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talk2us@finetunegums.com
#1 Posted : Friday, November 7, 2014 10:35:59 AM(UTC)
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talk2us@finetunegums.com

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What would the CPT code be when billing an OSA appliance to Medicare when a sleep test has been done and confirmed that the patient indeed has OSA?

I have done some research and I have found that Medicare does not cover CPT code E0486.
courtneydsnow
#2 Posted : Friday, November 7, 2014 10:44:28 AM(UTC)
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courtneydsnow

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Hi talk2us@finetunegums.com!

Great question and the great news is, Medicare does cover E0486!

Since it is DME, it is actually a HCPCS code instead of a CPT code.

Here is a direct link to the Medicare LCD for coverage of oral appliances for sleep apnea. This shows codes, coverage criteria, etc:
https://www.noridianmedicare.com/dme/coverage/docs/lcds/current/oral_appliances.htm

A few main things with billing Medicare for oral appliances:

- your facility must be enrolled as a Medicare DME supplier. There is an application process associated with it! Here is a link to out study group that goes over the application process if you're interested!
http://www.screencast.com/users/DentalWriterStarter/folders/Study%20Group%20Recorded%20Session/media/dbb50445-1416-4840-ae02-a08825c657b3

- Medicare has not included the allowed amounts for E0486 in their fee schedules yet (which is why it appears they don't cover it! Also - E0486 is covered by Medicare DME, so you will not find it on the Medicare Part B fee schedule for your region), even though have paid for them for several years! Jurisdiction D has release it's fees for 2010-2012, but we have seen nothing yet beyond it! Here is a link to that bulletin:
https://www.noridianmedicare.com/dme/news/docs/2012/06_jun/e0486_fee_schedule_amount.html

- When billing to Medicare once you are enrolled as a DME supplier, you will use the modifier NU like you do with your private payers, but will also use KX for Medicare if all required documentation is met.

Hope this helps! Let me know if you have any further questions!

Edited by user Friday, November 7, 2014 10:45:57 AM(UTC)  | Reason: Not specified

 1 user thanked courtneydsnow for this useful post.
talk2us@finetunegums.com on 11/7/2014(UTC)
Guest
#3 Posted : Thursday, November 20, 2014 12:32:04 PM(UTC)
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Guest

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must a dentist have their oral appliance for Treatment of OSA approved by Medicare and what is the cost to do so if they do?
courtneydsnow
#4 Posted : Friday, November 21, 2014 8:21:08 AM(UTC)
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Hi guest!

Great question. Basically, in order for a dentist to be able to bill claims to Medicare, they must be enrolled as a DME supplier.

Once they are a DME supplier, there is a certain set of oral appliances for Obstructive Sleep apnea that they can choose from in order to satisfy Medicare guidelines. This is the "PDAC" cleared list of appliances for the code E0486 (which represents the custom made oral appliance to treat OSA)

As far as the cost for services - it will depend on the dentist you choose. If they are a participating DME supplier with Medicare DME, then you will either: pay nothing out of pocket (if you have a supplemental policy), or the usual 20% of services if you do not have a supplemental medical policy (depending on what state you're in, it is usually approx $200-370)

If the dentist you choose is a non-participating DME supplier, they can choose to charge additional on top of the Medicare allowed amount, so you will want to check with them what you out of pocket cost would be, with and without supplemental insurance.

Keep in mind, the information outlined above is for initial treatment through 90 days of follow up care. There is also suggested follow up care (at least annual) after that 90 days, and until Medicare will reimbursement for a new oral appliance (5 years).

Hope this helps, please let me know if you have any further questions!
Guest
#5 Posted : Tuesday, August 23, 2016 10:00:44 AM(UTC)
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Can you please tell me the current (2016)or most recent oral appliance (E0486) reimbursement rate for medicare?
courtneydsnow
#6 Posted : Tuesday, August 23, 2016 11:27:17 AM(UTC)
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Hi guest!

No problem. It depends on where you are located :) What state are you in?
Guest
#7 Posted : Tuesday, August 23, 2016 12:51:58 PM(UTC)
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Ohio
courtneydsnow
#8 Posted : Tuesday, August 23, 2016 5:40:50 PM(UTC)
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courtneydsnow

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Hi guest!

The allowed amount for Medicare DME for E0486 for Ohio is currently approx. in the $1250-1320 range. Your allowed amount is 5% less if you are a non-participating DME supplier than if you are a participating DME supplier.

Hope this helps! Have a great day.
Guest
#9 Posted : Sunday, September 18, 2016 10:25:11 AM(UTC)
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Looking for the reimbursement for e0486 for Colorado?
courtneydsnow
#10 Posted : Monday, September 19, 2016 7:03:44 AM(UTC)
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Hi guest!

Medicare DME allows approx. $1000-1060 for E0486 in colorado. (more towards $1060 if you are a participating DME supplier, closer to $1000 if you are a non-participating DME supplier).

Medicare will always pay 80% of the allowed amount.
The patient (or secondary insurer if they have one) will be responsible for the other 20%.

Hope this helps, have a great day!
Guest
#11 Posted : Wednesday, September 21, 2016 12:59:32 PM(UTC)
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Where can I find the reimbursement for Northern California for E0486. I can't find it anywhere! Also, do you have an current link for this info?
Thank you!!

Edited by user Wednesday, September 21, 2016 1:47:53 PM(UTC)  | Reason: updated question

mbrzezinski
#12 Posted : Wednesday, September 21, 2016 3:56:11 PM(UTC)
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mbrzezinski

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Hi Guest!

Medicare DME allows approx. $1300 for E0486 in Northern California.

Medicare will always pay 80% of the allowed amount.
The patient(or secondary insurer if they have one) will be responsible for the other 20%.

Medicare does not have a posted fee schedule.

Hope this helps, have a great day!
Guest
#13 Posted : Tuesday, October 4, 2016 9:36:20 AM(UTC)
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Hello, Im having some trouble with reimbursement for E0486 from Aetna. They are saying on the EOB that the member's policy allows up to 100% of the medicare allowable rate for charges covered by their plan. The allowable they put on the EOB is $201.48. I am in Texas. This seems very low to me, especially compared to the other allowable fees for other states that you have mentioned in this thread. Any idea what the rate for medicare in Texas is? Any idea why Aetna might be saying it is only $200?
mbrzezinski
#14 Posted : Tuesday, October 4, 2016 9:53:33 AM(UTC)
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mbrzezinski

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Hi Guest!

Medicare reimbursement for Jurisdiction C is approximately $1020.

Has the patient met their deductible for the year?
Guest
#15 Posted : Tuesday, October 4, 2016 12:10:42 PM(UTC)
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Yes, deductible is met, they only have cost sharing which they are basing on the fee of $201.48, so their part is 80.59.
Guest
#16 Posted : Tuesday, October 4, 2016 12:28:00 PM(UTC)
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It was because modifier "NU" needed to be used. Hopefully this helps others if anyone else ever runs in to something like this. That raised the allowable to 2,014.81. It was hard to get the insurance rep to help, but I eventually talked her into it.

Edited by user Tuesday, October 4, 2016 12:28:53 PM(UTC)  | Reason: additional info

mbrzezinski
#17 Posted : Wednesday, October 5, 2016 4:36:30 PM(UTC)
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mbrzezinski

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Hi Guest!
Thanks for the update. The modifier NU is very important when billing for DME appliances.
Guest
#18 Posted : Thursday, October 20, 2016 9:32:06 AM(UTC)
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What's the reimbursement for Kentucky?
mbrzezinski
#19 Posted : Thursday, October 20, 2016 10:30:30 AM(UTC)
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mbrzezinski

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Hi Guest!
Medicare DME allows approx. $1250 for E0486 for Jurisdiction B.

Medicare will always pay 80% of the allowed amount.
The patient(or secondary insurer if they have one) will be responsible for the other 20%.


Hope this helps, have a great day!
Guest
#20 Posted : Thursday, October 20, 2016 2:36:05 PM(UTC)
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Thank you for your quick response!
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