Payment Provisions for Dental Services as Finalized in the Calendar Year (CY) 2023 Physician Fee Schedule (PFS) Final Rule

Published 06/08/2023

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 by Medicare. 

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
In the CY 2023 PFS Final Rule, CMS finalized the following provisions related to dental services: 

  • Effective for CY 2023, a clarification and codification of certain aspects of the current Medicare FFS payment policies for dental services when that service is an integral part of specific treatment of a beneficiary's primary medical condition 
  • Effective for CY 2023, Medicare Parts A and B payment for dental services, such as dental examinations, including necessary treatment, performed as part of a comprehensive workup prior to organ transplant, or prior to a cardiac valve replacement or valvuloplasty procedures 
  • Effective for CY 2024, Medicare Parts A and B payment for dental services, such as dental examinations, including necessary treatments, performed as part of a comprehensive workup prior to the treatment for head and neck cancers
  • Effective for CY 2023, a process to identify for CMS’s consideration and review submissions of additional dental services that are inextricably linked and substantially related and integral to the clinical success of other covered medical services

Also, effective for CY 2023, payment can be made under Medicare Parts A and B for covered  dental services that occur within the inpatient hospital and outpatient setting, as clinically appropriate.

Changes effective for CY 2023 are effective for claims with dates of service on and after January 1, 2023. 

Under this finalized policy, payment may be made under Medicare Parts A and B for dental services that are inextricably linked to, and substantially related and integral to the clinical success of, a certain covered medical service. Payment may be made under Medicare Parts A and B for 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 as a result 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

Inextricably Linked
There are instances where dental services are so integral to other medically necessary services that they are inextricably linked to the clinical success of that medical service(s), and, as such, they are not 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. Rather, these dental services are inextricably linked to the clinical success of an otherwise covered medical service, and are payable under Medicare Parts A and B.

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. 

This integration could take the form of a referral or other exchange of information between the physicians, non-physician practitioners, or other practitioners involved in the delivery of dental and other covered medical services.

This coordination should occur between the health care professionals furnishing the dental and other covered services regardless of whether both individuals are affiliated with or employed by the same entity. 

If there is no exchange of information, or integration, between the health care professionals regarding the dental services, then there would not be an inextricable link between the dental and covered medical services within the meaning of the regulation at § 411.15(i)(3). This is because the professionals would not have the necessary information to decide that the dental service(s) is inextricably linked to a covered medical service, and therefore, not subject to the statutory payment exclusion under section 1862(a)(12) of the Act.

CMS makes payment for covered dental services furnished by a physician, including a doctor of dental medicine, dental surgery, or a non-physician practitioner in accordance with state law and scope of practice in the state where the service is furnished. 

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.

Dental services inextricably linked to a non-covered medical service(s) are not covered or payable. No payment is made for dental services that may be inextricably linked to, and substantially related and integral to the clinical success of other non-covered services. Such services remain subject to the statutory exclusion at § 1862(a)(12) for items and services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth. 

CMS provides additional details and guidance in the CMS Internet Only Manual (IOM), Publication 100-2, Chapter 15 (PDF), Section 150 – Dental Services.  

Enrolling into the Medicare Program
If not already enrolled with Medicare, dentists and other individual practitioners must enroll with their jurisdictional Medicare Administrative Contractor (MAC) 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. 

Requesting a Railroad Medicare Provider Transaction Access Number (PTAN) 
Once a dentist or other individual practitioner is enrolled with Medicare, the provider is eligible to provide care for Railroad Medicare patients. If enrolled as a Part B Medicare provider, you will need to request and receive an Railroad Medicare PTAN before we can process your Part B claims. Part A claims are submitted to and processed by the Jurisdictional MACs. You will not need a Railroad Medicare PTAN if the dental services you provide are billed to Part A.  

There are no CMS-855 enrollment forms required for Railroad Medicare. To verify if you have a Railroad Medicare PTAN number and then to request a new PTAN if you do not have one, you will simply use our online Railroad Medicare PTAN Lookup and Request Tool. 

When you request a Railroad Medicare PTAN, Palmetto GBA verifies the enrollment information on file with your Part B MAC and creates a corresponding Railroad Medicare enrollment file. The effective date of your Railroad Medicare PTAN will be retroactive to the effective date of your Part B Medicare PTAN. 

For complete instructions, please see the following Railroad Medicare Provider Enrollment resources:

Billing Claims to Medicare
Part B claims for dental services can be billed to Palmetto GBA Railroad Medicare electronically on ANSI 837P claims or on CMS-1500 claim forms, if the provider meets an exception to mandatory electronic billing. See our Claims page for instructions on submitting electronic and paper claims. 

Electronic Claim Billing
Before submitting claims electronically to Railroad Medicare, providers need to complete Electronic Data Interchange (EDI) enrollment with Palmetto GBA Railroad Medicare. Please do not submit EDI enrollment before completing provider enrollment and receiving a Railroad Medicare PTAN. You can find links and instructions for EDI enrollment options on our Electronic Data Interchange (EDI) pages. 

Submitting a Claim for Denial 
When a Medicare claim denial is needed to bill a third-party payer for a statutorily non-covered dental service, append an appropriate HCPCS modifier to the service claim line. Use HCPCS modifier GY to indicate a service is statutorily excluded or does not meet the definition of any Medicare benefit. A voluntary Advanced Beneficiary Notice of Non-coverage (ABN), Form CMS-R-131, may be obtained but is not required for statutorily non-covered services. A provider must be enrolled in Medicare and have a Railroad Medicare PTAN to submit a Part B claim for denial purpose. 

Medical Review
Submitting dental claims is a certification that the dental service is inextricably linked to a Medicare covered medical service as specified under §411.15(i), and could be subject to normal post-pay review in accordance with Medicare policies. Information about the Railroad Medicare Medical Review program can be found in our Medical Review resources. 

Any additional guidance regarding the medical review of dental claims will be developed in the future by CMS and/or Palmetto GBA.

Resources


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