Editor’s intro: This article, by Christine Taxin, offers valuable tips on billing for OSA and TMD that can allow your practice to expand patients’ options and add a valuable revenue stream.
Christine Taxin discusses how to help patients get the necessary care and coverage
Since the recommended amount of sleep for a child ages 6- to 12-years-old is between 9 and 12 hours each night,1 when that sleep is continually interrupted or not the best quality, many problems can arise in the young bodies of developing children. With this in mind, how can orthodontists help gently guide their parents to answers? Management and care of obstructive sleep apnea (OSA) can help improve the overall health and wellness of the children and allow them to flourish during childhood rather than struggle with an untreated airway issues.2
In 2013, a position paper, developed by a Task Force of the American Academy of Craniofacial Pain on Mandibular Advancement Oral Appliance Therapy for Snoring and Obstructive Sleep Apnea, contained recommendations for dentists engaged in the management of patients with snoring and obstructive sleep apnea utilizing mandibular advancement oral appliances.3 Therefore, a large percentage of children being treated with expanders and appliances that can grow with the child should be billed as medical.
Some dental ofﬁces avoid billing medical insurance for covered dental procedures because they fear that they will be accused of fraud. However, most states have laws recognizing both DDS and DMD providers as capable of billing medical insurance for conditions that fall under their specialties. The American Dental Association has put together an overview of some of these state laws. In most states, if an insurer covers a procedure when a physician or nurse practitioner performs said procedure, it must also cover the same procedure when a dentist performs it.4
How does the law pertain to the orthodontic practice?
What does the law define, and how can it apply to dental practitioners? As of 2014, the definition of physician/practitioner has been revised as follows:
“For purposes of this provision, the term ‘physician’ is limited to doctors of medicine; doctors of osteopathic medicine; doctors of dental surgery or of dental medicine; doctors of podiatric medicine; and doctors of optometry who are legally authorized to practice dentistry, podiatry, optometry, medicine, or surgery by the State in which such function or action is performed; no other physicians may opt out.”4
Now that we have established how the orthodontist and practice are covered and able to bill from dental to medical, let’s take a look at how to use this specific type of billing to help patients obtain the care and coverage they need. For example, both removable and ﬁxed appliances are routinely covered under most medical plans and programs, including temporomandibular joint dysfunction (TMD) issues, the correction of mandibular position or narrow airway leading to obstructive sleep apnea, and the modiﬁcation or correction of development anomalies such as a narrow palatal vault. Additionally, it is imperative to remember that the American Academy of Pediatrics reports that OSA is a common condition among children and can cause signiﬁcant complications when left untreated.5
There are certain steps to begin the journey of adding the ability to refer a child for diagnosis for either treatment of sleep apnea or TMD. Of course, you must determine the treatment after the test results are available and collaborate with your patients’ medical provider.
Know the questions to ask. Does the child:
- Take any medications?
- Have medical professionals taking care of him/her? Get their name and number.
- Walk around during the night?
- Urinate in his/her sleep?
- Sleep in class?
- Act out in class or at home?
- Mouth-breathe? (Children with en-larged adenoids tend to breath with their mouths open.)
- Experience breathing pauses during sleep?
- Exhibit daytime sleepiness?
- Have difficulty concentrating?
- Have poor performance at school?
Because enlarged tonsils and/or adenoids are the most common causes of sleep apnea for children, having surgery to remove the tissues often corrects the symptoms of sleep apnea in 90% of cases.6 For children whose sleep apnea is attributed to obesity, weight management and lifestyle programs are usually employed to help children manage their weight. Additionally, continuous positive airway pressure (CPAP) therapy may be recommended; however, many cannot tolerate the CPAP. The medical provider can send a form to the dental professional for treatment using an oral appliance with a copy note that the patient cannot tolerate the CPAP. Dental appliances then may be recommended, or if the primary physician does not recommend surgery at this time. Most children need to have severe issues for a surgical procedure at least 3 times within a certain period.
Bottom line: Every insurance policy is different. Always know the guidelines.
For OSA, when walking through the documentation needed for each specific patient case, establishment of medical necessity is imperative. For example, pediatric orthodontics requires documentation to support the severe handicapping malocclusion and the presence of a qualifying medical condition, and a score of 42 points or greater on the Modiﬁed Salzmann Index. Documentation must include a completed Salzmann assessment and a written report from the attending medical specialist who is treating the patient for deformity/anomaly.7 Progress notes, photographs, and other relevant supporting documentation may be included as proper. To be considered medically necessary (needed to treat, correct, or improve a medical defect or condition), orthodontic services must be an essential part of an overall treatment plan developed by both the physician and the dentist in consultation with each other. Note: Orthodontic treatment for dental conditions that are primarily cosmetic in nature or when self-esteem is the primary reason for treatment does not meet the deﬁnition of medical necessity.
When addressing TMD, the Salzmann assessment record is intended to show whether a handicapping malocclusion is present and to assess its severity according to the criteria and weights (point values) assigned to them. The weights are based on tested clinical orthodontic values from the standpoint of the effect of the malocclusion on dental health, function, and esthetics. Etiology, diagnosis, planning, complexity of treatment, and prognosis are not factoring in this assessment.
Here is a brief broad-brush overview of nonsurgical management of TMJ/TMD: Reversible intraoral appliances may be considered medically necessary in selected cases only when there is evidence of clinically signiﬁcant masticatory impairment with documented pain and/or loss of function. Prolonged (greater than 6 months) application of TMD/TMJ intraoral appliances is not considered medically necessary unless, upon individual case review, documentation supports prolonged intraoral appliance use. Only one oral splint or appliance is considered medically necessary for TMD/TMJ therapy. For plans that cover intraoral appliances, adjustments of intraoral appliances performed within 6 months of initial appliance therapy are considered medically necessary; while adjustments performed after 6 months are subject to review to determine necessity and appropriateness.8 Note: All insurance carriers have slightly different requirements, so be sure to call ahead to ﬁnd out what is covered.
Treatment of OSA in children and adults is an important endeavor. The beneﬁts of treatment include better sleep, better health, and a better quality of life for patients. For the dental professional, the beneﬁts are numerous. You can set your practice apart from the competition by offering sleep apnea services. By building a network of referring physicians, you will see more patients that may come to you for all their dental needs. With medical coverage of oral appliance therapy, you can add a valuable stream of income to your practice as well.
Besides tips on billing for OSA and TMD, Chris Bentson offers more observations on growing an orthodontic practice in his article that can be found here.
- Marcus, MB. New Sleep Guidelines for babies, kids and teens. CBS News, CBS Interactive June 13,2016. www.cbsnews.com/news/new-sleep-guidelines-for-babies-kids-and-teens. Accessed June 19, 2019.
- American College of Physicians/Internal Medicine. (ACP). https://www.acponline.org/online-learning-center/obstructive-sleep-apnea. Accessed June 19, 2019.
- Spencer, Patel M, Mehta N, et al Special consideration regarding the assessment and management of patients being treated with mandibular advancement oral appliance therapy for snoring and obstructive sleep apnea. Cranio. 2013;31(1):10-13.
- MMA-Private Contract Manual Change to Include Dentists, Podiatrists, and Optometrists in the Definition/List of Physicians Who Can Opt Out of Medicare. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM3016.pdf. Accessed June 19, 2019.
- Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome. American Academy of Pediatrics. Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2002;109(4):704-712.
- Mehra P, Wolford LM. Surgical management of obstructive sleep apnea. Proc (Bayl Univ Med Cent). 2000;13(4): 338–342.
- Salzmann Evaluation Form. Aetna Dental [Claim Submission Tips & Guidelines]. https://www.aetnadental.com/professionals/pdf/salzmann-evaluation-index.pdf. Accessed June 19, 2019.
- Temporomandibular Disorders. Aetna [Clinical Policy Bulletins/Medical Clinical Policy Bulletins]. www.aetna.com/cpb/medical/data/1_99/0028.html. Accessed June 19, 2019.