A guide to documentation requirements for oral appliance therapy for sleep apnea
The great news is medical insurers consistently offer coverage for custom-made oral sleep appliances for patients suffering from Obstructive Sleep Apnea (OSA)…. even Medicare! That is right – medical insurance, not dental! Although custom-made oral appliances (HCPCS code E0486) for OSA (ICD-10 code G47.33) are provided by dental practices, they are covered by a patient’s medical insurance because they are considered medically necessary services/equipment provided in the dental practice setting. The question is: what all is needed for successful reimbursement?
There are 3 standard items across ALL medical insurers that are always required:
1. The patient’s sleep study report
Medical insurers typically only cover a custom-made oral sleep appliance if the patient is diagnosed with OSA – either mild (AHI 5-15), moderate (AHI 15-30), or severe (AHI 30+). Currently, the only way to diagnose OSA is through a sleep study, so a copy of the sleep study report is always required to provide the diagnosis of OSA. We have seen a *few* medical insurers state in their coverage policies that Upper Airway Resistance Syndrome (UARS) may be covered when attempts at behavioral modification have been tried & failed, however that is currently rare. It is also rare to see coverage if the diagnosis is primary snoring vs sleep apnea.
2. A prescription or written order from a physician
Custom-made oral sleep appliances for OSA are categorized as Durable Medical Equipment (DME). As with most DME, the majority of medical insurers require a physician’s written prescription/written order (“physician” is typically defined as MD, DO, NP PA, or CNS working within their scope of practice). The written prescription to the dentist requests that a custom-made oral sleep appliance be provided to treat OSA. To make it simple to document, there is even a field on the medical claim form to indicate the referring/ordering physician’s name and NPI number! (field 17).
3. Clinical/SOAP notes from the dentist’s evaluation
The clinical notes, preferably in SOAP format (subjective, objective, assessment, plan) are extremely important for several reasons. One scenario is an increasing trend we have seen developing over the last year or so – many medical insurers are now stating in their coverage policies that for a patient to meet coverage criteria for a custom-made oral appliance for OSA, the dentist’s evaluation notes must include that the patient is free from active periodontal disease and active TMJ disorders.
Another scenario would be if the patient is diagnosed with mild OSA – many medical insurers require that if a patient is diagnosed with mild OSA, in order to meet coverage criteria for a custom-made oral appliance they must have at least one comorbidity of OSA documented in their medical history (the subjective section of the clinical notes). The items necessary to document include symptoms of problems including excessive daytime sleepiness, impaired cognition, mood disorders, insomnia, hypertension, ischemic heart disease, or history of stroke.
There are 3 other items we see extremely frequently, so it is a great idea to always have these on file so you have them handy if the medical insurer requests them:
1. Clinical notes from treating/ordering physician
The clinical notes from the treating/ordering physician are another growing trend we have been noticing over the last year or so. For example, United Healthcare’s medical policy lists as part of their coverage criteria that “a patient presenting with symptoms of OSA be seen in a face-to-face evaluation with a qualified physician (MD or DO) trained in sleep medicine prior to beginning treatment for OAT”. The medical policy goes on to state in further coverage criteria “If the patient refuses CPAP therapy, documentation of the refusal from the patient’s treating physician (MD or DO) must be supplied”.
2. Proof of delivery form
Proof of delivery is a standard piece of documentation in the DME medical billing realm. This is a form signed by the patient (or tracking information if the item is shipped) to prove that the patient actually received the equipment/item. Due to a long history of fraud in DME medical billing, custom oral appliances for OSA should not be billed to the medical insurer until the patient has the appliance in their possession (in other words, the date of service on your medical claim will not be the date of impressions, it will be the date of delivery). The proof of delivery form is also essential for documentation since some medical insurers only offer coverage when the appliance used is PDAC approved (aka Medicare-approved) for the medical billing code, E0486. These appliances can be viewed at www.dmepdac.com by searching code E0486 in the product classification list option.
3. CPAP/PAP therapy affidavit of refusal or intolerance/noncompliance
When a patient is diagnosed with severe OSA, most medical insurers require documentation that Continuous Positive Airway Pressure (CPAP/PAP) therapy has been tried and failed, the patient refused this therapy or CPAP/PAP therapy or the physician determines that therapy is contraindicated prior to coverage being offered for a custom-made oral appliance. The guidelines pertaining to the PAP therapy trial vary. For example, some medical insurers require a 30 or 45-day trial, while others do not specify any specific time period. Additionally, some medical insurers will accept a specific form signed by the patient (CPAP/PAP affidavit of intolerance/non-compliance), while some medical insurers require documentation from the physician as we see in United Healthcare’s medical policy mentioned above stating “If the patient refuses CPAP therapy, documentation of the refusal from the patient’s treating physician (MD or DO) must be supplied”.
Having a system in place to gather information, store, and create SOAP reports is key for a streamlined & successful protocol. Nierman Practice Management’s DentalWriter software helps practices implement dental sleep medicine & medical billing by generating SOAP reports and medical claims to successfully work with their patient’s medical insurance. With the right tools, you can be confident that your documentation ducks are in a row!
Article by: Courtney Snow, Nierman Practice Management
Please feel free to contact us with any questions related to this article. We host a variety of online and live 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 Nierman Practice Management at 1-800-879-6468 option 1, by sending us an email at firstname.lastname@example.org or by visiting niermanpm.com.