Determining Inextricable Linkage for Dental Services

Do you know what types of evidence is required to demonstrate that a dental service is inextricably linked to a covered medical service? The evidence submitted should include at least one of the following examples to support the linkage between the dental and covered medical services:

1. Evidence to support that the standard of care would be to not proceed with the covered medical procedure until a dental or oral exam is performed to clear the patient of an oral or dental infection; or, in instances where a known oral or dental infection is present, the standard is such that the medical professional would not proceed with the medical service until the patient received the necessary treatment to immediately eradicate the infection. We note that the dental services necessary to immediately eradicate an infection may or may not be the totality of recommended dental services for a given patient; or
    
2. Literature to support that the provision of certain dental services leads to improved healing, improved quality of surgery, or the reduced likelihood of readmission and/or surgical revisions, because an infection has interfered with the integration of the implant and interfered with the implant to the skeletal structure; or
    
3. Evidence that is clinically meaningful and demonstrates that the dental services result in a material difference in terms of the clinical outcomes and success of the medical procedure; or
    
4. Clinical evidence that is compelling to support that certain dental services would result in clinically significant improvements in quality and safety outcomes. For example, fewer revisions, fewer readmissions, more rapid healing, quicker discharge, and/or quicker rehabilitation for the patient.

Examples of literature could include any of the following:

1. Relevant peer-reviewed medical literature and research/studies regarding the medical scenarios requiring medically necessary dental care
    
2. Evidence of clinical guidelines or generally accepted standards of care for the suggested clinical scenario
    
3. Other supporting documentation to justify the inclusion of the proposed medical clinical scenario requiring dental services

Integration and Coordination Between Dental and Medical Professionals

Medicare payment may be made when a dentist furnishes dental services that are an integral part of the covered primary procedure or service furnished by another physician, or nonphysician 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 in regard to the dental services, then there would not be an inextricable link between the dental and covered medical service within the meaning of our regulation at § 411.15(i)(3).

Integration between medical and dental professionals can occur when these professionals coordinate care. This level of coordination can occur in various forms such as, but not limited to, a referral or exchange of information between the medical professional (physician or nonphysician practitioner) and the dentist. This coordination should occur between a dentist and another medical professional regardless of whether both individuals are affiliated with or employed by the same entity. Without both integration between the Medicare enrolled medical and dental professionals, and the inextricable link between the dental and covered medical services, dental services fall outside of the Medicare Part B benefit as they would be in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth within the meaning of section 1862(a)(12) of the Act; though they may be covered by types of supplemental health or dental coverage. This is because the medical and dental professionals would not have the necessary information to decide that the dental service is inextricably linked to a covered medical service, and therefore, not subject to a statutory payment exclusion under section 1862(a)(12) of the Act.

Usage of the KX HCPCS Modifier for Dental Services Inextricably Linked to Covered Medical Services for Medicare Payment

If a physician, including a dentist, believes that they possess information to support that the dental services are inextricably linked to a covered medical service that demonstrates adherence to the requirements of this policy and that coordination of care between the medical and dental practitioners has occurred and have met the criteria of the payment policy, providers may include the KX HCPCS modifier on the claim in order to expedite determination of inextricable linkage determinations by the MACs.

Providers are encouraged (but not currently required) to include the KX HCPCS modifier on the claim to indicate that they believe that the dental service is medically necessary, that the provider has included appropriate documentation in the medical record to support or justify the medical necessity of the service or item and demonstrates the inextricable linkage to covered medical services, and that coordination of care between the medical and dental practitioners has occurred for services with dates of service in CY2024.

Existing Policy and Uses for Modifiers for Denial

Providers should continue to submit claims as normal with Healthcare Common Procedure Coding System (HCPCS) modifiers used to show that the provider believes Medicare should not pay the claim. For claims submitted on the 837d transaction, only the GY HCPCS modifier is allowable per transaction rules.