If a dentist treats obstructive sleep apnea using a custom oral appliance, then the treatment can be billed to the patient’s health insurance. But what are the steps you need in medical billing for dental sleep apnea appliances? In this latest blog, we will provide 3 key steps for dental sleep apnea medical billing success.
1. Know The Medical Codes
Most medical insurance plans provide coverage for custom oral appliances for Obstructive Sleep Apnea (OSA). While the medical codes are not the only thing you need for successful medical reimbursement, it’s surely important to have the correct ones! Not only to bill the medical claim but also to predetermine if the patients’ medical plan covers oral appliances for OSA.o
You will need two codes to bill or predetermine coverage for the oral appliance:
• ICD-10 Diagnosis Code G47.33: Obstructive sleep apnea (adult) (pediatric)
• HCPCS Code E0486: Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment
Pro tip: most medical insurers require the modifier “NU” with HCPCS code E0486.
See the “Rose’s Rules” video blog on the medical codes for dental sleep apnea appliances.
2. Gather Data
Prior to placing the oral appliance for OSA, copy the front and back sides of the medical card. Most practices then call the insurer to verify benefits.
Use the telephone number designated for eligibility/verification of benefits or predeterminations.
Gather key patient questionnaire information including their medical history, symptoms, treatment attempts, co-morbidities, and a copy of a diagnosed sleep study when available. *Diagnosis must come from a sleep physician.
Gathering this data builds your case of medical necessity, ensuring you have your ducks in a row, ready to respond to pertinent questions such as co-morbidities or other treatment attempts that the health insurance carrier may require in order to reimburse.
Pro tip: Use software to establish a repeatable system that allows your patients to complete their medical history & sleep screening questionnaire online.
3. Verify Benefits
Verifying medical benefits is always step #1!
Keep in mind, without verifying benefits, you can’t even be sure that the patient’s medical plan is currently active, let alone get an idea of what the patient’s out-of-pocket costs may look like, or if a pre-authorization is required. (super important to know!)
For dental practices, benefit verifications are typically accomplished with the medical plan by telephone.
You will find some medical insurers that allow providers to perform these online, however many times will require a phone call for a dental practice, as the information available online is not always as detailed as needed. When you verify benefits, be sure to record the remaining deductible, co-insurance percentage, out-of-pocket maximum remaining, and whether or not a pre-authorization is required.
Pro tip: For out-of-network providers: always verify both in and out-of-network benefits when available, you may be able to use the patient’s in-network benefits with an approved gap exception/network deficiency request!
Receive the Dental Sleep Medicine Patient Questionnaire
To download a free example of NPM Dental Sleep Medicine questionnaire fill out your information here:
We know that medical insurance reimbursement for dental sleep medicine has a significant impact on the patient’s decision to accept treatment.
Whether you are calling for benefits, doing a preauthorization or filing the medical claim for an oral appliance for OSA, there is a reason for every question the insurance representative asks. All of this information is needed before the medical insurance will agree to release any benefits the patient is due per their policy.
As stated above, most policies do reimburse for sleep apnea appliances. Your office can have incredible success with the right documentation and records and by learning the medical billing ropes.
That is why we, at Nierman Practice Management have the motto: “Get your ducks in a row” with dental to medical cross-coding solutions – including software systems, medical billing services, and above all, continuing education and training resources. Learn as much as you can about medical billing for dentists so that more patients can access life-altering oral appliance therapy for OSA.
Please feel free to contact us with any questions related to this article on getting started with medical billing for dental sleep appliance therapy, or the sample dental sleep apnea questionnaire. Send us an email at firstname.lastname@example.org or call 1-800-879-6468 option 1.
About: Nierman Practice Management
Nierman Practice Management is the leader in medical billing and cross-coding solutions for dental practices.
They have been helping dental practices expand into medical billing, sleep apnea treatment, & TMJ/orofacial pain since 1988, with innovative technology platforms, training, and medical billing services.
Their solutions include:
DentalWriter Software – for SOAP Reports, Medical Billing, Sleep Apnea, TMD, & Implants
Nierman Medical Billing Service
CE Courses, Training, & Resources – Live, Online, and In-Office
See upcoming courses in medical billing for dentistry and happy cross-coding!
Article by: Rose Nierman