Join the Movement for CrossCoding and Airway Health

by Rose Nierman, Founder & CEO, Nierman Practice Management

Great news for dental practices! The average allowed amount that clients of Nierman Practice Management’s (NPM) medical billing service saw in 2019 for a custom-made oral appliance for OSA (Code E0486) was approximately $3,000. Some insurers pay more, some less, but all of them have one thing in common; prior to providing reimbursement, the insurer wants to ensure that the services meet their guidelines for medical necessity.

So, what are the guidelines for medical necessity of a custom-made oral appliance for OSA? The requirements vary per insurer, but there is a common denominator – a narrative report from the dentist’s oral exam in the SOAP format. Insurers require these narrative reports, “the clinicals”, during preauthorization of an oral appliance. The SOAP report includes subjective symptoms and comorbidities, objective exam findings, assessment (with ICD-10 codes), and the plan, including follow-up.

Convert to a medical practice model by doing the following:

1. Many insurers now require a SOAP report generated from the delivery appointment, in addition to the exam. Implement a system for documentation of medical necessity for each oral appliance visit.
2. When a pre-authorization is required for an oral appliance, submit the documentation of medical necessity and await an approval prior to delivering the appliance to the patient.
3. Include the sleep study, a prescription from the treating physician and documentation of CPAP refusal or
4. Provide documentation of hypertension, excessive daytime time sleepiness and other comorbidities of OSA.
5. Be prepared to request the clinical notes from the physician who saw the patient prior to a sleep test.
6. If you would like to provide oral appliance therapy for Medicare beneficiaries, you must become a DME suppli Review Medicare documentation guidelines and know when to execute a signed waiver of financial liability for situations such as when there is previous CPAP use.
7. If your facility is not a DME supplier and you are providing oral appliance therapy to a Medicare beneficiary, a signed waiver of financial liability informing the patient that Medicare will not reimburse is required.

Join the movements for airway health and Cross-Coding to transform your office into the medical model and a comprehensive wellness office. Nierman Practice Management strives to stay abreast of changes in medical billing for dentists relating to dental sleep medicine, oral surgeries, TMD, CBCT, and other procedures. We’re happy to help you with any questions and review proven, repeatable strategies that many DSM dentists have applied to be successful.