Sleep tests are vital when treating any sort of sleep breathing disorder. Think of them as your x-rays or imaging in dentistry. It may be possible for any dentist to complete a root canal without an PA x-ray or digital image but most will refuse, as it will be impossible to know what you will find without it. The same goes for sleep tests. Don’t get me wrong – taking records for a sleep appliance is not the same as a root canal by any means, but the sleep test for a custom-made sleep appliance is just as important as a PA x-ray or digital image are to a root canal procedure. Therefore, team should be educated on all the aspects related to testing just as we are to all the aspects related with x-rays and imaging.
Let’s take a quick look at some rules regarding dental offices when it comes to sleep testing, how to talk to patients about them and what to do with them once we have them.
First off, should every dental office offering oral appliance therapy have a home sleep test (HSTs) unit? I say yes! I am a firm believer in helping your patients to make educated decisions and there is no better way to teach someone then looking at the situation head on. Home sleep tests minimally allow us to evaluate if they stop breathing, how much oxygen they are depriving their bodies of and how many times this happens over several nights. Brilliant! In fact, the retail industry happens to think so too! There are several new products on the market that help us to evaluate our sleep – none as sophisticated as home sleep apnea tests (HSATs) to score breathing but some evaluate how much sleep we are getting and what stage of sleep we spend our time at night in. The more we learn about sleep the more we will want to know the quality of our own, our family and our team’s sleep and HSTs are the way to go!
As a DSM coach I am constantly asked about rules of using HSTs so here are the rules as I understand them in a nutshell:
Rule 1. Dentists cannot diagnose any kind of sleep disordered breathing condition. Unfortunately, a dental license does not include diagnosing medical conditions in any state at this time. But, a sleep test in a dental practice can be used for three good purposes. A. Screener, B. Diagnosis with physician interpretation and C. Follow up testing after device placed with physician interpretation.
Rule 2. Focus on how it can be used to educate your patients. Different sleep test units record and report data differently. Some will record real sleep time and sleep staging, others have cannulas and chest belts to record nasal resistance and respiratory effort and some will record muscle activity to analyze clenching. What is important to understand is there could be a big difference between units and no matter which unit you use, focus on how it can be used to educate your patients.
Rule 3. Don’t count on medical insurance reimbursement. Yes, there are codes and if the patient has been previously diagnosed billing a follow up efficacy sleep test may qualify for benefit. However, just as mentioned above, any sleep disordered breathing condition cannot be diagnosed by a dentist and those diagnostic codes happen to be the only codes medical insurance companies will pay for when it comes to the use of a home sleep test. Therefore, a physician’s diagnosis is required. It is my experience about 50% of insurance companies follow Medicare’s policy, which states that a home sleep test cannot be ordered, dispensed, or billed by a DME supplier (aka dentist providing an oral appliance enrolled as a Medicare DME supplier). Also, a home sleep apnea test can be used for primary diagnosis only if ordered by a physician as result of a face-to-face evaluation. Lots of rules to follow! So if we are not billing the insurance but rather focusing on how we can use the information for educating the patient, we can help our patients choose what is best for them. Once educated, patients always have the option to do what is necessary for insurance reimbursement. You may be surprised how many patients opt for a “out of pocket” objective test once they understand the process of what is needed to gain benefit.
Ok, now that we got that out of the way, we can focus on communicating with patients and what to do with the tests once we have them.
As team members, we pride ourselves on understanding and following systems which means we like to keep our office moving and producing. This requires us to look ahead to make sure we have all we need to deliver the product. A sleep test in a dental sleep medicine practice is one of the first action steps in any system or process. When we are communicating with patients that have never had a sleep test, the message we strive to deliver should be all about getting tested and finding out how that specific patient is breathing during sleep. Once this occurs, we and our doctors can spend time educating the patients on their results and our doctors can suggest the appropriate treatment. In order to educate the patients on their results their base line sleep test must be in hand; this will allow us to talk about all the great information these tests reveal. As team we are responsible for getting a copy of our patient’s base line sleep test to our doctors for them to evaluate and prepare themselves for the patient visit. It should be part of room set up just like a mouth mirror – have a copy of the base line sleep test in the room before the evaluation starts. As a team member personally, I got into the habit of highlighting information “for my doctor,” which really was for my use. Things like confirmation of base-line study versus PAP titration, date of study, notes from physician, diagnosis, AHI, Nadir SPO2 (lowest oxygen level) and percentage of N3 (deep sleep). If a copy of the test is not obtained the evaluation cannot be completed. If patients who have not had a sleep test call your practice don’t turn them away to go get a test. Get them in the door! We team can play a vital role in educating the patient about the process to get diagnosed and referrals can be made to physicians, which should strengthen referral relationships. If a patient has insurance that requires a physician face-to-face evaluation to order a sleep test, educate the patient about this process. An educated patient may choose a different approach to obtain a diagnosis, deciding what’s in their best interest regardless of insurance coverage.
When using HSATs in the practice it is important to track them. One unit is easier to track then five, but a system is needed. A pick-up, drop-off system should be put in place to know where they are at all times. Get training with your product – some units require you to change batteries between patients and others require 4-8 hours of charging before being able to record data. These are important factors with scheduling pick up and drop off times. Learn how to use the unit(s); most require you to pre-load minimal patient information and get it ready for each patient. It’s never fun when patients return units only to find out no information was recorded because it was not set up properly. Downloading the data is equally important for the same reason. When delivering the HSAT to your patients demonstrate how they are used. Each unit should have written instructions and most have video instruction for the patient to follow. It’s always a great idea to try out the unit(s) yourself! Not only will it give you the experience of wearing it so you can explain to patients what to expect, but it will also give you great knowledge about your quality of sleep!
Editor’s Note: This Sleep Team Column will be dedicated to the team and provide practical tips and resourceful information. Let us know your specific issues by email to: SteveC@MedMarkAZ.com, while we can’t respond to every individual. Your feedback will help us create the most useful Sleep Team Column we can!