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Oral Appliances for Obstructive Sleep Apnea—Billing Information (A49580)

Many providers of oral appliances for obstructive sleep apnea (OAOSA) items are not traditional DME suppliers, coming instead from the medical and dental communities. Reimbursement policy for DME often differs from the billing for E&M services or medical and surgical procedures. This article will review some key elements about billing for OAOSA. Please note that this is not intended as an exhaustive discussion of all DME billing requirements.

Medicare provides reimbursement for OAOSA (E0485, E0486) under the DME benefit. This means that, in order to bill for these items, a provider must enroll as a Medicare DME supplier. Claims for these items must be submitted to the DME Medicare administrative contractor (MAC). Do not submit claims to a Part B carrier or to an A/B MAC. Information about enrolling as a DME supplier is available from the National Supplier Clearinghouse or by calling, 866-238-9652.

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 item are provided.

Some E&M services may be separately billable. Contact your Medicare Part B carrier or A/B MAC for information.

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 two-piece appliance, top and 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.

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 nonadjustable, 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 nonadjustable, 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 Jurisdiction B DME MAC Supplier Manual.

Oral Appliances for Obstructive Sleep Apnea—Billing Information (A49580)
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