Hi JIN KIM DMD!

No problem. The diagnosis pointer (field 24E) is going to be the letter that the diagnosis code that applies to the line item appears in that is entered in field 21. For example, if there is only one diagnosis code, the diagnosis pointer with simply be "A". If there are two and they both apply to the service, the diagnosis pointer will be "AB", if three, it will be "ABC".

For field 24I, that is generally left blank.

For field 24B (place of service), if you are billing Medicare DME for an oral appliance for OSA, the place of service will be 12, which stands for home. If you are billing a private insurer or Medicare part B for other services like office visits, x-rays, etc, the place of service will be 11, which stands for office.

Here is a link to the full CMS1500 claim form manual, which gives additional details on each section of the claim form:
http://www.nucc.org/images/stories/PDF/1500_claim_form_instruction_manual_2012_02-v4.pdf

Our software DentalWriter help you complete medical claims for dental practices and does most of this for you. If you'd like to see a demo of it, here is a link where you can schedule in a demo:
https://niermanpm.com/demo

Hope this helps!

Edited by user 7 years ago  | Reason: Not specified

Hi Amanda!

Per the policy article to the Medicare LCD for oral appliances for OSA, if the sleep appliance used is not PDAC cleared for E0486, it must be coded using A9270, which stands for: Non-covered item or service, here is the language below the references this:

"All custom fabricated mandibular advancement devices that have not received a written PDAC Verification Review must use HCPCS code A9270 (NON-COVERED ITEM OR SERVICE)"

Hope this helps, have a great day!

Hi guest!

Yes most medical insurers include 90 days of follow up care included in E0486, including Medicare.

For Medicare DME specifically, a sleep lab/physician should not be delivering custom made oral appliances for OSA, as the Medicare LCD for oral appliances for OSA specifies that only a DDS/DMD should be the one to deliver & bill for E0486 in the coverage criteria.

Hope this helps!

Hi guest!

The allowed amounts for E0486 are actually not currently published on the Medicare DME fee schedule. However, if you would like to tell me what state you're interested in, I can let you know what we see coming back on EOB's as the current allowed amount for Medicare.

Hi guest!

The allowed amount for E0486 for Medicare DME for Tennessee is approx. $1144.87

Medicare covers 80% of that, and either the patient or the secondary if they have one will cover the other 20%.

Hope this helps!

Hi Guest!

The approximate allowed amount for E0486 for Medicare DME Florida is $1051.04

Hope this helps!

Hi Guest!

The allowed amount for Medicare DME for E0486 is approx. $1051.04

Medicare covers 80% of that, and either the patient or the secondary if they have one will cover the other 20%.

Hope this helps!

Hi hm!

Medicare's allowed amount for E0486 for Montana is approximately $1311.05. Medicare covers 80% of that, and either the patient or the secondary if they have one will cover the other 20%.

As far as modifiers, yes you will certainly use the "NU" modifier. Then, either KX, GA or GZ, depending on the situation.

KX tells Medicare you have all of the required documentation on file
GA means Waiver of Liability statement on file. Use this modifier to report that an ABN was issued for a service and ABN is on file
GZ means is used to report an item or service expected to be denied as not reasonable and necessary.

The Medicare LCD for oral appliances for OSA states:

"If all of the coverage criteria have not been met, the GA or GZ modifier must be added to a claim line for the oral appliance. When there is an expectation of a medical necessity denial, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or the GZ modifier if they have not obtained a valid ABN. Claim lines billed without a GA, GZ, or KX modifier will be rejected as missing information."

Hope this helps!

Hi Guest!

Medicare's allowed amount for E0486 for Illinois is approximately $1281.36. Medicare covers 80% of that, and either the patient or the secondary if they have one will cover the other 20%.

Hope this helps!

Hi Cindy!

Feel free to send me an e-mail and we can set up some time to chat. courtney@dentalwriter.com