Starting July 1, dentists enrolled in Medicare to provide Part B covered services will need to include specific administrative modifier codes on the ADA Dental Claim Form. These changes aim to streamline the claims process and improve coordination of benefits for dental services linked to Medicare-covered medical procedures.
Why the Change?
In 2023, the Centers for Medicare and Medicaid Services (CMS) began reimbursing for dental services that are essential to the success of a Medicare-covered medical procedure. While Medicare does not typically cover routine dental care, this policy expansion allows for certain dental treatments to qualify for reimbursement if they meet strict criteria.
Mark A. Moats, D.M.D., chair of the ADA Council on Dental Benefit Programs, explains the importance of the modifiers:
“Dentists will use the modifiers when submitting claims to signal to claim administrators to either begin processing the qualifying claim for dental services or deny the claim to allow for the subsequent coordination of benefits.”
Understanding the New Modifiers
Two modifiers, KX and GY, are now available for use:
– KX Modifier:
Used to identify dental services that are inextricably linked to a Medicare-covered medical procedure. By adding this modifier, dentists indicate they have coordinated care with a physician and documented the medical necessity of the dental service in the patient’s record.
– GY Modifier:
Used for submitting claims to Medicare for denial. This allows dentists to pursue reimbursement from a third-party payer or Medicaid. The GY modifier certifies that the dentist believes Medicare should not pay for the service, and it can also be applied to excluded services as non-covered line items on a claim.
Steps Dentists Should Take
- Add Modifiers to Claims:
Dentists must include the KX or GY modifier alongside each procedure code on the ADA Dental Claim Form starting July 1. The ADA has provided interim instructions for paper claims until the updated form is released.
- Coordinate with Physicians:
Dentists must exchange information or coordinate care with a physician before performing a service linked to a Medicare-covered procedure. Documentation of this collaboration can be recorded using the ADA’s new Medicare Referral Form, which should be kept in the patient’s file.
- Update Electronic Claims:
CMS has established mechanisms to process Medicare claims for dental services electronically. Dentists should reach out to their practice management software vendor for guidance on adding the modifiers to the 837D electronic dental claim form.
Resources and Support
The ADA is committed to helping dentists navigate these changes. Members can access the following resources:
– List of Qualifying Medicare-Covered Dental Services
– Medicare Referral Form
– Detailed Instructions for Adding Modifiers
These tools are available on [ADA.org/medicare] https://ADA.org/medicare.
For additional assistance with electronic claims, dentists can contact dentalbenefits@ada.org.
Stay Compliant and Streamline Your Claims Process
These updates represent a significant shift in Medicare claims processing for dental services. By adopting the new requirements and utilizing the ADA’s resources, dentists can ensure compliance, improve coordination of care, and potentially expand access to Medicare reimbursements for qualifying dental treatments.