 42 CFR 411.15(a) and (i)
- Code of Federal Regulations - 42 CFR 440.100
- Code of Federal Regulations - 42 CFR 410.26
- Title XVIII of the Social Security Act, Section 1862(a)(1)(A)
- Title XVIII of the Social Security Act, Section 1862(a)(7)
- Title XVIII of the Social Security Act, Section 1862(a)(12) Dental Services Exclusion
- Title XVIII of the Social Security Act, Section 1833(e)