by Marianne Harper
Does the following scenario sound familiar?
Your practice now offers oral sleep apnea appliance therapy to patients, and they're asking you to file claims with their medical insurance plans. Your first reaction might be, "Not us, we're dental." This is a very understandable reaction. This article provides details on how to make coding sleep apnea appliances easier.
Oral appliance therapy (OAT) can be covered by a patient's medical insurance plan. More and more dental practices are adding dental-medical cross coding to their insurance processing systems for medically necessary dental procedures, of which oral sleep apnea (OSA) is just one.
Keep in mind during this decision making process that insurance coverage can make OAT much more affordable, thus increasing the chances of case acceptance. For the most part, medical insurance does not have yearly maximums like dental insurance does. This can potentially provide a higher level of benefits.
In addition, even Medicare covers appliances for mild to moderate cases of OSA when dentists enroll as durable medical equipment providers. But it limits coverage to UCLA Modified Herbst (Space Maintainers Laboratory) and Herbst Sleep Appliance (Gergen's Ortho Lab).
Those dental practices that relate to the "Not us, we're dental" reaction have a choice.
Cross coding can be done either within the practice, or it can be outsourced. There are companies that handle the claim filing process for dental practices, such as Dental Medical Billing LLC; however, many practices have implemented cross coding directly from within the practice.
If your practice would like to learn how to handle this internally, the first step is to determine if your practice management software provides a cross coding component. Many do. When inquiring about this, you will also need to determine if you can file medical claims electronically.
If you cannot, you will need to make a choice as to whether to file paper claims or use claim-filing software, such as InstaClaim, that is not part of your practice management software but will allow you to file medical claims electronically.
Medical claims are filed on a CMS-1500 (08/05) form. If your practice will file paper claims, you will need to purchase these forms since medical claim software does not print the complete form as dental software does. It only fills in the form.
Prior to filing an OAT claim, contact should be made with the patient's medical insurance plan, and the responses to your questions should be documented. Questions that need to be asked are:
- Is OAT covered by the plan?
- Will a preauthorization be required?
- What percentage will be paid?
- What is the deductible, how much of the deductible has been met, and when does the new plan year begin (to determine if a new deductible will apply)?
- What is the replacement time period?
- Is a referral necessary from the primary care provider?
- Do you require modifiers for the appliance?
- What is the claim mailing address?
Thorough documentation is essential when cross coding. An example of SOAP notes for a sleep apnea case would be:
- Patient reports history of snoring, interrupted sleep due to choking and gasping, fatigue during the day, hypertension, heart attack, or stroke. These conditions and symptoms should be indicated on the medical claim through the use of diagnosis codes that would follow the primary diagnosis code of obstructive sleep apnea.
- Examination findings: Male patient, weight 214 pounds, height 5 feet 11 inches, neck size 17.5 inches
- Assessment: Possible sleep breathing disorder
- Plan: Refer for sleep study to determine diagnosis. If the diagnosis is mild to moderate obstructive sleep apnea, the patient will be fitted with an oral sleep apnea appliance.
Insurance carriers follow a policy that says if the diagnoses and procedures are not documented, it did not happen. Therefore, be thorough with documentation.
It is important to obtain a prescription from the patient's physician for the oral appliance that indicates the patient has been diagnosed with obstructive sleep apnea. It may be helpful to use a copy of the form as a claim attachment.
The actual process of filing a medical claim involves three elements -- diagnosis codes, procedure codes, and the medical claim form. Diagnosis codes are the ICD-9 codes. It is through the use of these (up to four per claim) that a provider explains to the carrier the details as to why procedures were performed.
The procedures are reported through the use of the CPT code set, which includes the HCPCS code set. Within the CPT code set is a subset of codes called modifiers. Modifiers are used to help explain how a procedure was altered by a specific circumstance. With respect to OAT, modifiers may be required to explain that the appliance was new instead of rented.
Part of the implementation process will involve your examination protocol. There are obvious signs that point toward sleep apnea, such as rounded bellies, obesity, short and thick necks, and large tongues. Other signs may be an elongated palate, enlarged uvula, enlarged tonsils, as well as redundant lateral pharyngeal wall mucosa.
Craniofacial abnormalities that include micrognathia, retrognathia, or maxillary hypoplasia are also associated with OSA. A visual exam and keeping these signs in mind, as well as asking pertinent questions, can help identify those patients who might suffer from OSA.
The following questions should be asked and added to your health history forms:
- Do you snore or have you been told that you snore?
- Do you wake up during the night?
- Do you have excessive daytime sleepiness?
- Have you ever had a sleep study?
- Do you have high blood pressure?
Please refer to Table 1 for the most commonly used codes that are specific to OAT claims.
