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Describes when to use the new K code
If your dental practice is navigating the complexities of dental sleep medicine billing, you’ve likely heard the buzz around the new “K” code, K1027. In this article, we’ll explore the nuances of oral appliance billing and discuss key updates uncovered by Nierman Practice Management.
Understanding the OSA Oral Appliance Codes
For years, E0486 has been the go-to code for custom oral appliances. Now, a new contender has emerged: K1027. But what sets K1027 apart? Simply put, it’s similar to E0486 but without the mechanical hinge.
- E0486: Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom-fabricated, includes fitting and adjustment.
- K1027: Oral device/appliance used to reduce upper airway collapsibility, without a fixed mechanical hinge, custom-fabricated, includes fitting and adjustment.
Why Two Codes for Oral Appliances?
In 2012, Medicare introduced a requirement for a mechanical hinge in relation to E0486, sparking discussions about reimbursement. This requirement puzzled many dental professionals, as no clear evidence showed that hinged devices were superior to non-hinged ones. The creation of K1027 as a separate code was an alternative solution, aimed at offering a broader range of reimbursable appliances. The question remains, “Why not just amend the criteria?” The answer lies in the complexities of regulatory processes and the often perplexing decisions made by these bodies.
The Connection Between the Hinge and Reimbursement
The connection between the hinge and reimbursement for E0486 began with the Pricing, Data Analysis, and Coding (PDAC) organization. Contracted by the Centers for Medicare & Medicaid Services (CMS), PDAC establishes coding guidelines for durable medical equipment, including oral appliances for obstructive sleep apnea (OSA). The PDAC criteria are outlined in Medicare’s Local Coverage Determination (LCD) for Oral Appliances for OSA, established in 2015. Among the criteria: To be coded as E0486, custom-fabricated mandibular advancement devices must have a fixed mechanical hinge at the sides, front, or palate.
A fixed hinge is defined as a mechanical joint with an inseparable pivot point. Certain mechanisms, such as interlocking flanges, elastic straps, or compression-based articulation, do not meet this requirement.
Currently, 75 appliances are verified for E0486 and 23 for K1027, with more being added regularly. To check PDAC-verified devices, visit.DMEPDAC.com and enter the codes in the product classification area.
Nierman Practice Management’s Insurance Carrier Survey Results
As these policy changes roll out, many DSM providers are seeking coverage guidelines for both codes during insurance verification. Nierman Practice Management tracked 500 verification calls and received EOB data from several providers for K1027. Here’s what we found:
- Many insurance plans cover both codes, although some only cover E0486.
- While K1027 initially required less preauthorization than E0486 in early 2024, it now seems to require it almost as often.
- Reimbursement for E0486 has been relatively consistent, while K1027 shows more variability.
As policies continue to evolve, consider these strategies for optimizing your practice:
- Optimize Verification Processes: Verify insurance benefits for both K1027 and E0486 upfront. During these calls, ask specifically about the need for preauthorization.
- Analyze Reimbursement Trends: Track payments for both codes to identify patterns or discrepancies in reimbursement.
- Streamline Billing Processes: If an insurer consistently offers lower reimbursement for one code, consider using the other, keeping the appliance type—hinged or non-hinged—in mind.
- Documentation: When billing either code to medical, submit a detailed narrative report in the SOAP format, including complaints, clinical data, assessment, appliance type, and design. Your billing codes should always be present in your clinical notes and narrative sent. Remember to include a sleep study and a prescription for the oral appliance.
By following these steps, you can navigate the evolving landscape surrounding K1027 effectively and optimize reimbursement outcomes for your practice. For Medicare claims, a significant shift may hinge on Medicare’s establishment of an LCD for K1027.