Welcome to the blog

The CMS final rule is here effective January 1, 2023 and I want to answer some common questions about how this might affect your practice.

Original Medicare provides benefits for treatment directly related to medical conditions. However, original Medicare has traditionally excluded all dental treatments unless the treatment is directly related to a covered medical condition which is published in the following statement:

Statement of exclusion (Code of Federal Regulations § 411.15 [section i])

“Dental services in connection with the care, treatment, filling, removal, or replacement of teeth, or structures directly supporting the teeth, except for inpatient hospital services in connection with such dental procedures when hospitalization is required because of –

(1) The individual’s underlying medical condition and clinical status; or

(2) The severity of the dental procedures. “

There are exceptions to these exclusions. Medicare has always permitted payment for some medically related procedures.   For example:

• Treatment of fractured jaw, including any tooth necessary tooth extractions
• Extraction of teeth prior to radiation for head or neck cancer
• Dental examinations prior to kidney transplant or cardiac valve replacement

What has changed? 

Effective January 1, 2023, an amendment to this regulation will specify “in order for Medicare payment to be made, the dental services must be inextricably linked to, and substantially related and integral to the clinical success of certain other covered medical services.” 

This re-interpretation of the exclusion exceptions allows dentists to provide patients with much-needed dental care associated with specific surgical procedures.

What will be covered?

Expanded definition of benefits include:

“Dental or oral examinations, including treatment, performed as part of a comprehensive workup prior to organ transplant (including hematopoietic stem cell and bone marrow transplantations) or prior to cardiac valve replacement or valvuloplasty procedures.” The examination and/or treatment may be performed either inpatient or outpatient.

 Before this new ruling, only the examination was covered (no treatment) and must be performed, inpatient. Also, until this revision, only kidney transplant was indicated for coverage—now, all organ transplant types are included.

Treatment is now defined to include the following:

• Extraction of teeth
• Removal of infection, including restorations of tooth structure (i.e., fillings) and periodontal treatment for infection (i.e., scaling and root planing)

Coverage is limited only to treatment immediately required to ensure a successful and safe transplant procedure. Additional services, such as a dental implant, crown, or future hygiene visits, may not be considered immediately necessary and will not be covered. 

It is important to note that with this new ruling, some previous verbiage has been revised. For example, “wiring of teeth” will change to “stabilization.” In addition, it is anticipated that there will be additional verbiage changes, adding clarity for providers.

How does this new coverage rule affect dentists?

Dentists will be providing these covered services to Medicare beneficiaries on a more regular basis than ever before. So, what rules and regulations should a dentist be mindful of?

Covered services are subject to the mandatory filing requirement. The mandatory filing requirement has been in effect since September 1, 1990. There are exceptions to the mandatory filing rule – covered services provided free of charge are not required to be filed. So, you must either file a claim for the patient or provide the service for free.

What reimbursement can I expect? CMS has indicated the rate of reimbursement will be determined by the individual Medicare contractors. 

CMS advises dentists to verify their enrollment status and determine whether any action is necessary. 

Not sure how to determine your enrollment status? There are a couple of ways to determine your enrollment status.

1. Contact your Medicare Administrative Contractor, commonly referred to as a MAC
2. Use this link to access provider enrollment data
3. Use this link to confirm your Opt-out status with Medicare

Medicare Enrollment

1. A provider must be enrolled as a Part B provider of service to file for covered services under original Medicare.
2. Enrollment as an order/referring provider does not allow filing claims and receiving reimbursement for covered services.
3. Opted-out providers may not file claims to either original Medicare or medical coverage of Medicare Advantage plans. (Opted-out dentists are permitted to file claims to Medicare Advantage dental plans)

If you expect to file claims, enroll now as a Part B provider.

Opted-out dentists may continue to enter into private contracts with patients and treat patients on a self-pay basis. However, entering into a private contract is crucial as part of the opt-out agreement. Don’t’ overlook this essential requirement.

Medicare Advantage—how is it affected by the CMS final ruling

Medicare Advantage (MA) plans are required to provide medical benefits equal to or greater than Original Medicare. This will include medical benefits for the expanded coverage as outlined in the CMS final rule. 

Previously, these services may have been covered under the MA dental plan. As a result, dentists could submit claims and receive payment regardless of enrollment status with Original Medicare.

It is important to note that opted-out providers are not permitted to receive reimbursement for medical services. Therefore, dentists currently opted out will continue to enter private contracts and provide medical services as self-pay for all services considered covered under original Medicare.

What’s in the future?

As research on the link between oral and physical health continues to grow, we expect all healthcare, including Medicare, to expand coverage for medically related dental coverage. 

CMS continues to review and potentially revise its policy on dental coverage. In addition, they have stated that future Final Rulings may include coverage for other medically related dental treatments. 

Your input matters! Recommendations are encouraged and should be submitted via email by February 10 of the calendar year 2023. The email is: MedicarePhysicianFeeSchedule@cms.hhs.gov

Recommendations and comments should include all clinical evidence to support the correlation between dental treatment and significant improvement in the quality and safety of patient outcomes.

Next Steps

You may be asking yourself, now what? First, confirm your enrollment or opt-out status with Medicare. Make an informed decision on Medicare enrollment. Educate your team on how your enrollment status and this final rule may affect your practice so that your team can effectively and accurately communicate with patients. Make no assumption that only patients aged 65 and over are Medicare beneficiaries. Medicare patients may be younger patients who are receiving social security disability benefits or have end-stage renal disease.

This new ruling is a step in the right direction in providing benefits for dental procedures related to certain medical conditions. This includes commercial and Medicare. Commercial payers tend to follow Medicare coverage criteria, so expect the need to submit medical claims to continue to increase. Attend one of our upcoming medical billing workshops to learn how to implement medical billing in your practice, or contact us to discuss how our consultation services can support your practice with this, and other important coding and billing questions.