Advocacy Update: CMS Expands Medicare Dental Coverage and Simplifies Billing Processes

CMS Medicare Physician Fee Schedule Rule

On November 2, the Centers for Medicare & Medicaid Services (CMS) announced significant updates to the Medicare Physician Fee Schedule (PFS), expanding coverage for specific dental services available to Medicare beneficiaries undergoing cancer and structural heart disease treatments. The new coverage policies demonstrate the agency’s recognition of sound clinical evidence linking oral health treatment and improved health outcomes for Medicare patients. All payment policies will go into effect on January 1, 2024.

New Coverage for Dental Services Integral to Cancer Treatment
Effective January 1, CMS will provide coverage under Medicare Part A and B for dental diagnostic and treatment services prior to or during specific treatments for cancer. The agency will cover dental services in either inpatient or outpatient settings for the following cancer treatments:

• Chemotherapy.
• Chimeric antigen receptor (CAR) T-cell therapy.
• Administration of high-dose bone modifying agents (antiresorptive therapy).

Furthermore, CMS will provide Part A and B payment for oral examinations, diagnostic, and treatment services before or during radiation, chemotherapy, and surgery for all head and neck cancers.

Clarification on Coverage for Dental Services Linked to Cardiac Interventions 
CMS also provided clarification on last year’s coverage policy by codifying coverage of inpatient or outpatient dental exams, diagnostics, and treatments for oral or dental infections prior to or during:

• Organ transplants.
• Cardiac valve replacement.
• Valvuloplasty procedures.

*Please note: AAE members providing dental treatments for cancer and cardiac therapies not explicitly outlined in the final rule should seek prior approval from CMS on a case-by-case basis to ensure the treatment qualifies as a covered service under Medicare. The agency clarified its willingness to make exceptions to Section 1862 (a)(12) of the Social Security Act in cases of medical necessity when dental treatments are essential to preventing serious health complications.

New Dental Billing & Coding Policy Changes
In January, the agency will update its Health Common Procedure Coding System (HCPCS) and PFS payment and coding files to include Current Dental Terminology (CDT) codes, aligning them with industry-accepted dental billing measures. Additionally, CMS will introduce new dental specialty provider codes, including “E5 – Endodontics.” Both policy changes aim to reduce administrative burden and increase enrollment and participation by dentists in the Medicare payment program. For more information on the CMS Physician Fee Schedule (PFS) rule, please visit CMS.gov/medicare/payment/fee-schedules/physician.

CMS Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule

On November 2, the Centers for Medicare & Medicaid Services (CMS) announced their annual Hospital Outpatient Prospective Payment System (HOPPS) and Ambulatory Surgical Center (ASC) Payment System final rule. This rule governs coverage and payment decisions for dental and medical-covered Medicare services in outpatient settings. Over the past two years, CMS has expanded its coverage for dental services, associated with the clinical success of covered medical care such as, cancer and cardiac intervention treatments.

This expansion of dental coverage has led to an increased role for endodontists in the coordinated care of Medicare patients in outpatient facilities. The 2024 final rule increases payment rates by 3.1% to Medicare hospital outpatient systems, thereby ensuring continued patient access to Medicare-care covered dental services.

Below is a summary of the key dental provisions in the HOPPS rule that impact endodontists participating in the Medicare payment program.

Implementation of New Dental Codes for Simplified Billing   
One of the primary challenges faced by dentists seeking meaningful participation in the Medicare payment program has been the limited coding mechanisms available to ensure fair reimbursement for dental services provided to Medicare patients. CMS is addressing this challenge in two significant ways.

First, CMS is assigning an additional 229 Current Dental Terminology (CDT) codes to define dental services within Clinical Ambulatory Payment Classifications (APC) – CMS’ method for reimbursing outpatient facilities for Medicare-covered services. The full list of dental codes can be found in Table 110 of the final rule. CMS recognizes that CDT is the uniform code for dental procedures and believes its adoption into the Medicare payment model will reduce administrative burdens on dentists and billing specialists, facilitating more meaningful participation in the program.

Furthermore, starting in January 2024, CMS will assign more than 240 Healthcare Common Procedure Coding System (HCPCS) codes to define dental services within APCs. This policy adjustment will further simplify the integration of dentists into the Medicare payment program by using commonly used or similar coding descriptors.

CMS Guidance on HCPCS Code G0330 – Facility Services Dental Rehab 
Last year, CMS introduced HCPCS code G0330 to describe dental rehabilitation procedures that necessitated monitored anesthesia and were performed in an operating room. In response to feedback from stakeholders indicating limited usage and a devalued payment rate for this code, CMS has provided new guidance this year on its utilization for Medicare providers.

CMS recommends using a more specific CDT or Current Procedural Terminology (CPT) code, when possible, to account for the full range of services furnished. Additionally, the agency will reassign the code from APC 5871 to APC 5164 to encourage more appropriate use. The agency advises using HCPCS code G0330 when no other code applies to the services rendered.

For more information on the CMS Hospital Outpatient Prospective Payment System (HOPPS) and Ambulatory Surgical Center Payment System (ASC) final rule, click here.