By Rose Nierman, RDH
There are no specific dental codes available for oral appliances for obstructive sleep apnea (OSA), and it's almost unheard of for dental plans to reimburse for these devices. On the other hand, medical insurance routinely reimburses dentists for oral appliances. For those dental practices billing medical insurance, here are some recent changes that have taken place and some tips for success.
Does medical insurance cover snoring appliances advertised on the internet?
No, and for good reason. That snore could be something more! Even though an over-the-counter oral appliance may eliminate snoring, the patient could still be having sleep apnea episodes known as "silent apnea." For this reason, and to ensure appliances are "medically necessary," medical insurance restricts coverage to custom mouthpieces inserted by qualified dentists. Follow-up sleep studies are frequently covered by medical plans to confirm the efficacy of the custom-made device.
Medical claim form revised
The standard medical claim form was revised as of April of 2014 to add additional areas for diagnosis codes and other fields. The new claim form is mandatory, so it's important to use the new form to prevent denials. Also, an original claim form, as opposed to a copy, should be submitted to prevent delays in reimbursements. For ordering the new medical claim form, specify the form CMS 1500 v. 02/12.
Document your history and exam for medical necessity
The best way to document your time spent during an exam is to tell a story about your patient's symptoms, history, past treatments, exam findings, and plan. Five levels of evaluation codes are available to report visits for new or established patients for sleep apnea oral appliance screening. These codes may be reviewed for the amount of time spent with the dentist and whether or not the visit is problem-focused or detailed. Instead of noting, "screening appointment for oral appliance," indicate specific history taking and exam elements. In other words, tell a detailed story in your notes.
Radiographs such as a panorex taken during the screening can be billed to medical insurance (CPT code 70355) along with the evaluation codes. Keep in mind that if your practice is billing for CT scans, most cone-beam X-rays require preauthorization.
When the time comes to deliver the appliance, the oral device is categorized as durable medical equipment. The billing code, E0486, for the custom oral device, is submitted with the insertion date as the date of service.
Diagnosis, diagnosis, diagnosis
Just as you've heard the adage in real estate, "location, location, location," the key to successful oral appliance therapy and medical insurance reimbursement is "diagnosis, diagnosis, diagnosis."
According to the International Classification of Disease, the medical diagnosis of OSA should be coded as ICD 327.23. This ICD code applies to child or adult OSA when diagnosed by a laboratory or home overnight sleep study and interpreted by a sleep physician. A copy of the sleep study should be sent to the medical insurer with your office notes and a letter of medical necessity or written order from a physician. Medical histories should document high blood pressure, daytime sleepiness, cognitive or mood disorders, heart disease, and other consequences of sleep apnea.
How do I know if my patient's insurance covers oral appliances?
Many medical policies do cover oral appliances. Since Medicare approved oral appliances in 2011, medical plans have stepped up and generally offer coverage for FDA-approved appliances. Medical plans vary, so it's important to perform a benefit check by telephone or to preauthorize the claim. The good news is that oral appliances are classified as durable medical equipment (DME), and DME benefits are considered an essential health benefit in the Affordable Care Act. Although mandatory benefits do vary by state, it's advantageous to review your state's health plans.
Are sleep studies covered?
Most comprehensive health insurance policies have coverage for home or laboratory sleep studies. Some health insurance companies, such as Aetna, have specified that, in order to get reimbursed, physicians must typically utilize home sleep studies in lieu of referring the patient for a laboratory sleep study. This policy keeps costs down for the insurer when OSA is suspected. It also benefits patients by reducing their copayment. Equally important is the fact that many patients are more comfortable having a sleep study in the comfort of their home and are more open to diagnosis.
Does Medicare pay for apnea oral appliances?
Yes. "Medicare approved" oral appliances for obstructive sleep apnea are covered when specific criteria are met, such as a physician visit prior to oral appliance therapy. To receive reimbursement, a dentist must enroll as a Medicare DME Supplier. It's important to note that a DME supplier cannot order sleep tests for a Medicare beneficiary.
Medical billing can help patients receive treatment for a serious concern. When you help patients get life-changing treatment and help your practice expand services, that's worthwhile.
Each practice is responsible for adhering to local regulatory guidelines concerning OSA treatment.
Rose Nierman, RDH, has been at the forefront of educating dental practices on medical billing in dentistry, cross-coding, and services expansion for over 25 years. Each year, Nierman Practice Management assists their dental clients in treating thousands of patients for medically necessary disorders and obtaining millions of dollars in medical reimbursement for these treatments.