Big changes are coming to ICD-10 coding for dental services in 2025. As of July 1, 2025, using ICD-10 codes on dental claims for Medicare is mandatory, not just recommended. This shift impacts how you document and bill for services inextricably linked to covered medical procedures.

Key Changes & Requirements:

Mandatory ICD-10 Reporting:

You must include an ICD-10 diagnosis code on all dental claims, both electronic (837D) and paper (2024 ADA), for services linked to a covered medical procedure. This ensures accurate documentation and facilitates proper reimbursement. Claims without a valid ICD-10 code will be rejected.

KX Modifier Requirement:

Use the KX modifier on claims to certify that the dental service is medically necessary, documentation supports the link to a covered medical service, and care was coordinated between medical and dental providers. This is also mandatory as of July 1, 2025. Claims without the KX modifier may be denied as statutorily non-covered.

Common ICD-10 Codes:

While the specific code depends on the linked medical condition, some relevant codes may include those for pre-procedure exams and cleanings (Z01.20 if no abnormalities, Z01.21 if abnormalities found), or codes related to disorders of teeth and supporting structures (K08.-). Refer to the complete ICD-10 code set for appropriate codes based on the patient's specific medical condition.

Why This Matters:

These changes aim to improve the clarity and accuracy of dental claims, ensuring appropriate reimbursement for medically necessary dental services. Accurate ICD-10 coding demonstrates the medical necessity of the dental procedure and justifies Medicare coverage.

Stay Compliant:

• ⚬   Verify Requirements: Double-check each patient's insurance plan requirements, as some may have specific guidelines beyond Medicare's.
• ⚬   Update Systems: Ensure your PMS is updated to accommodate these changes and prevent claim rejections.
• ⚬   Train Staff: Adequately train your billing and coding staff on these updates to ensure accurate and compliant claims submission.

Need Help?

Several resources are available to help you navigate these changes, including the ADA, CMS, and Revv Systems RCM services. Staying informed and prepared will ensure smooth billing processes and timely reimbursement.