ADA comments on proposed Medicare payment policies for dental services in 2025

The ADA formally submitted comments to the Centers for Medicare & Medicaid Services in response to the proposed rule for 2025 payment policies under the Physician Fee Schedule.  
 
This submission marks the third consecutive year the ADA has provided comments to CMS on payment for dental services related to covered medical treatments. Over the past three years, the ADA has supported the inclusion of payment for dental services for conditions where oral health is intrinsically linked to overall medical success. In 2022 and 2023, the ADA agreed with CMS on vital role dental care plays in preparing patients for organ transplants and the importance of treating oral infections prior to chemotherapy and radiation therapy for cancer. The ADA continues to work closely with CMS, highlighting the need for sustainable, evidence-based policies that improve care for Medicare beneficiaries while reducing the burden for dental professions who provide services under Medicare. 
 
For this year’s proposed rule’s comment submission, the ADA provided feedback on several critical areas where dental services intersect with broader healthcare provisions. In the letter addressed to CMS Administrator Chiquita Brooks-LaSure, the ADA  said it supports CMS’ proposal to cover payment for dental services for patients with end-stage renal disease who are undergoing dialysis. The ADA commended CMS for recognizing the critical role that oral health plays in ensuring successful dialysis outcomes, especially in preventing infections that could jeopardize patient health. In the letter, the ADA requested to be included in future reviews of scientific evidence related to the limited medically necessary dental benefits, noting its expertise in dental science and practice.  
 
The ADA also responded to CMS’ request for feedback on dental care for patients with diabetes.  The ADA underscored that, while there is strong scientific evidence supporting the role of dental care in improving health outcomes for diabetic patients, there is no evidence that dental services are inextricably linked to the clinical success of a Medicare-covered procedure in the treatment of diabetes. 

Additionally, the ADA requested clarification on several points, such as whether a dental claim must be submitted with administrative modifiers to coordinate dental benefits with a state’s Medicaid program, even in cases in which the Medicaid provider knows a dually-eligible patient will be ineligible for dental benefits under the medically necessary payment rules. It also requested that the requirement for KX and GY, both administrative claim modifiers, be waived until Jan. 1, 2026.  
 
“This delay would provide sufficient time for comprehensive testing and demonstration among a broad range of providers, vendors and payors,” the letter reads. “During this period, the ADA recommends that CMS allow [Medicare administrative contractors] to adjudicate claims without modifiers, with an approved claim report advising providers that modifiers will be required starting January 1, 2026. This approach would minimize disruption to quality patient care and ensure a smooth transition to the new coding requirements.” 
  
The ADA commented on ICD-10 implementation for Medicare claims, noting that while including these codes in Medicare dental claim submissions is intended to improve the accuracy and coordination of care between medical and dental providers, the transition to ICD-10 coding brings challenges to the dental community. 
 
In order to help support dental providers transition to reporting ICD codes on a claim form for Medicare covered beneficiaries, the ADA also expressed support for CMS’ consideration of delaying the requirement for ICD-10 codes in Medicare dental claim submissions until Jan. 1, 2026. 
 
In its letter, the Association noted that dental services linked to the clinical success of qualifying medical procedures can only be reimbursed by Medicare if there is an exchange of information. The ADA noted that there is currently no standard to define what qualifies as an exchange of information or care coordination in the dental claims process.  
  
“This lack of clarity creates significant challenges in coordinating care, particularly given that physicians and dentists often provide services in separate settings. To resolve this ambiguity and prevent inconsistencies in the claims process the ADA requests that CMS provide clear guidance to [Medicare administrative contractors] on this issue,” the ADA said, specifically proposing the adoption of the ADA Medicare Referral Form as “a standard template for verifying care coordination and reducing administrative burden.” 
   
The letter also included ADA comments regarding fee guidance for dental services, in which the ADA offered to share market data which accurately reflects fees submitted by dentists in various geographies. It concluded by commending CMS for soliciting input in its continued efforts to integrate dental and medical care under Medicare and for recognizing the importance of oral health’s connection to overall health and well-being.