Dentists and medical insurance: sleep-apnea appliances, TMJ and the supplier rule. For Medicare, the dentist is the supplier.

Summary

Can a dentist bill medical insurance for a sleep apnea appliance?

Yes, under HCPCS E0486, when the coverage conditions are met: the treating practitioner evaluates the patient, a covered sleep test supports the diagnosis, and an order is on file. Medicare also requires the dental practice to be enrolled as a DMEPOS supplier, and the appliance is billed under that supplier number. Each commercial plan writes its own policy, and many want approval before the appliance is delivered.

An oral appliance for obstructive sleep apnea is billed to the patient's medical plan, not the dental plan, under HCPCS E0486.^A, B The same is true of a good share of jaw-joint imaging, and of oral surgery tied to an injury or a medical diagnosis. The medical plan pays for that work on its own terms: medical codes, a medical diagnosis, and a provider it has enrolled. The dental claims stay where they are.

The sleep appliance is equipment, and Medicare treats it that way.

Medicare places the appliance in durable medical equipment, the category it calls DMEPOS. Its coverage policy for oral appliances says the device is provided and billed for by a licensed dentist.^A The dentist who fits the appliance has to be the one who bills it, which means the dentist enrolls with Medicare as a DMEPOS supplier before the first claim. Billing through someone else's supplier number is not the Medicare path. The practice holds the supplier number. A billing company cannot bill the appliance under its own.

The claim itself goes out as E0486, and the KX modifier goes on it only when every coverage criterion in the policy is met.^F Supplier enrollment is its own application, separate from the dentist's enrollment as a practitioner, and it carries a federal application fee on top of any service fee. It also calls for a surety bond of at least $50,000. Medicare treats a dentist who fits an appliance another practitioner prescribed as acting only as a supplier, so the exception for a physician's own patients does not apply.^G, H A dentist does not need DMEPOS accreditation to furnish a sleep appliance.^I A new supplier also gets a site visit, and every owner of 5% or more gives fingerprints for a background check.^G Before filing, we confirm in writing which bond amount applies to your practice and what the federal application fee will be.

Who makes the sleep-apnea diagnosis for Medicare.

For Medicare, the dentist cannot be the one who evaluates the patient for obstructive sleep apnea. The policy wants an in-person evaluation by the treating practitioner before the sleep test, an order from a physician, nurse practitioner, clinical nurse specialist or physician assistant, and a covered sleep test, and it states that a dentist is not a treating practitioner.^A The claim carries the diagnosis code G47.33.^F

The sleep test result has to clear a threshold. An apnea-hypopnea index of 15 or more qualifies, with at least 30 events recorded. A result from 5 to 14 qualifies, with at least 10 events, when the record documents the symptoms or conditions the policy lists. Above 30, the policy also wants the record to show the patient could not tolerate positive airway pressure, or that the treating practitioner ruled it out for medical reasons.^A The treating practitioner's notes and the test report belong in the dentist's file before the appliance is delivered.

Commercial medical plans write their own policies, and approval before delivery is a common first step with them.^B Before your first case we get each plan's written policy and ask whether it wants approval before the appliance is delivered.

TMJ imaging: the same scan, a different code set.

A cone-beam CT taken to diagnose a jaw-joint disorder can go to the medical plan instead of the dental plan. Where the plan's policy covers it, it is billed as CPT 70486, the maxillofacial CT without contrast. We check each plan's written policy before the first claim.^C The diagnosis comes from the temporomandibular joint disorder codes that begin M26.6.

The description of 70486 does not say cone beam, and the trade article warns that some payers audit the code when a CBCT is billed under it.^C A scan taken for a covered medical reason, with the reason written in the record, is the one that holds up. A routine dental screening does not become medical because the code changed.

Oral surgery, trauma and the medically compromised patient.

Procedures tied to an accident, a disease or a medical diagnosis can bill to the medical plan. The categories that come up most are third-molar extractions, IV sedation, trauma repair and periodontal treatment for a medically compromised patient. Routine implants are usually excluded unless an injury made them medically necessary.^E Each of these pairs a CPT code with an ICD-10 diagnosis that depends on the case, so there is no single crosswalk to hand the front desk. The record has to show why the work was medical, in the medical plan's terms.

Where we come in.

We enroll the practice and the dentist with the medical plans the practice wants to bill. For Medicare, the billing review checks the supplier rules against the practice before the first claim goes out. If sleep appliances are a new service for the practice, a Service Line Made Billable answer sets out which plans cover the appliance, what each needs on file, and whether the supplier enrollment applies.

When we run the practice's billing for this work, we build the medical claims to each plan's policy, post what comes back, and follow every denial until the plan pays or answers in writing. Our enrollment fees are printed on the pricing page.