Billing for the treatment of OSA with oral orthotics:

PROObstructive Sleep Apnea is a medical disease. All time and procedures spent evaluating for or treating OSA is, therefore, generally covered only by the patient’s medical insurance. All claims must be submitted on a CMS 1500 form printed in the original red or electronically submitted.

Evaluation:
Unlike dentistry, medical codes (CPT) are based on time the provider spends directly with the patient. There are no codes for time an ancillary staff spends with the patient. If periodontal probing and charting is done by a hygienist or dental assistant, the dentist cannot legally bill for the time spent gathering data; the dentist can charge for the time he / she spends reviewing the charting.

Consultation:
99241
99242
99243
99244
99245

Specialist Visit:
99201
99202
99203
99204
99205

Examination / Follow-up Office visit
99211
99212
99213
99214
99215

Oral Orthotic:
E0486 Used by most private medical insurers: Defined as a custom fabricated oral orthotic for the treatment of obstructive sleep apnea. This includes 90 – 180 days of follow-up visits without additional cost.
E0485: An uncovered service with most insurers. This includes a prefabricated device, that is fitted in one visit by heating and remolding the device in the mouth, or adding additional acrylic. These have been proven to be more bulky and less well tolerated thatn custom fabricated devices.
21085: Used by Tricare (U.S. Armed Forces Coverage)

There are codes for radiographs including full mouth series and lateral cephalometric films e.g. 70250. Even though the codes exist, they are rarely considered a ‘covered service’.

Diagnosis Codes:

327.23 Obstructive Sleep Apnea (ICD code)
327.20 Disordered breathing not otherwise specified (ICD code)
786.09 Snoring***** (CPT code)

Most insurance companies have very strict guidelines as to which diagnosis code is considered a disease, and treatment is therefore covered. Very few, if any, insurance companies will cover treatment for snoring or upper airway resistance syndrome.

It is highly recommended that dental office seek “predetermination of medical necessity” for all oral orthotics from the patient’s insurance company. This will make it easier for the patient to seek reimbursement from his medical insurer if the dentist does not accept insurance. The insurance company will require a letter explaining the treatment to be provided, the pertinent codes and fees involved. They will also want a copy of the polysomnogram reports, a letter of medical necessity from the referring physician and possibly a copy of the dentist’s evaluation notes / letter to the referring physician and an explanation why CPAP is not being used. The majority of insurance companies have an oral surgery/ maxillofacial reviewer who is responsible for determining if the patient meets the guidelines set forth in the insurance companies “Medical Policy for obstructive sleep apnea”. If so, then, pre-determination will be granted. This does not guarantee payment on the claim. Pre-certification deals with payments. Always check the policy guidelines for each patient to make sure they have benefit coverage for oral orthotics.

Other than oral surgeons, most dentists are considered “out-of-network” medical providers. Some dual degreed (DDS and MD) dentists do have contracts with medical insurance companies, but many do not. Thus, dentists can often request “Gap exception” from an insurance company. If a patient is required to utilize in-network providers for maximum benefit coverage, and the insurance company does not have anyone in-network who can do oral orthotic therapy, then many policies allow the insurance company to reimburse out-of-network providers at in-network rates. This is known as Network Gap or Network Insufficiency. Coverage at the higher rate must be requested by the dental office. Depending on the insurance company and the policy, this may be handled by the Precertification group or by Benefits / claims; who grants this exception may vary within one medical insurance company.

Some employers ask that oral orthotics not be covered under the policies they buy for their employees. The “Big Three Auto” makers write this coverage out off their policies. Note that some medical insurance companies will argue that “orthotics” are not covered by a patient’s policy. They are referring to foot orthotics and not oral orthotics for the treatment of OSA. It is common that a representative will absolutely refuse to authorize coverage for oral orthotics and discussion with a supervisor, the medical director or a request to obtain a copy of their medical policy on obstructive sleep apnea may be required.

Denist1

Dentists play an important role in the team approach to the treatment of obstructive sleep apnea.

Physicians, dentists, psychologists, and respiratory therapists all pool their knowledge to treat each patient appropriately and effectively.

Dentists who are specifically trained in aspects of sleep medicine and have a command of multiple appliance modalities are of great help to physicians in treating patients with sleep disordered breathing problems.

AVALABLE OFFICE HOURS:

Monday – Friday
8:30 A.M. – 2:30 P.M.
In Massachusetts Call:
617-964-4028
or click here
 In Indiana Call:
317.842.9866

The National Center on Sleep Disorders Research, can provide you with sleep education materials. As well as publications on heart, lung and blood research:
Two Rockledge Center, Suite 7024, 6701Rockledge Drive, MSC 7920, Betesda, MD 20892-7920
(P)301.435.0199 /
(F) 301.480.3451
www.nhlbi.nih.gov/about/ncsdr/

Information about sleep disorders may be obtained from NHLBI:
NHLBI Information Center
P. O. Box 30105, Bethesda, MD 20824-0105
(P) 301.251.1222 / (F) 301.251.122
www.nhlbi.nih.gov/