Despite the "dental services exclusion" in §1862(a)(12) of the Act (see the Medicare Benefit Policy Manual, Chapter 16, "General Exclusions from Coverage," §140), an oral or dental examination performed on an inpatient basis as part of a comprehensive workup prior to renal transplant surgery is a covered service. This is because the purpose of the examination is not for the care of the teeth or structures directly supporting the teeth. Rather, the examination is for the identification, prior to a complex surgical procedure, of existing medical problems where the increased possibility of infection would not only reduce the chances for successful surgery but would also expose the patient to additional risks in undergoing such surgery.
Such a dental or oral examination would be covered under Part A of the program if performed by a dentist on the hospital's staff, or under Part B if performed by a physician. (When performing a dental or oral examination, a dentist is not recognized as a physician under §1861(r) of the Act). (See the Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, "Definitions," §70.2, and the Medicare Benefit and Entitlement Manual, Chapter 15, "Covered Medical and Other Health Services," §150.)
Inpatient Hospital Services
Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.
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The OIG conducted a study dated June 2019 wherein they indicated that there were approximately $269 million in overpayments for polysomnography services for the period of 2014 through 2015. According to the OIG “These errors occurred because the CMS oversight of polysomnography services was insufficient to ensure that providers complied with Medicare requirements and to prevent payment of claims that didn’t meet those requirements.”
So what are those requirements?
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