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ADA, AAOMS asks CMS to fix ‘ongoing issue’ with oral pathology claims

Organizations note samples removed from the mouth or jaws have encountered frequent denials by agency

September 23, 2021

By Jennifer Garvin

Baltimore — The ADA and American Association of Oral and Maxillofacial Surgeons sent a joint letter Sept. 17 to the Centers for Medicare & Medicaid Services regarding an ongoing issue related to oral pathology claims.

In the letter to CMS Administrator Chiquita Brooks-LaSure, ADA President Daniel J. Klemmedson, D.D.S., M.D., and AAOMS President B.D. Tiner, D.D.S., M.D., said claims for samples removed from the mouth or jaws have encountered frequent denials even though such procedures are considered covered services by CMS in other sites.

They said this is especially true for cases submitted with ICD-10 diagnosis codes related to the teeth or tissues that support the teeth and noted that while the basis for claims denials has not always been clear, “it appears that a major factor may lie with the Medicare Benefit Policy Manual.”

They pointed to the manual’s Dental Services Exclusion chapter that begins with the statement: “Items and services in connection with the care, treatment, filling, removal, or replacement of teeth, or structures directly supporting the teeth are not covered.”

“We believe that there is a distinction between dental care and a diagnosis as a step that precedes the care of patients with oral lesions,” Drs. Klemmedson and Tiner wrote. “Biopsy or sample collection is not a form of dental treatment. Such procedures are performed to obtain a diagnosis. Only after a definitive diagnosis is established can the most appropriate, cost-effective care or treatment be applied.”

The groups concluded the letter by asking CMS for a meeting to discuss the issue.

For more information on the ADA’s advocacy efforts, visit ADA.org/Advocacy.