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We are a non participating medicare provider. If the patient wants to get a non medicare covered sleep appliance will medicare still pay their portion and the patient will pay the difference?
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Rank: Administration
Joined: 11/21/2012(UTC)
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Hi drlmdds!
Great question. It depends! The short answer is likely, no. However! Here's the deal:
When you bill Medicare for a custom made oral appliance for OSA that is not PDAC approved, the LCD instructs you to code the appliance as A9270 instead of E0486.
A9270 stands for: non-covered item or service
So of course, likely the claim will be denied, but you can appeal it so it goes to medical review if there is a good medical reason why the patient did not get an appliance that is PDAC approved. If it was just a preference with no good reason, they may not cover.
I would certainly be sure to have the patient sign an ABN so that if Medicare ultimately does not cover it, the patient is responsible for payment.
Hope this helps!
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Joined: 9/8/2012(UTC)
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Does the 90 day E0486 coverage include the 1st consult/Office Visit ? or just the 90 day care which starts with records ??
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Rank: Administration
Joined: 11/21/2012(UTC)
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Hi Guest!
Great question. In a statement released by Palmetto GBA several years ago, it indicated that the initial evaluation as well as any radiographs needed to fabricate the appliance would be considered included in E0486 for Medicare billing.
Hope this helps!
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Rank: Guest
Joined: 9/8/2012(UTC)
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Is a dental provider required to be a DMEPOS Medicare eligible supplier to dispense E0486 to a Medicare recipient?
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Rank: Administration
Joined: 11/21/2012(UTC)
Posts: 1,732
Thanks: 39 times
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Hi Guest!
Yes, in order for a dental practice to be reimbursed by Medicare, the practice must be enrolled as a Medicare DME supplier location (participating or non-participating). If the practice is not enrolled, they are supposed to let the patient know that it could be covered it they went to a practice currently enrolled before they dispense the item.
Hope this helps!
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