As more dentists move into procedures to aid sleep, questions about how to bill oral appliances to medical insurance are becoming more prevalent. Oral appliances for obstructive sleep apnea (OSA) have no specific dental codes, and it’s almost unheard of for dental plans to pay for these products. However, medical insurers often reimburse them. Here are some effective tips for dental practices in billing medical insurance.
OSA Billing for High Deductibles and Policy Limitations
It is between the patient and their insurance provider if the patient has a high deductible. For certain patients, having the oral appliance add to their deductible is also a plus. If the health company has a continuous positive airway pressure therapy (CPAP) clause or a Policy Limitation, an oral appliance case would be quickly disqualified from billing to medical insurance.
Other insurance companies only cover OSA appliance therapy every three years. So, if a patient had treatment and the insurer paid for it a year ago, the insurance would not pay for another oral appliance treatment until the time requirement is met. In this scenario, the patient will have to wait for their appliance or pay cash. If they don’t want to wait for the insurance time limit, they can use financing like CareCredit to get the appliance now.
Your dental office is not responsible for the coverage provided by the patient’s medical policy. It is your duty to manage the patient and assist them in improving their general health and quality of life. Begin billing medical insurance as a service you offer to your patients in order to reduce their patient section.
If the patient’s medical insurance includes the use of a CPAP, the patient must use it for at least 30 days before exploring other options. This treatment is much more difficult, requiring the patient to jump through additional hurdles.
The Key Is Proper Documentation
Proper and accurate documentation is crucial to successfully bill medical insurance for OSA. The minimum requirements are as follows:
- Sleep test results
A copy of the sleep test is a necessary part of your documentation. A polysomnogram (PSG) or a home sleep test (HST) are two types of sleep tests. Some insurance companies have limitations on the types of tests they would cover. For instance, before Medicare can pay for PSG, it now requires that home sleep tests be used first. A number of sleep test machines are also available.
Some diagnostic devices are not FDA cleared. For this reason, a few payers refuse to accept them as diagnostics. As a guideline, you can use the same sleep test findings that the board-certified sleep specialist used to interpret them. As a consequence, the findings of your sleep test will fit the perception. To be eligible for treatment, certain payers recommend that a patient have a certain AHI. As a consequence, it’s important that the patient’s AHI be clearly stated in your sleep test reports. These will be repeated in the clinical notes, which we will go through in more detail later.
- Diagnosis from a board-certified sleep specialist
To cure sleep apnea, a patient must first be diagnosed. Only a board-certified sleep specialist may make this diagnosis. The sleep specialist will score the outcomes of the sleep test to decide the seriousness of the patient’s apnea.
It makes no difference if the sleep test was conducted in a lab or at home. An interpretation is a term for the scoring and diagnosis process. The board-certified sleep specialist interprets the results, confirms the diagnosis, and then documents the extent of the patient’s sleep apnea, as well as treatment guidelines. Diagnoses never actually expire, but only a few insurance providers have a time limit or expiration date from the date of interpretation, as long as it is before the treatment.
- The dentist’s clinical chart notes
The Subjective, Objective, Assessment, and Plan (SOAP) notes can be a source of anxiety or irritation in offices. In a SOAP note, you’re describing the patient’s symptoms, the diagnostic details you’ve gathered (which would include the sleep test as well as the severity interpretation), and the treatment recommendation you’ve made. You’ll also make notes about the patient’s comfort, updating home instructions, and the delivered titration position of the appliance.
In general, dentists perform intra- and extra-oral exams as part of their sleep appliance assessment. You want to make sure a patient is a successful candidate before treating them. Prior to care, you should perform a comprehensive examination of the jaw, including a range of motion and muscle palpation, and ensure that any jaw or tooth conditions your patient has been reported. A patient might complain after six months that your oral appliance has harmed their jaw joint or teeth. You would be able to prove that the patient had certain previous problems by having good documentation.
- CPAP affidavit
Not all payers require a CPAP affidavit, but enough of them do that we recommend you collect one on every patient. This affidavit does not prevent them from later getting treated with a CPAP machine. The affidavit simply states that they have been given both treatment options, and they are choosing the oral appliance for whatever reason they give. They will sign the affidavit and include any detail about why they feel a CPAP wouldn’t work for them. Again, reiterate this to your patient, this does not prevent them from getting a CPAP at a later date. It simply states they choose the oral appliance at this time.
- Presenting Medical Billing To The Patient
Now you know exactly what documentation you’ll need to bill an oral appliance to medical insurers. From here, you’ll need a copy of the patient’s medical insurance card, as well as full benefits, to check to see if the patient is covered.
You’ll learn if they have a remaining deductible to meet and if they have any plan exclusions during the verification of benefits (VOB). if they have a history of using continuous positive airway pressure (CPAP) or if there are any other explanations why the device might not be covered. You won’t know the allowable at this stage since they don’t release a fee schedule unless you’re a participating provider.
Don’t let possible roadblocks stand in the way while you learn more about the method of billing medical insurance for oral appliances. Don’t be afraid to give medical billing to your patients as a payment option. Keep in mind that the ultimate aim is to lower the patient portion while increasing case acceptance.
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Sleep medicine is a growing field that is very daunting to coders and physicians as it’s a subspecialty of neurology. It comes with highly complex technicalities in the guidelines and procedure code descriptions. Fortunately, code selection is simple when codes are grouped and compared by elements. Doctors, medical providers, and medical coders can be uncertain of how to code sleep studies and other services for patients with sleep disorders. This article will outline effective coding habits for sleep medicine practices to ensure the best reimbursement possible while providing accurate documentation in patient records.
Different Types of Code Sets for Sleep Medicine
The CPT® code range 95803-95783, as well as the HCPCS Level II code range G0398-G0399, comprise sleep medicine procedure codes. Miscellaneous sleep diagnostic testing, home sleep study tests, sleep studies, and polysomnography are the different types of code sets.
Miscellaneous Sleep Diagnostic Testing Codes
Two different types of sleep diagnostic tests can be used.
95805 – Multiple sleep latency or wakefulness monitoring, recording, examination, and interpretation of physiological sleep measurements during multiple trials are used to determine sleepiness.
Multiple sleep latency monitoring consists of four or five brief naps arranged a few hours apart in the office environment. During these nap sessions, the patient’s brain waves, muscle function, and eye movements are all tracked and documented. This information can be used to identify narcolepsy and prolonged daytime sleepiness, as well as evaluate the effectiveness of breathing disorder therapies. Modifier 52 Reduced services should be added if there are less than four nap opportunities reported.
95803 – Testing, documenting, analyzing, interpreting, and reporting on actigraphy (minimum of 72 hours to 14 consecutive days of recording)
Patients should be given an actigraph device to put on their wrist in the home setting for this test. Over three to 14 days, the actigraph device records sleep and movement. When the unit is returned to the provider’s office, the data can be accessed to a computer and analyzed using advanced software to aid in the evaluation and monitoring of sleep disturbances including circadian rhythm disorders and sleep-disordered breathing.
Home Sleep Studies Codes
Since they are conducted at the patient’s home, home sleep studies are less expensive than in-office/hospital sleep studies. Overnight, a piece of special equipment monitors breathing, oxygen levels, and breathing effort. To diagnose sleep disorders, this data is extracted from the device and interpreted using specialized software.
There are three HCPCS Level II codes for documenting home sleep study studies, with the number of channels used during recording being the distinguishing factor:
Unattended home sleep test (HST) with type IV portable monitor; minimum of three channels Both in-office/hospital sleep studies are coded in the CPT® code range 95806-95783. These are either sleep studies or specialized polysomnography.
Unattended home sleep test (HST) with type III portable monitor; at least four channels: two respiratory movement/airflow, one ECG/heart rate, and one oxygen saturation.
Unattended home sleep study test (HST) with type II portable monitor; at least 7 channels: EEG, EOG, ECG/heart rate, EMG, airflow, respiratory effort, and oxygen saturation
Sleep Studies (Non-polysomnographic) Codes
Sleep studies that are not polysomnographic can be attended to or left unattended. An attended, non-polysomnographic sleep study has only one code which is:
A technologist is present during the sleep analysis, which includes a simultaneous recording of breathing, respiratory effort, ECG or heart rate, and oxygen saturation.
The code is chosen based on the parameters used during the recording. Modifier 52 should be included if the total recording time is less than six hours. Three CPT codes exist to report unattended, non-polysomnographic sleep studies which are:
Simultaneous monitoring of heart rate, oxygen saturation, respiratory airflow, and respiratory effort (eg, thoracoabdominal movement) during an unattended sleep study.
Simultaneous monitoring of minimum of heart rate, oxygen saturation, and respiratory analysis (eg, by airflow or peripheral arterial tone) during an unattended sleep study.
Simultaneous monitoring of minimum heart rate, oxygen saturation, respiratory analysis (eg, by airflow or peripheral arterial tone), and sleep time during an unattended sleep study.
Polysomnography is a form of sleep study that records brain waves, blood oxygen levels, heart rate, breathing, eye movements, and leg movements in an office or hospital setting. It may be used for diagnostic, therapeutic, or “split” purposes.
To disclose strictly diagnostic polysomnography, use one of three codes:
- 95782 Sleep staging with four or five additional sleep parameters for children under the age of six, with a technologist present.
- 95808 Sleep staging with 1-3 additional sleep parameters for anyone of any age, supervised by a technologist
- 95810 Sleep staging with four or five additional sleep parameters for children aged six and up, with a technologist present.
The number of parameters used during recording and, in the case of 95810 and 95782, the patient’s age are used to determine the code. If the total recording time is less than six hours, add modifiers 52 to 95808 and 95810. If the cumulative recording time is less than seven hours, add modifier 52 to 95782.
Therapeutic and Split Polysomnography Codes
For patients with a history of sleep apnea, therapeutic polysomnography is used. The test aims to figure out what titration levels of therapies like continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) are adequate for treating the patient’s apnea. On the other hand, split polysomnography is a part of the research that is diagnostic. If the patient is discovered to have sleep apnea during recording, CPAP or BiPAP titration is started to assess therapeutic levels for the patient.
Therapeutic and split polysomnography are reported using two codes, which are chosen solely based on the patient’s age:
95811 Sleep staging with 4 or more extra sleep parameters at the age of 6 years or older, with the initiation of continuous positive airway pressure therapy or bi-level ventilation under the supervision of a technologist.
If the total recording time is less than six hours, add modifier 52.
95783 Sleep staging with four or more additional sleep criteria, as well as the implementation of continuous positive airway pressure therapy or bi-level ventilation, with a technologist present. If the cumulative recording time is less than seven hours, add modifier 52.
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