Billing Considerations for the Initial Sleep Apnea Dentist Visit

By Peter Blais, RPSGT

The decision whether to file an initial dentist office visit for a sleep apnea patient with either medical or dental insurance can be challenging.

“It depends upon what is done at the first visit,” says Marianne Harper, owner of The Art of Practice Management, a dental practice management consulting company that focuses on revenue and collection systems, front desk systems and forms, dental insurance processing, medical/dental cross-coding systems, and employment-law compliance.

“If it is strictly sleep apnea treatment, then medical should be filed first. The patient should always be asked if he or she wants procedures filed with medical. Some patients have lifetime maximums to consider or may not want sleep apnea to be part of their medical record. If he or she consents, then medical should be primary and dental secondary, although I believe that there’s not much coverage for sleep treatment with dental.

“Keep in mind that exams for sleep apnea treatment are not always covered by medical and if it doesn’t pay, then it might be best to not send it to dental (if it was strictly a sleep exam) and to save the exam submission for when a dental exam is done. That needs to be a decision made by the patient.”

Then there is the matter of what codes to use when filing for coverage. Harper, a 30-year veteran of the dental field, notes she always uses the code for obstructive sleep apnea if that’s the diagnosis based on the sleep study. G47.33 is the ICD-10 code for that. ICD-10 codes are required as of date of service Oct 1, 2015. This code would be used as the first listed diagnosis code on the claim. Any other codes, for conditions such as history of stroke or a current status of heart disease, etc, can be used as additional codes to provide the carrier with a full picture of the patient’s condition(s).

With regard to scans, Harper recommends that the medical carrier be contacted prior to taking the scan. Some scans must be preauthorized. If a staff member is able to handle that at the first visit and either a prior authorization is not needed or the practice is given a prior authorization number immediately, then it should be fine to scan at the first visit. Dental practices should keep in mind that if a prior authorization number is given, then that number must be entered on the CMS1500 medical claim form in box 23.

Marianne Harper

“I always advise that dentists and staff establish good collaborative relationships with the physicians in the area,” Harper concludes. “Oftentimes the patient may need a letter of medical necessity from the physician or the dental practice may need to request certain diagnosis codes that pertain to the patient’s sleep treatment, but these may be conditions that dentists cannot diagnose.

“In turn, these good relationships may encourage those physicians to refer their patients to the dental practice who need a sleep appliance. So it’s a win-win situation. I also encourage business office staff to always check with a patient’s insurance carrier prior to treatment to determine eligibility, coverage, and expected out-of-pocket costs for the patient. This ensures that there will be no financial surprises for the patient and the practice.”