Unlocking the code to medical insurance for oral appliances for OSA

Rose Nierman, founder and CEO of Nierman Practice Management, offers advice to facilitate insurance reimbursement

PM_Nierman_Insurance_600x300Unlocking 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.

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.

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.

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.

Nierman_Headshot_150x150Rose Nierman has been at the forefront of educating dental practices on medical billing in dentistry, cross-coding, and the expansion of patient services for more than 26 years. She is the creator of DentalWriter™ Software and a CE provider for Cross-Coding; Unlocking the Code to Medical Billing in Dentistry™. Contact Nierman Practice Management toll-free at 1-800-879-6468, or visit www.NiermanPM.com.

Stay Relevant With Orthodontic Practice US

Join our email list for CE courses and webinars, articles and mores

Subscribe Today

Orthodontic Practice US is a leading dental journal and your publication for Orthodontic continuing education, Orthodontic case studies, and more. Subscribe to Orthodontic Practice US today!

Online Dental CE

Earn 16 dental continuing education credits as an Orthodontic Practice US subscriber per year.

Other Dental Publications
Dental Sleep Practice
Endodontic Practice
Implant Practice
Orthodontic Practice

MedMark Media is the leading interactive marketing and advertising company specializing in marketing and advertising, custom media, and public relations for the U.S. dental industry.

AGD PACE MedMark White

Copyright © 2024 Orthodontic Practice US - Dental Journal and Online Dental CE | MedMark LLC
15720 North Greenway Hayden Loop, Suite #9 Scottsdale, AZ 85260 | All rights Reserved | Privacy Policy | Terms & Conditions

Scroll to Top