General Coding Principles

Services provided by the Dental School and its affiliated Oral Health Center along with other programs/centers at the Dental School may involve the billing of services under medical codes (e.g. evaluation and management services, radiology, pathology services). When furnishing services, dentists must comport with the guidelines listed throughout these standards and procedures on documentation and coding. Thus, if a dentist furnishes surgical services, evaluation and management services, or consultation services, he or she must adhere to the applicable teaching, coding, and documentation guidelines herein.

General Medicare Coverage, Physical Presence and Documentation Principles

Medicare payment for services of dentists is limited to services in connection with those procedures which are not primarily provided for the care, treatment, removal, or replacement of teeth (or structures directly supporting, i.e., the periodontium). Covered services would include, among other things, the extraction of teeth in preparation for radiation treatment of neoplastic disease and the wiring of teeth in connection with the reduction of a jaw fracture. Other payers might cover a broader array of dental services.

It should be noted that Medicare regulations IOM 100-1, 5§70.2 and 100-2, 15§150 states a dentist qualifies as a physician if he/she is a doctor of dental surgery or dental medicine who is legally authorized to practice dentistry by the State he/she performs such functions and who is acting within the scope of his/her license when he/she performs such functions. Because the general exclusion of payment for dental services has not been withdrawn, payment for services of dentists is also limited to those procedures, which are not primarily provided for the care, treatment, removal, or replacement of teeth or structures directly supporting the teeth. The coverage or exclusion of any given dental service is not affected by the professional designation of the physician rendering the services; i.e., an excluded dental service remains excluded and a covered dental service is still covered whether furnished by a dentist or a doctor of medicine or osteopathy.

For Medicare covered services Dentists fall under Medicare’s teaching physician guidelines. Thus the following CMS Guidelines for physicians (supervising dentists), interns and residents apply.

• Physically Present
  When the teaching physician/dentist is located in the same room as the patient (or a room that is
  subdivided with partitioned or curtained areas to accommodate multiple patients) and/or
  performs a face-to-face service.
• Teaching Physician/Dentist
  A teaching physician/dentist, other than an intern or resident, who involves residents in the care of his or
  her patients. Generally, the teaching physician/dentist must be present during all critical and key
  portions of the procedure and immediately available to furnish services during the entire
  service in order for the service to be payable under the Medical Physician Fee Schedule.
• Critical or Key Portion
  The part or parts of a service that the teaching physician/dentist determines are a critical or key
  portion.

Services furnished in teaching settings are paid if the services are:

• Personally furnished by a teaching physician/dentist who is not a resident;
• Furnished by a resident when a teaching physician/dentist is physically present during the
  critical or key portions of the service.
• The services are identifiable teaching physician/dentist services, the nature of which require
  performance by a teaching physician/dentist in person and contribute to the diagnosis or treatment
  of the patient’s condition.
• The services furnished can be separately identified from those services that are
  required as part of the training program.

The complete CMS guidance can be found at http://www.cms.hhs.gov/

The clinical record documentation must support the personal involvement of the teaching physician/dentist as defined above.