Dental Medicare Provider Information
URGENT Attention Required
As of June 1, 2015, all providers that write prescriptions for Medicare-eligible beneficiaries must be enrolled in the Medicare system through the Provider Enrollment Chain Ownership System (PECOS) in order for the Medicare beneficiary to obtain coverage for the prescriptions through the Medicare Part D Benefits. All providers, including dentists, who treat Medicare beneficiaries and write prescriptions for these patients must be recognized formally in the Medicare system or the prescriptions will not be covered and the patient will have to pay out of pocket.
There are now more unique enrollment issues for some types of practitioners or physicians that allow for special or infrequent reimbursement from the government Medicare Program.
On the list of practitioners that may receive reimbursement are Dentists and Oral Surgeons.
Do I have to do to enroll? Most general dentistry is not covered by Medicare but if you treat patients with Medicare Advantage Plans that may cover some dentistry you will not be able to bill and the patient will not get reimbursed unless you are enrolled in the system.
If you have to write a prescription or refer your patient to a lab, pathologist or radiologist you risk your patient being denied under Medicare for the services and potentially you may have to write off the services.
You may choose the option of enrolling as an ordering/referring provider if you do not perform any services in your office that are covered by Medicare. However, if you refer Medicare patients to other facilities, you must be enrolled before the service provider can be paid. For example, if you refer a patient to a lab for blood work, in order for the lab to get paid, you (the ordering/referring provider) have to be enrolled in the PECOS system
- You will need a individual provider NPI type 1. Organizational NPI do not qualify.
- You must be enrolled in Medicare as an approved or in an opt out status. You can write prescriptions that will be covered as an opt out provider.
- You must be of a specialty type that is eligible in order to refer-dentists are.
Form 8550 link: This is the form to fill out to be a ordering/referring doctor. If you are going to be a provider for medical devices, TMD splints or sleep apnea devices you must enroll as a participating provider or a non-participating DME (Durable Medical Equipment Provider).
Please refer to the Medicare Enrollment Guidelines for Ordering/Referring Providers published June 2014 Department of Health and Human Services/Centers for Medicare and Medicaid Services
Do I have to enroll to provide my patient reimbursement for medical devices such as TMD splints or sleep apnea devices?
Durable Medical Equipment Provider: Medicare does provide coverage for Oral Sleep Apnea appliances in some instances. The benefits are provided under the DME contract and require providers to enroll as a DME provider. A provider who has opted out of Medicare Part B, or who enrolled as an ordering/referring provider only, cannot enroll as a DME provider. They must enroll as a participating provider to bill Medicare Part B for services associated with the appliance, such as evaluations, radiographs, and more.
- Medicare announced that prefabricated appliances are not covered and only a licensed dentist can bill for custom oral appliances.
- A dentist must become a Medicare Durable Medical Equipment (DME) supplier in order to bill for oral appliances.
- Some commercial carriers have required that dentists have a Medicare DME supplier license in order to receive reimbursement.
- Most dentists sign up as a “nonparticipating” DME supplier so they have the ability to bill patients for the difference between what Medicare covers and their fee.
- Medicare does not reimburse for TMJ/TMD appliances under DME.
- The beneficiary must have a face-to-face clinical evaluation by the treating physician prior to a sleep test.
- Medicare requires a physician written order (Rx) for an oral appliance.
- Commercial carriers have set policies that may be similar to, or differ from, Medicare’s policy.
FAQ’s regarding Medicare’s policy:
- What must we do to provide Oral Appliances for Obstructive Sleep Apnea to Medicare beneficiaries?
- In order to submit a valid claim to Medicare for oral appliances, you must enroll with the Medicare program as a Durable Medical Equipment supplier.
- How do we become a Durable Medical Equipment Supplier?
- Submit the Medicare Enrollment Application CMS 855S for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers.
- Must a Medicare approved appliance be used?
- Effective Nov. 1, 2012, only those appliances and laboratories that have been reviewed through the Medicare’s coding verification review process may be reimbursed.
- What services are billable to Medicare Durable Medical Equipment (DME) for Oral appliances?
- The medical code has been established as EO486: Device used to reduce upper airway collapsibility, adjustable, custom fabricated. Includes fittings and adjustments.
- How long does a Medicare patient have to wait until he or she gets a new OSA appliance?
- Medicare has a five-year replacement policy.
- What is the most important thing for dentists to know about Medicare now that it has approved Sleep Apnea Appliances?
- Documentation is critically important when dealing with Medicare and medical insurance. Also, there are modifiers that should be used for sleep apnea appliances. The modifier NU indicates that the DME is new (some DME can be used or rented). The Medicare modifier KX is used to indicate that specific required documentation is on file. Using the KX modifier carries a lot of weight because it attests to the fact that the Medicare guidelines are met as stated in the LCD, Medicare Coding Guidelines, and DME supplier standards.
Hundreds of dentists have received their DME supplier licenses to date. How do these dentists make sure that they’re following Medicare guidelines? They become educated about medical insurance and Medicare to ensure that everything required is carefully documented in their records.
The number of patients with Obstructive Sleep Apnea is astounding. The average practice may see up to 440 patients with a high risk of suffering from sleep apnea. Of those patients, 80% to 90% have not yet been undiagnosed.
The great news is that dentists can collaborate with physicians and provide oral appliance therapy for OSA patients who are intolerant to or refuse CPAP, and this helps save lives and relationships. And insurance may have you covered!
Coding for sleep apnea cases
Using the cross medical/dental billing codes below will help offset costs to the patient when you can bill medical and dental codes at the same time.
The medical code usage is CPT 95806 (Watch-PAT 100 home sleep study) and ICD 780.53 (Obstructive Sleep Apnea with Hypersomnia).
The dental code usage is D21110 (Oral Appliance), D21089 (Oral Appliance), D99070 (Diagnostic Study Models), D92520 (Pharyngometer-Laryngeal Function Study), and D92512 (Rhinometer-Nasal Function Study).
Please note that all dental patients must be first referred by a medical doctor to a dental office for the treatment of sleep apnea.
There is not one right answer for every practice. The choice you make will depend on the number of Medicare patients you have in your practice, the type of services you perform.
If you do nothing you will not be able to have the flexibility to help a very large group of patients, those 65 years or older that may need referrals or prescriptions under your care. This entire group will be covered by either MediCare or Medicare Advantage. Please refer to the MediCare Flow Chart Decision Tree to help with your decision.