Dental Services as Finalized in the Calendar Year (CY) 2023 Physician Fee Schedule (MPFS) Final Rule

General Information 

Background
As indicated under the general exclusions from coverage in 42 Code of Federal Regulations (CFR) 411.15(i), and subject to exceptions, items and services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth are not covered.

Two statutory exceptions to this policy allow for Medicare payment for inpatient hospital services in connection with the provision of dental services if the individual, because of the individual’s 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.

There are some other instances where medical services necessary to diagnose and treat the individual’s underlying medical condition may require the performance of certain dental services and the dental exclusion may not apply.

Dental services that are inextricably linked to, and substantially related and integral to the clinical success of, certain covered medical services are not excluded. Such non-excluded dental services could include dental and oral examinations as well as medically necessary diagnostic and treatment services to eliminate an oral or dental infection.

Policy
CMS makes payment for covered dental services furnished by a physician, including a Doctor of Dental Medicine, dental surgery, or a nonphysician practitioner in accordance with state law and scope of practice in the state where the service is furnished.

Integration between the health care professionals furnishing dental and other covered services is a key component in assessing whether dental services are inextricably linked to, and substantially related and integral to the clinical success of, other covered medical services.

Payment may also be made for covered dental services and supplies furnished incident to the professional services of the billing physician or practitioner by auxiliary personnel. For example, services performed by a dental technician, dental hygienist, dental therapist or registered nurse who is under the direct supervision of the physician, including a dentist, are covered if the services meet the requirements for “incident to” services as described in 42 CFR Subsection (§) 410.26.

Ancillary services and supplies furnished incident to covered dental services are also not excluded, and Medicare payment may be made under Part A or Part B, as applicable, regardless of 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, otherwise covered procedures.

CMS provides additional details and guidance in the CMS Internet Only Manual (IOM), Publication 100-2, Chapter 15 (PDF), Section 150. Medicare Benefit Policy Manual. Additional billing guidance will be added as instructed by CMS.

Enrolling into the Medicare Program
If not already enrolled with Medicare, dentists and other individual practitioners must enroll using the CMS 855I form, and all state requirements must be met, (e.g., be licensed by the state licensing board) to enroll in the Medicare Program. Providers that are members of a group must reassign their Medicare benefits to their group by also completing a CMS 855R enrollment form Individual practitioners are not required to pay a fee to enroll in Medicare Part B.

• Become a Medicare Provider or Supplier
• Palmetto GBA: Enrollment Application Finder

Billing Claims to Medicare

Electronic Claim Billing
To bill claims electronically an EDI application must be submitted. To find the application and additional information view the appropriate jurisdiction link below.

• Jurisdiction M Part B - Electronic Data Interchange (EDI)
• Jurisdiction J Part B - Electronic Data Interchange (EDI)

All providers are required to submit claims electronically unless they meet one of the following exceptions:

Exceptions

• Claims submitted by a "small provider" (fewer than 10 full time employees for Part B)
• Roster billing of vaccinations
• Claims submitted to Medicare Demonstration Project
• MSP claims with more than one primary payer
• Claims submitted by Medicare beneficiaries
• Dental claims
• Services furnished outside the United States

Additional guidelines on paper claim waivers can be found withinFee Schedules the Internet Only Manual (IOM) 100-04, Chapter 24 (PDF), Sections 90–90.7 Medicare Claims Processing Manual.

When a Medicare claim denial is needed to bill a third-party payer, the GY HCPCS modifier appended to the services serves as certification that the provider believes Medicare should not pay the service. Additional information regarding the GY HCPCS modifier can be located using the correct jurisdiction link below. A provider must be enrolled in Medicare to submit a claim for denial purpose.

• Jurisdiction J Part B — HCPCS Modifier GY
• Jurisdiction M Part B — HCPCS Modifier GY
• Advanced Beneficiary Notice (ABN) Beneficiary Notices Initiative (BNI) 
• Palmetto GBA has developed a Local Coverage Article A59449 to assist providers in understanding the medical necessity requirements of billing these dental services. Any additional guidance regarding medical review will be developed in the future by CMS and Palmetto GBA.
• CMS provides examples of inextricably linked services in IOM 100-02, Chapter 15 (PDF), Section 150. Medicare Benefit Policy Manual

Fee Schedules