Imagine a customized device that reduces high blood pressure, heart disease, improves cognitive disorder and relationships, not to mention reduces the incidence of motor vehicle accidents! Dentists have the means to supply this device in the form of an oral appliance therapy (OAT) for obstructive sleep apnea (OSA).  Oral appliances for OSA provide a “dental solution for a medical condition” and can be very rewarding for patients and the dental practice.  OAT also provides a dental practice the opportunity to work in partnership with physicians and to bill medical insurance for the benefit of their patients, especially for sleep apnea appliances.

Medical Claims for Dentists and Sleep Apnea Appliances

There are no specific dental codes available for sleep apnea appliances for obstructive sleep apnea so medical insurance is the insurance of choice.  It’s important for dental offices to learn medical billing in dentistry oral appliances and other procedures such as temporomandibular joint disorder (TMD) and oral surgeries.

When billing medical insurance in dentistry use the standard medical claim form, as opposed to a dental claim form.  Electronic billing is also a viable option for medical billing for dental practices by using dedicated software such as DentalWriter software.

Billing Dental X-Rays and Exams to Medical Insurance

The first appointment involving the oral exam and the upper airway screening visit is typically billed to a patient’s medical.  Most commercial carriers reimburse for this initial exam and the necessary imaging.

There are numerous medical exam codes available for dentists as well as radiographs such as a panorex.  Cone beam computed tomography (CBCT) is also reimbursable by many medical insurance carriers.

Medical Exam Codes Can Be Submitted By Dentists

The medical code for oral device for OSA is a type medical code called a HCPCS code which are designated for supplies or durable medical equipment.  There is a specific code for OAT: ORAL DEVICE/APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE OR NON-ADJUSTABLE, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT.  Remember this code is billed on the date of delivery of the device, not the date of impressions.

Does Medical Insurance Cover Snoring Mouth Guards Found on the Internet?

No, and for good reason. That snore could be something more!  Even though snoring may be eliminated by an over-the-counter oral appliance, the patient could still be having sleep apnea episodes known as “silent apnea”.  For this reason, and to ensure that appliances are “medically necessary”, medical insurance restricts coverage to custom mouthpieces inserted by a qualified dentists. Follow up sleep studies are frequently covered by medical plans to confirm the efficacy of the custom-made device.

 

doctor diagnosing sleep apnea

Diagnosis, Diagnosis, Diagnosis

Just as you’ve heard the adage in real estate, location, location, location, the key to successful oral appliance therapy and medical insurance reimbursement is diagnosis, diagnosis, diagnosis.

According to the International Classification of Disease, the medical diagnosis of OSA should be coded as ICD, G47.33.  This ICD code applies to child or adult OSA when diagnosed by either a laboratory or home overnight sleep study and interpreted by a sleep physician.  A copy of the sleep study should be sent to the medical insurer along office notes and a letter of medical necessity or written order from a physician. Medical histories should document high blood pressure, daytime sleepiness, cognitive or mood disorders, heart disease and other symptoms or comorbidities of sleep apnea. It’s important that dentists keep physicians in the loop with progress reports and updates.

How Do I Know If My Patient’s Insurance Covers Sleep Apnea Appliances?

Many medical policies do cover oral appliances and sleep apnea appliances.  Since Medicare approved oral appliances in 2011, medical plans have stepped up and generally offer coverage for FDA approved appliances. Medical plans vary, so it’s important to perform a benefit check by telephone or a preauthorization.  Oral appliances are considered durable medical equipment (DME) and DME benefits are considered an essential health benefit in the Affordable Care Act and so are typically covered.

 

For more info on billing medical insurance for oral appliances and other procedures, contact Nierman Practice Management or check out our cross-coding course schedule.

Author: Rose Nierman, CEO of Nierman Practice Management

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