Biopsies and the Medicare Patient

If you perform biopsies in your dental practice, even occasionally, it is important to understand that biopsies and excision of lesions are typically considered to be medical in nature. Most medical payers, including Medicare, provide reimbursement for these services. It is recommended that all medical procedures be submitted to a patient’s medical plan. This is a legal obligation when biopsy services are provided to Medicare beneficiaries.

Under the Social Security Act (Section 1848[g][4]) all covered services rendered to patients on or after September 1, 1990 must be submitted for reimbursement by Medicare. This is true of both traditional Medicare and Medicare Advantage Plans. Compliance to this requirement is monitored by the Centers for Medicaid and Medicare Services (CMS). Violators may be subject to a penalty of up to $2,000 for each violation. This may also result in a 10 percent reduction of a physician’s Medicare reimbursement and/ or exclusion from the Medicare program.

This requirement may be problematic for dentists, since many are not aware of this regulation and are not enrolled as Medicare Part B providers. It is important to note that enrollment as an ordering or referring provider does not allow one to submit claims to Medicare for medical procedures.

There are exceptions to the mandatoryfiling law. These include:

»» Services that are not covered by Medicare (e.g., routine dental care).

»» Services provided by a dentist who has opted out of Medicare (except in emergency situations).

»» Services provided free of charge.

Some general dentists choose to provide this service to Medicare patients at no charge, thus avoiding the filing requirement, because they perform very few biopsies. Most choose to refer all Medicare patients to a specialist for medically related procedures. A dentist may also choose to enroll as a Medicare provider or may opt out.

There are many factors to consider regarding enrollment as a Medicare provider, and the various choices can become confusing. These options have previously been detailed in recent issues of Insurance Solutions Newsletter. In summary, Medicare enrollment is a decision that should be made by each provider based on his or her practice.