New Medicare Billing Requirements and Dental Insurance Reimbursement
Published by the American Dental Coders Association
Introduction
Medicare billing requirements are evolving rapidly, especially in how dental services are billed and reimbursed. With new modifiers, diagnosis code mandates, and expanded coverage rules taking effect, dental billers and coders must prepare to navigate a changing landscape. This article breaks down what’s changing, what it means for your practice, and how you can stay ahead.
Expanded Medicare Coverage for Dental-Linked Services
Medicare is broadening its definition of what constitutes a medically necessary dental service. Dentists can now bill Medicare for procedures connected to major medical treatments such as dialysis, cancer therapy, or organ transplants. This marks a critical shift toward integrating dental care with whole-patient health.
New Billing Requirements Effective July 1, 2025
Starting July 2025, dental providers submitting claims to Medicare for services tied to medical procedures must:
Use the KX modifier to confirm that the dental service is related to a Medicare-covered medical condition.
Include a valid ICD-10 diagnosis code on the 837D claim form.
Ensure that medical necessity is documented thoroughly to support the submitted claim.
These updates are designed to enhance claim accuracy and curb inappropriate billing.
Billing Guidelines for FQHCs and RHCs
Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) will now be allowed to bill separately for medically linked dental services even if performed on the same day as other visits. This helps rural and community-based clinics receive full reimbursement for vital care.
Subregulatory Guidance and More Changes Ahead
CMS will be releasing detailed subregulatory guidance and training tools in the coming months to help providers understand:
When and how to use new modifiers.
What constitutes valid documentation.
How to handle cross-coded services between Medicare Part A and B billing streams.
Reimbursement Expansion: Still in Discussion
While recent changes mark a step forward, broader efforts to add routine dental coverage to Medicare are still under discussion. Professional associations and lawmakers continue to advocate for:
More inclusive reimbursement models.
Standardized templates for dental claims.
Education programs to ease the transition into new billing practices.
Preparing Your Dental Practice
Here’s what you should be doing now to stay compliant:
Update billing software to support KX modifier and ICD-10 code entry on dental claims.
Train your team on the latest CMS expectations for documentation and coding.
Reassess workflows in FQHC/RHC settings to align with updated billing opportunities.
Monitor for upcoming CMS subregulatory guidance and adjust processes as needed.
Support from the ADCA
The American Dental Coders Association is committed to supporting dental billing and coding professionals as policies evolve. Whether you’re an experienced provider or new to the field, you can:
Ask your toughest coding questions using Ask-The-Coder
Enroll in online training like the Certified Dental Billing Specialist (CDBS) or the Certified Dental Coder (CDC)
Explore the Dual Certification Program for complete mastery in both disciplines.
Conclusion
With Medicare’s expanded coverage for dental services and the addition of new billing requirements, it’s essential for dental offices to adapt quickly. Accurate documentation, compliant coding, and advanced training will ensure your practice not only stays ahead of regulatory changes but thrives within them.
