Medical Code for Custom-Fitted Obstructive Sleep Apnea Appliance
E0486 is the current HCPCS medical code for a custom-fitted mandibular sleep apnea appliance, used for dental sleep medicine medical billing.
The description for E0486 is an oral device/appliance used to reduce upper airway collapsibility. This includes adjustable or non-adjustable, custom fabricated, fitting and adjustment
Typically when billing for the E0486 code, most insurance companies require the use of the modifier NU. Thus, on the medical claim form, the full code is E0486-NU.
NU stands for new equipment, and is needed because insurance companies won’t pay for a returned appliance that you tried to re-use! Actually, the real reason is that E0486 is a DME code (Durable Medical Equipment). In that category of equipment, many items can be new or used, such as wheelchairs or CPAP parts.
E0486 Code for Medicare Dental Sleep Medicine Billing
When billing a dental sleep medicine case to Medicare, another modifier is required with the E0486 code. That modifier is KX, which means your documentation for that case is on file. So when billing to Medicare, the full code to use is E0486-KX-NU.
If the documentation requirements have not been met, you should not use the KX modifier. Instead, you will use the EY, GA or GZ modifier depending on the situation.
EY modifier stands for: No physician or other licensed health care provider order for this item or service.
GA modifier stands for: Waiver of liability statement issued, as required by payer policy.
GZ modifier stands for: Item or service expected to be denied as not reasonable and necessary.
Note that dentists must have their DME supplier license before they can begin treating Medicare patients for obstructive sleep apnea with oral appliance therapy. Nierman Practice Management has a DME supplier license application service that has helped hundreds of dentists acquire their DME license.
What ICD-10 Diagnosis Code Goes with E0486 Dental Sleep Medicine Code?
Dental sleep medicine practices that are billing obstructive sleep apnea treatment to medical insurance need to have the correct ICD-10 diagnosis code on the claim form when billing the E0486 code.
The ICD-10 diagnosis code for obstructive sleep apnea is G47.33. Keep in mind that this diagnosis MUST come from a sleep physician and that a dentist CANNOT diagnosis obstructive sleep apnea.
For more information on dental sleep medicine medical billing protocols, visit www.NiermanPM.com for cross-coding seminars, software programs, and other resources to help your practice implement medical billing in dentistry. See our current schedule of cross-coding courses to obtain the most up-to-date knowledge and strategies for maximizing your medical billing reimbursement success for sleep apnea, TMD, and oral surgeries.