Test your Knowledge with our Medical Billing for DSM Quiz by Rose Nierman, CEO Nierman Practice Management


Revised ABN Form is Now Mandatory for DSM Treatment

When teaching medical billing to dental practices, I encounter quite a bit of confusion about Medicare for Dental Sleep Medicine (DSM). In our sleep and temporomandibular joint (TMJ) treatment lectures and Medical Billing for Dentists course, we endeavor to dispel Medicare and DSM billing myths as well as make updates available to DSM dentists. One area of mass confusion is the Medicare Advance Beneficiary Notice (ABN) form. Most dental practices are not aware of the ABN form which is understandable since we don’t use it for dental insurance – but the ABN needs to be part of your toolkit for DSM. For those who are aware of it, there still seems to be quite a bit of confusion surrounding the proper use of the form.

For DSM practices, it’s important to avoid a situation in which you may have to refund fees for your services or supplies – and in short – that is the main purpose of the ABN. Whether you are new to the form or have it in your toolkit already, it’s important to know that Medicare has recently released a new version of the ABN, effective June 21, 2017. If you are a Medicare provider or supplier, you are obligated to use this new form. One of the changes is the addition of an expiration date of 03/20/20. Another change is this nondiscrimination clause:

CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call 1-800-MEDICARE or email: AltFormatRequest@cms.hhs.gov.

You can download a copy of the new ABN form from this link: https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html.

The following quiz is helpful to test your Medicare billing knowledge: Since Medicare’s policy places oral appliances for Obstructive Sleep Apnea (OSA) under the Durable Medical Equipment (DME) category, the quiz will reference DME.

  1. Our office doesn’t have to follow the Medicare OSA guidelines since we are only “referring and ordering providers.” True or False
  2. We are not a Medicare DME supplier, so we can simply charge Medicare patients cash for OSA oral appliances without the patient signing a form. True or False
  3. Since we opted out of Medicare, our patients do not have to sign any forms. True or False
  4. We can use any type of appliance that our dentist feels is appropriate and still be within Medicare guidelines. True or False
  5. If we sign up as a DME supplier, then we also must file TMJ treatment claims to Medicare DME. True or False

The answers to the all of the above questions are false. Explanations are below:

  1. A referring and ordering provider is for Part B for billing Medicare services. Since most dentists do not provide services that Medicare Part B covers, the majority of dentists have enrolled as referring and ordering providers so that prescriptions will be covered for the Medicare beneficiary. Becoming a DME supplier is a separate application process. The DME application is available at https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855s.pdf. It is a minimum of 90-day process to become a DME supplier and the application can be quite complicated. To ease the burden of the paperwork, Nierman Practice Management has a service for enrolling dentists as DME suppliers. More information about this service can be found at www.NiermanPM.com
  2. If you are not a Medicare DME supplier and you provide oral appliance therapy, the patient must sign an ABN form that tells them that the device would potentially be covered if the patient went to a Medicare DME supplier.
  3. The Opt-Out option is a 2-year period where the provider agrees that they (nor will the patient) file any Medicare claims for supplies or services. The patient must sign a different form which is called a private contract for practices which are opted out of Medicare.
  4. Medicare maintains a list of cleared appliances called the PDAC list. Only appliances found on this list are eligible for reimbursement for E0486, the HCPCS code used to bill a custom made oral appliance for OSA.
  5. Since Medicare DME does not cover appliances for the diagnosis of Temporomandibular Joint Disorder (TMJ), you do not need to bill TMJ orthotics to DME. An ABN does not need to be executed for items that Medicare never covers.

The purpose of an ABN is to inform the beneficiary that Medicare will not likely pay for a certain item or service in a specific situation on the basis of medical reasoning and necessity, even if Medicare might pay for the item or service under different circumstances. This allows the beneficiary to make an informed consumer decision about whether to receive the item for which they may have to pay out-of-pocket.

The ABN includes:

  • The items or services that Medicare isn’t expected to pay for
  • An estimate of the costs for the items and services
  • The reasons why Medicare may not pay
  • Three options for the patient to choose for moving forward with treatment…or not

In the DSM setting, here are a few examples of situations in which an ABN may be used:

  • The dental practice is not a DME supplier
  • A Medicare approved (PDAC cleared) appliance was not used
  • The patient does not meet the criteria for coverage
  • The patient does not have a Detailed Written Order (DWO) from their physician
  • Services are not covered (where in another situation they may be covered)

The main reason the ABN is so important: the ABN will ensure that if Medicare ultimately does not cover the oral appliance for OSA, you have the ability to charge the patient. The ABN proves that you informed the patient before providing services that it may not be covered, and why. If you do not have an ABN on file for the patient and Medicare ultimately does not cover the oral appliance, you cannot charge the patient – you must eat the cost!

So why is Medicare such an important topic in the DSM arena? Of course, Medicare is largest insurer in the United States, but another reason revolves around how patients will end up in your practice for treatment. Sure, you can market your services to patients, but a common denominator in the most successful DSM practices we see is a strong referral base from physicians in the local medical community. The sleep physicians you will be working with typically look for a dentist who is enrolled in Medicare, as most physicians do base where they refer their patients on insurance type. From a referral standpoint, the more medical insurers you work with, the better.

Dispelling some of the Medicare and Medical Billing Myths will not only help your practice treat patients who are suffering from OSA, but also gain reimbursement for them!


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