Is your dental practice treating patients suffering from sleep-disordered breathing, namely Obstructive Sleep Apnea (OSA)? If yes, and you are billing medical insurance, you have probably asked yourself this question we commonly hear at Nierman Practice Management: “how old is too old for a sleep study?”
The quick answer: the more recent the sleep study, the better! The longer answer: some medical insurers require that when an oral appliance for OSA is placed based on a sleep study, the sleep study can be no more than 12 months old, while others allow a study’s age to be older, such as 2-3 years. Some other insurers may not have a written guideline specifying a time frame for the age of a sleep study at all! So can vary by insurer.
An example of a required time limit is Medicare which requires that the sleep study be no older than 12 months before delivering a custom-made oral appliance for OSA. According to Medicare’s guidelines1, “Timely documentation is defined as a record in the preceding 12 months unless otherwise specified elsewhere in the policy”.
Dental offices should consider this question from both a clinical standpoint and a medical insurance standpoint. It is vital to be familiar with the required age for your patient’s treatment to be eligible for coverage from a medical insurance standpoint so that you can maximize the patient’s insurance benefits. You or your billing company can reference the insurer’s medical policy for diagnosis and treatment of OSA to confirm if there is a time frame specified for the age of sleep studies (or to be on the safe side, ask this question while verifying benefits).
Stay Up-to-Date with Evaluations and Diagnosis
From a clinical standpoint, ensuring up-to-date evaluation and diagnosis takes place will always benefit the patient and you as the health professional. Consider this scenario: a patient presents to your practice for an oral sleep appliance evaluation, and the most recent sleep study was three years ago. That study from three years ago revealed an Apnea-Hypopnea Index (AHI) of 11, and the patient was diagnosed with mild obstructive sleep apnea. The patient is determined to be an appropriate candidate for sleep appliance therapy and begins treatment. Once the appliance is properly calibrated and the patient shows subjective improvement, they are referred for the efficacy follow-up sleep study. The results are in: the AHI is now revealed to be 13, with the appliance in place. What Happened?!?! Is the appliance making the patient’s OSA worse? Possibly not! However, we won’t know until the patient has a new sleep study performed without the oral appliance in place.
Here’s what happened: Three years ago, the patient’s AHI was 11. During the last three years, the patient gained 20 pounds, has started taking blood pressure medication, and began drinking heavily at night. If a new sleep study had been performed, it would have revealed the patient’s current AHI had risen to 29. So, the oral sleep appliance did help reduce the patient’s AHI from 29 to 13, but this fact would never have come to light without a fresh baseline study to confirm the current severity of OSA.
Working with old sleep study results can harm your positive treatment results by making them look not so positive! Relying on an older sleep study can send a negative (and untrue) message to your patients and your referring health professionals. So the moral of the story is to find out what the insurer’s guidelines say about the sleep study age. With this knowledge, your patient can reap the benefits of a paid claim while your dental practice impresses referring offices with excellent results of oral appliance therapy.
Please feel free to contact us with any questions related to this article. We provide a variety of virtual and in-person courses for dentists, including topics such as dental sleep medicine, TMJ, craniofacial pain, and medical billing in dentistry. We also have a comprehensive, online course series for medical billing in dentistry. For more information, contact us at 1-800-879-6468 option 1, by sending us an email at firstname.lastname@example.org, or by visiting niermanpm.com.
Article by: Courtney Snow & Rose Nierman, Nierman Practice Management
1. Local Medicare Coverage Article: Standard Documentation Requirements (SDR) for All Claims Submitted to DME MACs (A55426)