Durable Medical Equipment (DME) Medicare Administrative Contractors (MACs) posted clarification on billing procedures for oral appliances on April 8, 2010, causing industry professionals to speculate about a forthcoming oral appliance local coverage determination (LCD).
The language preparing providers of oral appliances to enroll as a Medicare DME Supplier has led some to believe a formal LCD is on the way.
According to information distributed by the DME MACs, “Medicare provides reimbursement for oral appliances for obstructive sleep apnea (OAOSA) (E0485, E0486) under the Durable Medical Equipment (DME) Benefit. This means that, in order to bill for these items, a provider must enroll as a Medicare DME Supplier.”
Enrolling ahead of a LCD would allow providers to be prepared to bill for the device.
Billing information included in the DME MACs’ announcement states:
Billing for OAOSA items is all-inclusive, once the decision has been made to provide the device. Reimbursement for these items includes all time, labor, materials, professional services, and radiology and lab costs, necessary to provide and fit the device. It also includes all costs associated with follow-up, fitting, and any adjustments after the items are provided. Some evaluation and management (E&M) services may be separately billable.
For OAOSA (E0485, E0486), the unit of service is for the entire, complete item. Some items have multiple components. Each component is not separately billable. For example, billing E0486 (2 units) for a 2-piece appliance, top & bottom and E0486 (1 unit) for the piece that holds the tongue back, for a total of 3 units of service is not correct. One unit of service should be billed for the entire device, inclusive of all components.
“Confusion has occurred with tongue retaining devices in which 3 units of service have been billed (upper tray, lower tray, and tongue retaining strap),” says Steve Moore, VP Sales & Marketing, Airway Technologies, LLC. “All custom appliances are billed as 1 unit of service under E0486.”
The announcement goes on to say:
Selection of the correct HCPCS code is important. The essential difference between the codes is that E0485 is for a prefabricated item while E0486 is custom fabricated. The code narrative for E0485 is:
E0485 ORAL DEVICE/APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE OR NON-ADJUSTABLE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
A prefabricated device is defined as one that may be trimmed, bent, molded (with or without heat), or otherwise modified for use by a specific patient i.e., custom fitted. An OAOSA that is assembled from prefabricated components is considered prefabricated. Any device that does not meet the definition of a custom-fabricated item is considered prefabricated.
The code narrative for E0486 is:
E0486 ORAL DEVICE/APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE OR NON-ADJUSTABLE, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT
A custom-fabricated OAOSA is defined as one that is individually made for a specific patient (no other patient would be able to use this item) starting with basic materials. It involves substantial work to produce, usually by a specialized lab. It may involve the incorporation of some prefabricated components. It involves more than trimming, bending, or making other modifications to a substantially prefabricated item.
For additional information on Medicare billing requirements for DME items, refer to the Supplier Manual, which can be found on each DME MAC Web site.