What does ABC (Airway, Bruxism, and Craniofacial Pain) have to do with cross-coding from dental to medical insurance? Services for two of these are typically reimbursed by health insurance and one of them may be paid under certain circumstances.
Items that require repeated adjustments and modification beyond the initial 90-day fitting and adjustment period in order to maintain fit and/or effectiveness are not eligible for classification as DME.
Airway management is the most predicable in dental to medical cross-coding. Most medical insurers reimburse for the HCPCS code E0486 for a custom appliance to reduce upper airway collapsibility when paired with the ICD code for Obstructive Sleep Apnea (OSA), G47.33. It is important to know what coverage criteria and documentation various medical insurers require supporting medical necessity; This criterion is in the medical insurer’s medical policies (clinical policy bulletin, local coverage determination, etc.), which are typically located on their main website on their providers page. Criteria for medical necessity coverage can vary; for example, various commercial carriers are now following the guidelines set by the Pricing, Data Analysis, & Coding (PDAC) contractor (currently Noridian Healthcare Solutions) for E0486. Because Medicare DME has required PDAC approval for custom-made oral appliances for OSA for some time now, you will often hear this referred to as the “Medicare approved appliances.” What this means is that some commercial insurers require appliance PDAC approval to be billed as E0486. The list of devices are on PDAC’s website, www.dmepdac.com. The current criteria to meet PDAC approval as stated in the Medical LCD for Oral Appliance for OSA is below:
- Have a fixed mechanical hinge (see below) at the sides, front or palate; and,
- Be able to protrude the individual beneficiary’s mandible beyond the front teeth when adjusted to maximum protrusion; and,
- Incorporate a mechanism that allows the mandible to be easily advanced by the beneficiary in increments of one millimeter or less; and,
- Retain the adjustment setting when removed from the mouth; and,
- Maintain the adjusted mouth position during sleep; and,
- Remain fixed in place during sleep so as to prevent dislodging the device; and,
- Require no return dental visits beyond the initial 90-day fitting and adjustment period to perform ongoing modification and adjustments in order to maintain effectiveness (see below)
A fixed hinge is defined as a mechanical joint, containing an inseparable pivot point. Interlocking flanges, tongue and groove mechanisms, hook and loop or hook and eye clasps, elastic straps or bands, etc. (not all-inclusive) do not meet this requirement.
Items that require repeated adjustments and modification beyond the initial 90-day fitting and adjustment period in order to maintain fit and/or effectiveness are not eligible for classification as DME. These items are considered as dental therapies, which are not eligible for reimbursement by Medicare under the DME benefit. They must not be coded using E0486.”
The biggest barrier dental practices encounter in TMD/craniofacial pain reimbursement is the absence of a narrative report of medical necessity, written by the dentist, and sent with the claim or the preauthorization.
That brings us to Bruxism
Billing for a bruxism appliance to medical insurance will very likely be reclassified as “dental treatment” – not as a medical necessity. There are two bruxism ICD codes to consider: G47.63 for “Sleep-related
bruxism” and F45.8 for “Other somatoform disorders”, which include bruxism. Recent medical policies show that a “bruxism” diagnosis may be reimbursed for Botox when the patient has “painful bruxism”. For example, Aetna’s general medical policy titled “Botulinum Toxin” states that:
“OnabotulinumtoxinA (Botox Brand of Botulinum Toxin Type A): Aetna considers onabotulinumtoxinA (Botox) medically necessary for any of the following conditions: V. Painful bruxism”
Craniofacial Pain Cross-Coding
The biggest barrier dental practices encounter in TMD/craniofacial pain reimbursement is the absence of a narrative report of medical necessity, written by the dentist, and sent with the claim or the preauthorization. A well-written narrative report based on a detailed history taking and exam is a key to TMJ treatment reimbursement. Another factor that will make or break a TMD claim is the selection of an International Classification of Diseases (ICD) diagnosis code that is covered based on the medical policies. While there are many ICD codes pertaining to a patient suffering from craniofacial pain to represent symptoms and conditions like facial pain, myalgia, headaches, tinnitus, etc., most insurers will only consider the ICD codes that represent Temporomandibular Disorders (TMD) as the primary diagnosis. These TMD diagnosis codes range from M26.60-M26.69. Thirdly, think about your language when calling for a “benefits check” and in your narrative report. Medical carriers want to see the medical necessity for TMJ disorder indicating, perhaps, a disc derangement diagnosis with head and facial pain to ensure that the treatment is medical in nature instead of a bruxism appliance to protect teeth.
The fact that over 35 states mandate TMJ treatment coverage under medical plans improves access to care. When TMJ services are covered, an exam, a panorex, the orthotic and follow-up visits are typically reimbursable. A TMJ appliance is referred to as an “orthotic” or “jaw repositioning appliance” to treat the condition, not a bite “guard or an occlusal splint” designed to protect the teeth.
Incorporating Airway, Bruxism and Cranio-facial Pain services increases the services your practice offers. Learning the latest trends in successful reimbursement helps your practice, but more importantly, your patients with life-changing treatments.