Rose Nierman, founder and CEO of Nierman Practice Management, offers advice to facilitate insurance reimbursement
Unlocking the code to reimbursement for oral appliances for obstructive sleep apnea (OSA) is accomplished by understanding medical insurance. Seminars and workshops in cross-coding from medical to dental insurance can be helpful to decipher International Classification of Diseases (ICD) codes, Current Procedural Terminology (CPT) codes, medical claim forms, and proven processes.
Preauthorization
Successful medical billing for oral appliances typically necessitates a preauthorization, started by telephone, along with specific documentation demonstrating medical necessity. A proficient insurance coordinator initiates a benefit check call in much the same way you would for orthodontic care, with the exception of bringing ICD and CPT medical codes into play. Deductibles and copayments are then discussed with the patient. Keep in mind that there are no lifetime limits for oral appliances for OSA. In fact, some medical carriers will provide a replacement appliance within 3 or sometimes 5 years. Once the process is started, providing documentation of medical necessity is key.
Documentation requirements
Documentation to substantiate the medical necessity of oral appliance therapy involves a copy of the sleep study confirming a diagnosis of OSA (ICD-10 G47.33), a written physician order (Rx for oral appliance therapy), and confirmation of comorbidities such as hypertension, excessive daytime sleepiness, cognitive disorder, stroke, or insomnia. Some insurers ask for a written affidavit stating that the patient refused CPAP or is intolerant to CPAP. It’s vital to ask the insurer what documentation is wanted and needed.
Exams
Medical codes for exams, referred to as Evaluation and Management codes, may be submitted for an OSA oral screening and for follow up visits such as a 6-month or yearly check of the device. Just as dental insurance has different levels of exam codes, so does medical. There are five levels of medical exam codes, which range from a problem-focused exam to a comprehensive history taking and exam. When billing these “office visit” codes, it’s essential that the practice document medical history taking and exam components to support the level of the code billed, whether it be a quick check or a more detailed encounter.
Imaging
CT scans may be considered for reimbursement but do generally require pre-authorization. A panoramic view is more likely to be covered by a medical insurer with the diagnosis of OSA, and preauthorization is not required.
Oral appliance therapy
A sleep appliance is billed as E0486 — Oral Device/Appliance Used to Reduce Upper Airway Collapsibility, Adjustable or Non-Adjustable, Custom Fabricated, Includes Fitting and Adjustment. Most insurers will reimburse for repairs (unless neglect is a factor), and some also reimburse for a lost, missing, or stolen appliance.
Good and consistent documentation and records are the keys to unlocking the code to medical billing for OSA. Detailed narrative reports should be generated and sent to medical insurers to expedite reimbursement and to protect your practice. The narrative reports can also be sent to patients’ other caregivers to coordinate care and educate physicians about oral appliance therapy as an alternative to CPAP.
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