Medicare and Dental Coverage: What You Need to Know

Several routine dental services—checkups, cleanings, fillings, dentures, and most extractions—aren't covered under standard Medicare plans. This creates confusion for dental professionals and their Medicare-eligible patients, who often show up thinking they're covered when they're not.

Despite the general exclusion, some dental services are eligible for Medicare coverage when they are part of a covered medical procedure or condition.

Medicare consists of several components, and each relates differently to dental care:

• Medicare Part A (Hospital Insurance): Covers dental services that are integral to a covered procedure in a hospital setting. For example, Medicare will cover dental extractions needed before radiation treatment for jaw cancer or jaw reconstruction after an injury.

• Medicare Part B (Medical Insurance): Covers some dental services required for another covered medical treatment. For instance, Medicare might cover a tooth extraction if needed to properly repair a facial injury.

• Medicare Part C (Medicare Advantage): These plans often include dental coverage beyond original Medicare.

• Medicare Part D (Prescription Drug Coverage): Not directly related to dental procedures but may cover medications prescribed after dental treatments.

Recent Changes in Medicare Dental Coverage

Medicare's approach to dental coverage has recently shifted. In 2023, CMS finalized a rule expanding coverage for dental services necessary for certain medical treatments.

This expansion clarified that dental exams and treatments necessary for organ transplants, cardiac valve replacements, and head and neck cancer treatments fall within Medicare's scope, acknowledging the connection between oral and overall health.

These expansions create more opportunities to serve Medicare patients but with additional billing complexities. For example, your practice needs systems to identify which services qualify under the expanded coverage rules. The changes also require better documentation of medical necessity and an understanding of the specific requirements for each covered condition. 

How to Become a Medicare Provider

The process typically takes 45-60 days for approval, though CMS reports that online applications through PECOS process faster than paper applications.

Becoming a Medicare provider involves several key steps:

1. Obtain an NPI (National Provider Identifier) if you don't already have one. Apply through the National Plan and Provider Enumeration System.

2. Complete the CMS-855I application through the Provider Enrollment, Chain and Ownership System (PECOS). Do this online or by paper submission.

3. Submit required documentation, including proof of licensure, malpractice insurance, and relevant specialty certifications.

4. Complete Medicare enrollment screening, which may include background checks and site visits, depending on your risk level.

5. Sign a participation agreement with Medicare if you choose to be a participating provider.

Dental professionals have three options when enrolling with Medicare, each affecting reimbursement, patient costs, and administrative requirements. Your choice impacts reimbursement, patient costs, and administrative workload. 

As a Participating Provider, you accept Medicare’s approved amount as full payment. Medicare covers 80%, and the remaining 20% is billed to the patient or their secondary insurance. This option means predictable payments and a straightforward billing process.

A Non-Participating Provider can decide whether to accept Medicare’s assignment. If you don’t, you can charge up to 15% above the Medicare-approved amount (the “limiting charge”). This option offers flexibility but requires careful billing management.

Dentists who opt out file an affidavit with Medicare, which is renewed every two years. This allows private contracts with Medicare patients, but Medicare does not reimburse for services.

Medicare Billing Procedures for Dental Services

Proper Medicare billing involves submitting claims electronically using the appropriate claim form (typically the CMS-1500 form) unless you qualify for a waiver to submit paper claims.

For dental services covered by Medicare, you'll need to use medical procedure codes (CPT) rather than dental procedure codes (CDT) in most cases—a distinction that causes frequent claim denials.

Medicare Administrative Contractors (MACs) process claims based on your geographic region. Know your MAC's specific guidelines, as minor differences in their rules can affect approvals.

Documentation Requirements for Successful Reimbursement

Medicare demands thorough documentation to support medical necessity. Your records should clearly show:

• Why the dental service was necessary for treating a Medicare-covered medical condition

• The nature of the underlying medical condition

• How the dental service would improve the medical treatment outcome

Letters of medical necessity from referring physicians help establish the connection between dental service and a covered medical condition. According to Medicare guidelines, documentation must be detailed enough that a third party could reach the same conclusions about medical necessity.

Common Billing Errors and How to Avoid Them

Several errors consistently create problems with Medicare dental claims:

• Incorrect procedure coding: Using dental (CDT) codes instead of medical (CPT) codes

• Missing or insufficient diagnosis codes: Not properly linking the dental service to a covered medical condition

• Inadequate documentation: Failing to establish medical necessity

• Missing referring provider information: Omitting information about the physician who determined the dental service was necessary

Using a claims scrubber configured for Medicare rules can catch many errors before submission. Also, regular staff training on Medicare documentation requirements may reduce error rates.

Medicare Modifiers in Dental Billing

Modifiers in Medicare billing provide extra information about a service or procedure. They explain why a service was performed, the circumstances, and any special considerations affecting care.

For dental services, modifiers can indicate when a typically non-covered service becomes covered due to specific medical circumstances. They also help reviewers understand the treatment context and can determine whether a claim is approved or denied.

As dental industry trends evolve, stay informed about billing practices and modifier usage changes.

Common Medicate dental billing modifiers include:

• GA modifier: Indicates you've provided an Advance Beneficiary Notice (ABN) when you expect Medicare might deny the service as not medically necessary.

• GY modifier: Used when providing a statutorily excluded service. This tells Medicare that you understand the service isn't typically covered but needs a formal denial, often for secondary insurance.

• KX modifier: Certifies documentation in your records supporting medical necessity for the dental service.

• Q0 modifier: Indicates investigational clinical service related to an approved clinical trial.

CMS billing guidelines note that incorrect modifier usage commonly causes claim denials, making it essential to understand when and how to apply each.

Correlation between Dental Hygienists and Medicare Billing

In some states, dental hygienists can provide services under general supervision or independently though they must be mindful of legal limitations for hygienists.

Services like periodontal assessments before cardiac surgery or tobacco cessation counseling may be billable under Medicare. Some Medicare Advantage plans specifically cover preventive services performed by hygienists.

For hygienists to bill Medicare, they typically need to work with a Medicare-enrolled dentist, though requirements vary by state. In states with expanded practice acts, some hygienists may qualify to enroll as Medicare providers themselves for specific services.

Avoid Billing Headaches with the Right Team in Place

Medicare billing for dental services can be tricky, but understanding the rules helps you avoid claim denials and serve more patients. 

While routine dental care isn’t covered, Medicare will pay for some procedures linked to medical conditions—like extractions before cancer treatment or dental care needed for surgery. As Medicare expands its dental coverage, staying informed and training your team on best practices will help business run smoothly and get patients the care they need.

Building your practice can feel complicated, but Teero makes it easy to find and hire the right team to keep things running smoothly. Call us today or check out our website to find the best staff for your practice.