How do I bill a patient's medical insurance for a TAP snore guard appliance?
Although the office indicates the main questions they have are, what type of form to use, what codes are applicable and are they different, I would be doing them a disservice to only answer those questions without asking a few of my own.
Let’s take the email above and break it down.
My first question to the subscriber above would be, "Is this appliance for snoring?".
From the email it sounds like they are providing an appliance for snoring until you read further and see they have a referral from the medical provider as well as a sleep clinic. With this type of a study one might assume the patient has sleep apnea, but someone can have a sleep study and still not be diagnosed with obstructive sleep apnea.
My next question to them would be, "Does the polysomnogram indicate the patient has obstructive sleep apnea or some other respiratory condition (i.e., snoring)?".
The answer will drive the direction of claim submission. If the diagnosis is OSA (obstructive sleep apnea) the claim should be submitted to the medical insurance on a CMS 1500 claim form using medical codes. If the diagnosis is snoring it is unlikely there will be any reimbursement from the medical or dental plan. In most instances appliance therapy for the treatment of snoring alone is not considered medically necessary.
If the patient is diagnosed with snoring and or sleep apnea and insists that they would like you to submit a claim to their dental insurance, the following code may be used to submit the claim on the ADA 2012 claim form.
D5999 “unspecified maxillofacial prosthesis, by report”, is the CDT code the ADA recommends to use when billing a snore guard or sleep appliance to a dental plan. Please keep in mind that the dental carrier is highly unlikely to pay for these types of appliances.
When a patient is diagnosed with obstructive sleep apnea your best bet for coverage is the medical plan.
When verifying that the patient indeed has OSA there are a few steps you want to take before fabricating the appliance:
- Obtain information and records (polysomnogram, referral or written prescription, letter of medical necessity).
- Verify medical benefits (referral requirements, pre-authorization requirements, availability of benefits for out of network providers).
- Request a network gap exception (if no in network providers are available it is possible to request that the patient be seen by an out of network provider, do this prior to treatment).
- CPAP intolerance letter (some carriers require patients to try the CPAP prior to oral appliance therapy and if so they need to know the patient or patient’s spouse was intolerant to that treatment and why).
Now that you have taken the steps to make sure you have the proper documentation you are ready to file a claim to the medical insurance for the patient.
Make sure to bill all the related procedures leading up to and following the delivery of the sleep apnea appliance.
ICD-10 diagnostic codes that may be considered for coverage under the patients plan:
- G47.33 Obstructive sleep apnea (adult, pediatric)
- G47.30 Sleep apnea, unspecified
- R06.83 Snoring
CPT procedure codes considered for coverage:
Evaluation and Management codes:
- 99202 Expanded problem focused evaluation, new patient
- 99203 Detailed evaluation, new patient
- 99212 Expanded problem focused evaluation, established patient
- 99213 Detailed evaluation, established patient
- 70250 radiologic exam, skull, less than 4 views or
- 70320 radiologic exam, teeth, complete, full mouth
- 70355 orthopantogram
Oral appliance codes (may include adjustment appointments for up to 90 days):
- E0485 oral device or appliance to reduce upper airway collapsibility, adjustable or nonadjustable, prefabricated, includes fitting and adjustment
- E0486 oral device or appliance to reduce upper airway collapsibility, adjustable or nonadjustable, custom fabricated, includes fitting and adjustment
- NU – some carriers require this modifier to indicate “new equipment” with E0485 or E0486
Follow up care:
- 99212 expanded problem focused evaluation, established patient (if applicable)
It is important for offices to understand the challenges in obtaining coverage for appliances for sleep apnea. I can’t stress enough for you to contact the patient’s medical carrier to see what specific criteria you will need to meet for that particular plan. Many medical carriers provide the necessary information on their websites, while others will require you to contact them directly.