Aetna considers any of the following diagnostic techniques medically necessary for a member with symptoms suggestive of OSA. How do you get the suggestive component? From the Epworth. You need to have attended a full night of PSG. Well, good luck on that one. Most people don’t want to go to a sleep lab and spend the night.
You’ve got a couple of different devices that are available. You have device II, III, and IV. Those devices actually measure airflow at at least two different channels. The one I do is this one. This is the Watch-PAT you saw a minute ago. It is an unattended home sleep device that monitors three channels. Mine does pulse oximetry, actigraphy, and peripheral arterial tone. It also has a little snoring device. It’s a four-channel. It’s great. That will fall under that category as well.
Then, if you happen to do a split night where they do a PSG and find out that they are having apnea and they’re already on CPAP, they do a CPAP and a titration as well. Then, of course, videos of EEGs and so forth.
Aetna’s members that have AHI greater than or equal to 15 events per hour with a minimum of 30 events or AHI is greater than 15 and less than 15 with a minimum of 10 events. I mean, come one, really, guys, this is a lot of detail, and this is just Aetna’s requirements. Most insurances are a little bit heavy, but they’re a little bit different. So, you’ve got to look for those.
For Aetna, excessive daytime sleepiness has to be documented with an Epworth greater than 10 or MultipleSleep Latency. Now, let me tell you. On the Epworth, for the American Academy of Sleep Medicine, theirs is 8 or greater. I actually dropped mine to 7, but look at Aetna. This insurance is increasing the Epworth to 10 or greater so they’re excluding a lot of patients who have OSA.
Documented symptoms of impaired cognition, mood disorders, or insomnia. Documented hypertension, and documented ischemic heart disease. Documented than 20 episodes of stroke. Greater than 20 episodes of oxygen desaturation during a full night sleep study.
The bottom line is tell the patient you’re evaluating their limitation when it comes to their insurance. It is their policy. Therefore, the outcome of reimbursement on the patient is not for you. Your job is to work within the guidelines, but you want to obtain the most reimbursement.
Again, I’ve stressed this numerous times and you’ll hear it more in the next 20 minutes that we have: Case fee, courtesy bill. We have gotten everything from our full feedback on the patient all the way down to $68 from the patient, but if they know they’re going in, they’re okay with it.
The financial responsibility. The patient is ultimately responsible for the cost of their treatment. For every case, make sure you have a printed and signed financial agreement and insurance estimate because even an approved pre-authorization is never a guarantee of payment. You guys know that from the dental insurance perspective.
Again, we want to talk about modifiers really quick. These are the things that belong behind the codes. For example, NU is for new equipment, 25 is basically a description of it for significant. For example, if there’s multiple physicians, 59 basically means it tells the company they’ll pay for the next service as well. On the CM1500 codes, you have the boxes that you put in. For example, the modifier number 11 means that that particular event took place in the office. The modifier for 12 means it was a take home test.
So, all of this information is overwhelming. It’s really kind of just beyond belief to try to get it all together, and, again, I’m going to share with you a way to get around that.
Medical coding for oral appliances. All medical claims require that the ICD-9 code. You will use the following codes for oral made appliances: ICD-9 code for obstructive sleep apnea is 327. That’s the actual diagnosis that you need. Then, you’ve got the HCPCS code for oral appliances that are made. That’s the code for it for custom fabricated, adjustable appliances.
Then, here’s all the other codes, the ICD codes, that are needed on your claim forms. You cannot diagnose diabetes, hypertension, or any of that sort of thing. This is all from the medical side. So, if you get a referral from a medical doctor, these are the codes you use for your form in order to submit them. The more diagnostic cods that you can list on a medical claim, the better off you’re going to be in order to prove medical necessity, and you always want to list OSA as the first code, always.
So, coding your office visits. I think this is really a kind of a joke. We talked about billing for band aid and aspirin and the cup the aspirin is in. This is kind of how you guys do that. Basically, you want to know if your patient’s established or new, and there’s categories for each one of these. For example, if you have a new patient, there’s codes, for example, for how much time you spend with them. For example, 99201 is for 10, 99202 is for 20 minutes, 99203 for 30 minutes, 99204 for 40 minutes. The variation in those is basically the fee, how you’re going to charge. If you charge $25, $50, $75, and $100, it’s basically on how much time, but look at this really quickly.
If you look at 99203 and 99204, it says, “A detailed history, a detailed exam, and low complexity of medical decision-making.” For 99204, it’s another 15 minutes. You’re going to bill a little higher fee, you have comprehensive history, comprehensive exam, and a moderate complexity in medical decision-making. Guess what? You better prove that when you send that to an insurance company or else you’re going to get denial on that as well. That same thing is for the 60 minute one as well.
The same thing applies to different patients. The same codes, but again, it’s 10 minutes, 20 minutes, 30 minutes, and 40 minutes. The variance in fees and the variance in what you can get through with regards to how you’re presenting for the medical insurance company. For example, again, comprehensive history and comprehensive exams.
So, what qualifies you to bill as a consultation instead of an office visit? When you visit with a doctor. Again, you can bill for that if you want, but you can case fee it. Do you really want to spend all that time, energy, and effort in order to get a consultation fee? That’s totally up to you.
Again, face-to-face with the doc, they have different codes for the time limit that you’re spending, up to 80 minutes, but here’s the deal: If you have a patient that you have to spend 80 minutes with a referring doctor for OSA, you have no business treating that patient. Those really need to stay in a hospital study or with highly qualified sleep doctors.
Coding diagnostics. Let’s look at that for just a second. These are the codes that you use for the different services that you provide, for the different exams, and so forth. Each code is different, and you just follow what code you use depending on what it is you’re doing, whether it’s a single view, for example, you use a 300 or a 320 on a whole mouth. You also want to look out for TMJs and orthodontics and so forth. These are the codes that you use for that. If you want to do laryngeal function study, that’s the code you use for that, and that’s the code you use for supplies you use.
So, this ICD code thing is just going on and on and on. It’s really overwhelming, and I’m sure you guys are ready to disconnect and hang up, but hang in there with me for a minute because I’m going to show you a way to get around this. You’ve got additional codes for additional appliance repair and anything else you need to do.
Again, the Epworth Sleepiness Scale is totally required 100% with regards to any of the issues associated with the patient. I do Mallampati Scores. I you guys haven’t done it, it’s really simple. Ask the patient to say, “Ah”. On the “ah” stick their tongue out, look at the back of their throat. Figure out which one they are. Mark down the Mallampati score and submit that with your insurance claim. Home Sleep Study Test. We talked about that as well. The actual diagnostic report that comes out with this, submit that with the report as well.
Then, the fee range. Talk about that for just a minute. Look at this chart. This is what I was talking about with the band aid and aspirin component. You have a category of new patient, established patient, and consultation. Under each one of those, you have 10, 20, 30, 45 minutes and so forth divided based upon the insurance or the amount you’re going to charge based on that particular individual.
If you really want to spend the time, energy, and effort to keep track of all of that and find out exactly where you are, knock yourself out. It’s much easier to do a case fee and be inclusive and have the case fee set and then submit, for example, the 99203 for every new patient, 30 minutes on all of them because you’re going to get at least that information up there. You’re going to spend at least 20 to 30 minutes with them. So, just fill it in as a case fee. It works so much easier. If you want to break all of that down, more power to you.
Here’s the case fees basically for some of the stuff that we do: Pharyngometer, rhino, the pano, jaw joint x-ray, and the appliance. There you go. These fees are ranges. Every area is a little different, and you can put it all together. Let’s put all of this together really quick.
Example billing. We’re going to look at visit, service, codes, modifiers, charge. This is an initial consultation for an office visit. There’s your code, your modifier, and your charge. Here’s a panoramic x-ray, your code, your modifier, and your charge. Photographs of the airway, your code and your charge
Impressions and bite. Your established patient office visit, your code and your charge. Cone beam is the same as well. The actual appliance was a DNA appliance or a mandibular appliance plant. Again, there’s your code, your E0486 and your modifier in NU for new and your fee. Your fee can vary, whatever it is. It’s just an example.
Then, you want to deliver. We’ll tell you this. Fitting and adjustment is included with that actual fee for the appliance. So, you can’t double bill for that. Then, you have your follow-up fees as well. There you go. There’s your total.