LISA FISCHER -HERDT
YOU NEED TO KNOW THIS STUFF
MEDICARE, DIGITAL SCANS, DOCUMENTATION, & KENTUCKY WEATHER
T
he weather in my home sweet
home state of Kentucky and
the world of medical insurance
have one thing in common. Both
seem to change about every
24 hours. Maybe that’s why I’m
drawn to medical billing... but
that wouldn’t explain why I got
the heck out of KY and moved to
FL. Oh, nevermind.
Well, the winds of change
continue to blow. If you have a
reliable 3rd party billing partner
OR a team member that keeps
their finger on the pulse of
the industry, then you’re likely
already privy to the info below.
If you don’t, well, hear ye, hear
ye….
Medicare gives “green light” to
digital scans for OAT fabrication
Something so obvious shouldn’t
even require an update like
this, but it did. Until recently,
according to Medicare, Oral
Appliance Therapy would
only be covered if the device
was fabricated from analog
impressions. Fortunately, that
has changed. Below is the
update from the DME MAC’s:
“In late February, the Durable
Medical Equipment Medicare
Administrative Contractor (DME
MAC) Medical Directors released
a letter regarding whether
digital techniques of teeth
impressions could be used to
generate a physical model for
an oral appliance (OA). The DME
MAC Medical Directors clarified
that digital scanning can be
used as long as physical models
are still created, which are then
used to custom fabricate OAs.”
Medicare will be updating the
specific LCD (Local Coverage
Determination) in a future
revision but has not yet
determined a date. You can use
the following link LCD Article
A5212 for your reading pleasure.
Next, is just a friendly reminder
that you should follow the LCD
regulations regarding device
selection, correct coding, and
proper documentation.
If It Isn’t Documented, It Didn’t
Happen
Nothing has changed here. This
axiom should be tattooed in
your brain. Your notes should
paint a clear picture about your
patient encounters. You want
Caravaggio here, not Picasso.
And you cannot forget about
the Proof of Delivery (POD). Also
note that in some instances
commercial carriers are
requiring a lab invoice as well.
Change is inevitable.
It is imperative that you have a
resource that can guide you to
stay in the know. Let me know
how I can help.
According to Medicare, not all
devices are created equally.
PDAC approved devices must be
custom fabricated, fixed hinge
devices such as the TAP, Herbst,
and Snorehook.
Correct coding for the device
must be E0486 for coverage
consideration. Codes such as
E0485, which is a prefabricated
oral device, and A9270 which
includes a snore guard and a
tongue repositioner will result
in a denial of coverage for the
patient which will yield no
reimbursement.
LISA FISCHER-HERDT
Lisa is the Director
of Member
Communications at
Dental Sleep Solutions
and 4 Pillar Billing. She
has over 15 years of
Medical Billing experience
and serves on the
Manatee Tech College
Advisory Board.
[email protected]