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Hi robinpich!

Great question. The difference in billing medical insurance for an oral appliance for OSA for a patient and billing dental insurance for a crown is just that.......dental vs. medical!!

The difference only lies in the type of insurer you are working with, and the "standards", or even written policies, protocols & guidelines those insurers hold.

The reason you generally will not bill E0486 to a medical insurer on the day that you take the impressions, is that E0486 is a DME code, and oral appliances are DME, so you must follow the DME billing guidelines when billing these codes. Many insurers specifically state in their DME policies that you cannot bill for the item until it is delivered/received by the patient. Most FDA cleared oral appliances for OSA cannot be fabricated and delivered to the patient on the same day the impressions are taken.

I understand that this is a little different for dentists providing custom made DME, because you are not a "traditional" DME supplier that stocks DME items on their shelves, ships it out to the patient when the order is received, and can bill the insurer when the patient's receives it or picks it up. I do understand that you get a lab bill from the appliance manufacturer right away, then have to file the claim and wait for the reimbursement in some cases, but that is just kind of the way the cookie is crumbling at this point in time :)

If you are ever unsure and want a direct answer - my suggestion to you would be to call the insurer and ask when E0486 should be billed to them.

Hope that helps! Please let us know if you have any further questions.

Hi robinpich!

Great questions:

1) you can attempt to bill out for the office visit and the impressions on the same day, sure! However, since there is not a specific medical code for impressions/bite registration, most offices choose to use the code 99070 to represent the impressions/bite registration. This code is a "non-specific" or "miscellaneous" type code that stands for any supplies and material above and beyond that of a normal office visit (except eye glasses).
Some offices have seen success with reimbursement of the impressions/bite registration using that code - but a few things to be aware of:
a. when you use that code - you will need to send along a narrative letter explaining what the code is representing
b. that code is not always reimbursed right away, the first time you try it, or maybe not ever! It is basically the insurer discretion on whether they reimburse for that code with your narrative explanation or not.

2) Modifier 25 may not be the appropriate modifier to use for this particular situation, however. Modifier 25 stands for: Significant, separately identifiable evaluation and management (E/M) service by the same physician* on the day of a procedure.
So - an example of when to use modifier 25 would be when a pano and office are done of the same day.
99070 would not be considered an E&M service - as it is materials & supplies.

3) E0486 should always be billed to the insurer on the seat date of the oral appliance - and not before. E0486 is a DME code, and oral appliances for OSA are DME! So - by nature, DME codes should not be billed to the medical insurer until the DME has been delivered to the patient.

Hope this helps, please let us know if you have any further questions!

Hi chuckskinner!

Great question! The office visits leading up to the delivery of the oral appliance can be billed separately to most insurer. Then, on the day you delivery the oral appliance to the patient, you can bill the insurer E0486 for the oral appliance for OSA. So, each visit and the appliance are billed out separately on their own date of service, and depending on whether that patient comes in for a consult, then another visit later for the impressions & bite.........or if they get the impressions & bite done on their first visit with you bill determine whether you bill out one or two office visits to the insurance company before billed E0486 on the seat date.

Now - having said all of the above - some insurers you will come across (i.e. Medicare) have begun to "bundle" all service for oral appliance therapy from impressions & bite through 90 days of follow up care all into the code E0486, so in those cases, that will be the only code you bill for that patient, on the seat date!

Hope this helps, please feel free to contact us with any further questions!

Thanks and have a great day.