Medicare does not cover most dental services. In an outpatient setting, even if an excluded service is a complex or difficult primary procedure, Medicare will not cover it. Medicare Part A will pay for dental services if they are inpatient hospital services provided in connection with dental procedures that require hospitalization due to an underlying medical condition and clinical status or the severity of the dental procedures. Knowing what Medicare covers and doesn’t cover and ensuring proper billing and coding to meet payer requirements is essential to obtain optimal reimbursement. A dental billing company can help with this.

  • Know Medicare Dental Coverage: Generally, original Medicare (Part A and Part B) does not cover routine dental items and services connected with the care, treatment, removal, filling, or replacement of teeth, dental devices such as dentures or plates, or structures directly supporting the teeth.

    Medicare will pay for:

    • Dental services that are an integral part of a covered service
    • Extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw
    • Oral examinations, but not treatment, preceding kidney transplantation or heart valve replacement, under certain circumstances. These examinations would be covered under Part A if performed by a dentist on the hospital’s staff or under Part B if performed by a physician
    • If specific requirements are met, certain dental items and services, such as dental sleep apnea devices, may be covered in certain geographic areas through local coverage determinations
    • Whether services as the administration of anesthesia, diagnostic x-rays, and other related procedures are covered depends upon whether the primary procedure being performed by the dentist is itself covered. For instance, an x-ray related to the reduction of a fracture of the jaw or facial bone is covered, but a single x-ray or x-ray survey taken in connection with the care or treatment of teeth or the periodontium is not covered (uhc.provider.com).

    Medicare Advantage (Part C) plans are private health insurance plans that offer some dental benefits and may cover routine preventive care, such as cleanings, X-rays, and regular exams, either partially or in full, and also provide some coverage for extractions, root canals, dentures, crowns, fillings, and treatment for gum disease.

  • Know When to Enrol in Medicare: Dentists who provide Medicare Part B covered items and services need to either enrol in Medicare or formally opt out. Even if they don’t provide Medicare Part B covered items and services, they need to either enrol or formally opt out if they order covered clinical laboratory services, imaging services, or DMEPOS for patients who are on Medicare.
  • Have the Patient Sign the ABN if Medicare will not Cover a Service/Item: If Medicare does not cover a service/item that the patient wants, it is important that the patient signs the ABN (Advanced Beneficiary Notification) form. This confirms that the patient understands that Medicare will not cover the service/item and agrees to pay out of pocket for it. ABN forms are not necessary for things that Medicare typically doesn’t cover such as routine dental services like cleaning, root canals, etc.
  • Know Documentation Requirements: Dentists should provide documentation supporting along with the claims. This includes the ICD-10 codes to support the medical necessity for the surgery in an inpatient setting. Claims without such proper documentation will be denied. If the dental procedure performed is not the primary procedure, documentation of the primary procedure should be included in the patient’s medical records. CPT/HCPCS procedure codes should be used on medical claims to bill the medical insurance. For many procedures, dentists may need to provide their SOAP notes to the Medicare insurer for obtaining a pre-authorization approval or processing a claim.
  • Perform Dental Eligibility Verification: Verifying coverage and benefits is important for the practice and also for patients. Many older patients have a Medicare Advantage Plan that pays for dental services, since original Medicare doesn’t usually cover any dental services. While routine dental services would be considered additional coverage, Medicare Advantage dental services may vary from plan to plan. Dental eligibility verification should cover all major insurance eligibility aspects such as demographic information and policy date as well as coverage percentage by category, tooth cleanings, crowns, build-ups, tooth grafting coverage, tooth implant coverage, and x-ray frequencies and out-of-pocket requirements. Prior authorization should be obtained if needed.
  • Ensure Correct Medicare Billing: Dental practices are responsible for submission of accurate claims. Medicare makes coverage decisions accurately based on the code or codes that correctly describe the health care services provided. Billing dental services correctly is critical to ensure the claims are processed correctly and inaccurate payments are not made.
  • Use the Patient’s MBI: In 2020, Medicare removed SSNs from all Medicare cards and replaced them with a new, randomly generated Medicare Beneficiary Identifier MBI. The MBI should be used for all Medicare transactions. As Medicare beneficiaries can ask to change their MBI if the number has been compromised, providers should verify their patient’s MBI when they come for care.
  • Wait to Charge/collect the Medicare Part B Deductible: Medicare Part B beneficiaries have to pay a deductible before Medicare will provide them with coverage for additional costs. Medicare-participating providers are authorized to bill the beneficiaries for deductibles. However, collecting deductibles up front from Medicare recipients may not be a good practice as an incorrectly collected deductible may be considered over-collection and deemed program abuse. Dentistry IQ advises dentists not to collect the deductible amount from a patient until they can confirm whether or not it has been met. All deductibles should be properly recorded and any improper deductibles refunded.
  • Stay up-dated with Industry Rules and Regulations: To ensure correct billing, providers need to stay up to date with changes in industry rules and regulations. For e.g., the Stark Law or Physician Self-referral Law has been modernized in 2021 “to remove potential regulatory barriers to care coordination and value-based care”. Likewise, being aware of Local Coverage Determinations, National Coverage Determinations is crucial as these documents provide coverage information and determine whether services are reasonable and necessary on certain services offered by participating providers.

Partnering with an experienced dental billing service provider is the best way to optimize Medicare billing, collect proper reimbursement and boost patient satisfaction.