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Billing non-covered hospital outpatient dental services - Condition code 21
Medicare program’s coverage of dental services is limited. Medicare will pay for dental services if they are an integral part of a covered service or for extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw. Otherwise, items and services
in connection with the care, treatment, filling, removal or replacement of teeth or structures supporting the teeth are not covered.
First Coast understands that providers may need to bill Medicare for the non-covered dental services to receive a denial in order to then bill a secondary insurance for the patient. Please make sure you are properly billing for these non-covered dental services to ensure the claims are processed correctly and inaccurate payments are not made.
Billing Part A and B
When billing for services that are statutorily excluded or do not meet the definition of any Medicare benefit, you may use the GY modifier. The GY modifier is appended to each line item on the claim that meets the definition. Specifically for Part A only, these services should be listed on the claim itself as non-covered. The condition code 21 may also be used on the claim to obtain a denial from Medicare for submission to a subsequent insurer. These claims are referred to as no-payment claims. If you have any additional questions about the coverage or non-coverage of dental services, please review the resources listed below.
Sources: The Centers for Medicare & Medicaid Services’ (CMS’) Medicare Dental Coverage Web page; Internetonly Manuals (IOMs) Pub. 100-02, Chapter 1, Chapter 15,
& Chapter 16; Pub. 100-04, Chapter 1
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