Medicare claims for dental services to require administrative modifier codes

KX modifier identifies service as linked to covered medical procedure

Dentists who are enrolled in Medicare to provide Part B covered services will need to add the appropriate administrative modifier code next to each procedure code on the ADA Dental Claim Form beginning July 1.

The ADA has released instructions for adding the modifiers to the current paper claim form until the next version of the form is released. The modifiers — KX and GY —are available for use now.

“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,” said Mark A. Moats, D.M.D., chair of the ADA Council on Dental Benefit Programs.

While Medicare does not cover most routine dental services, the Centers for Medicare and Medicaid Services began reimbursing for dental services that are inextricably linked to the clinical success of a Medicare-covered medical procedure in 2023.

In order to qualify for reimbursement, dentists must exchange information or coordinate care with a physician before providing a service and submitting a claim. Dentists can document that they met this requirement through the ADA’s new Medicare Referral Form, which they should then save in the patient’s record.

The KX modifier identifies a dental service as inextricably linked to a Medicare-covered medical procedure. Adding the modifier to a claim indicates the dentist has coordinated care with a physician and the patient’s record includes the appropriate documentation supporting the medical necessity of the dental service and demonstrating its link to a covered medical procedure.

Dentists who are submitting a Medicare claim for denial in order to be reimbursed by a third-party payer or Medicaid should use the GY modifier to certify they believe Medicare should not pay for the service. They can use the modifier to submit excluded services as noncovered line items on a claim with other covered dental services.

CMS recently established mechanisms to receive and process Medicare claims for dental services electronically. The ADA advises dentists to contact their practice management software vendor for guidance when reporting modifiers on the 837D standard electronic dental claim form. The Association also encourages members to contact dentalbenefits@ada.org for help resolving any issues associated with electronic Medicare claim submission.

A list of qualifying Medicare-covered dental services, the Medicare Referral Form and the instructions for adding the modifiers are available at ADA.org/medicare.