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  2. Medical billing in dentistry

What does Medicare pay for E0486? (oral appliance to treat OSA)

Approximate allowed amounts for Medicare DME for custom made oral appliances (HCPCS code E0486) to treat Obstructive Sleep Apnea (OSA)

Medicare offers coverage for custom made oral appliances for Obstructive Sleep Apnea (OSA) for patients who have original/traditional Medicare (the red, white & blue card) who have Part B benefits (Part B will be listed on the front of the card under Part A if the patient does have Part B benefits). Please note the dental practice location must be properly enrolled as either a participating or non-participating DME supplier (the 855s enrollment application) in order to bill Medicare for E0486.

Although the patient must have Part B benefits in order to obtain coverage for E0486, custom made oral appliances for OSA are billing to Medicare DME. Medicare DME is split into 4 regions: Jurisdictions A, B, C and D. Below is a map of the Medicare DME jurisdictions, last updated June 2019):

 

Each jurisdiction has a different allowed amount, and some allowed amounts within the jurisdictions vary slightly by state. The allowed amounts have not yet been officially published on the Medicare DME fee schedule, however based on processed EOB's from our clients an our medical billing service, we know the approximate allowed amounts for each region (as of January 2018):

Jurisdiction A: approx $1850-1950
Jurisdiction B: approx $1280-1350
Jurisdiction C: approx. $1050-1150
Jurisdiction D: approx $1250-1550


Keep in mind, Medicare covers 80% of the allowed amount, so the numbers listed above are not the amounts that Medicare will actually reimburse - Medicare will reimburse 80% of the allowed amount (less any remaining deductible, if any) Then, either the patient or the secondary insurance (if applicable) will cover the other 20%.

If the practice location is enrolled as a non-participating DME supplier, they have the option on a claim by claim basis to accept assignment or not in field 27 of the CMS1500 medical claim. If "no" is selected in field 27 when the claim is submitted, the practice may then collect the remaining balance from the patient (or even collect the full amount up front, as the patient receives the reimbursement when assignment is not accepted). If the practice location is enrolled as a participating DME supplier, or selected "yes" as a non-participating DME supplier on the medical claim, then the remaining balance must be written off as a contractual provider write off.