Sleep Apnea Billing for Dentists: What You Need to Know

April 15, 2022

In the United States, it is estimated that about 22 million people suffer from sleep apnea, yet an astonishing 80 percent remain undiagnosed. Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops and starts during the night. If left untreated, it is associated with long-term health risks, including high blood pressure, diabetes, memory and concentration problems, depression, and heart failure. Dentists can play a crucial role in helping patients identify and treat sleep apnea.

infographic about sleep apnea and its comorbidities

Are you looking to implement sleep medicine into your dental practice? To get started, you will not only need to acquire the necessary expertise to diagnose and treat sleep disorders, such as obstructive sleep apnea (OSA), but you will also need to set up a billing system for diagnostic and treatment procedures. This article will go over everything you need to know about sleep apnea billing for dentists.

Since sleep apnea treatment is considered medically necessary, you can bill medical insurance for the sleep apnea services you provide. To do this, you will need to know the billing codes and have proper documentation and other prerequisites, which will all be explained below.

How Does Insurance Work?

Although most dental services are billed through dental insurance, some services and procedures can be billed through medical insurance if they are considered medically necessary. This can help patients afford necessary care that dental insurance might not cover. Treatment for sleep apnea is one such service that is considered medically necessary and, in most cases, will be covered by medical insurance.

Specifics regarding the billing procedures and cost to the patient will depend on the patient’s individual medical insurance coverage. If the patient has a high-deductible plan, for instance, the patient may be required to pay a full or partial amount until the deductible is reached. You can still bill the insurance company, and they will send the necessary charges to the patient. Whatever the case may be, it is crucial to find out details on the medical coverage beforehand and communicate with the patient so they don’t receive unexpected charges from their medical insurance.

To predetermine medical coverage, call the eligibility and benefits department using the contact numbers on the patient’s medical insurance card. When speaking with the insurance company, you will need to find out

  • the yearly deductible amount and how much has been met,
  • coinsurance or copayment amounts,
  • preauthorization requirements,
  • whether the oral appliance is required to be Medicare approved, and
  • whether a network gap exception is allowed for out-of-network providers to lower the cost for the patient.

If possible, it is best to have sleep study information prior to the call because the insurance representative may need to know the diagnosis codes and the severity of the sleep apnea to provide more accurate benefit information.

Once you find out the specific insurance information, communicate with the patient about their options and how much it will cost them before moving forward.

What Billing Codes Are Used?

There are two types of codes that will be included in your bill to the medical insurance companies: diagnosis codes and treatment codes.

The diagnosis codes are ICD-10-CM codes, which are used to classify healthcare conditions and diagnoses. The following are the ICD-10-CM codes for sleep apnea and related disorders:

Primary Diagnosis code utilized for billing Obstructive Sleep Apnea in adults and is the main Diagnosis needed in receiving reimbursements for OSA:

  •  G47.33: Obstructive sleep apnea 

This diagnosis must come from a medical doctor to be utilized in billing a medical claim for Obstructive Sleep Apnea.

Additional Diagnosis codes that may be used to further support medical necessity in the case:

  • G47.10: Hypersomnia, unspecified
  • G47.30: Unspecified sleep apnea
  • G47.63: Sleep related bruxism
  • G47.69: Other sleep-related movement disorders
  • G47.8: Other sleep disorders
  • G47.9 sleep disorder, unspecified
  • R06.3: Snoring

The treatment codes are HCPCS codes, which represent common healthcare procedures. The following are the HCPCS codes for oral sleep apnea devices:

  • E0485: Prefabricated oral device/appliance used to reduce upper airway collapsibility, including fitting and adjustment
  • E0486: Custom-fabricated oral device/appliance used to reduce upper airway collapsibility, including fitting and adjustment

What Are the Billing Prerequisites?

Medical insurance companies require certain documentation when billing for sleep apnea diagnosis and treatment. The specific requirements depend on which insurance company is being billed, but here is a general list of possible prerequisites you might expect:

  • Documentation of a physician’s request, order, or referral to the dentist for the oral sleep apnea treatment
  • Documentation of a performed sleep study that was read and diagnosed by a medical doctor 
  • A copy of the appliance order, which identifies the name or description of the appliance and is signed by the dentist
  • Documentation that impressions or molds were taken, in the case of a custom-fabricated appliance
  • Proof of delivery, confirming the appliance was delivered to the patient
  • A copy of the insurance preauthorization approval
  • Proof of a CPAP refusal or intolerance (Some insurance companies might require an atrial period using a CPAP machine before oral appliances are authorized.)
  • All doctor and chart notes for consultations and exams
  • Patient medical history, intake forms, and sleep questionnaires completed by the patient

These are some of the prerequisites to prepare for, but be sure to check with the patient’s insurance company on their specific requirements.

Sleep apnea is a common problem affecting many people in the country and around the world. As a dentist, you can play a vital role in helping diagnose and treat sleep apnea. With this help, not only will you grow and expand your practice, but you will also be able to help your patients combat a disorder they might not even know is affecting them.

When you begin to implement sleep medicine into your practice, refer to this information to set up a smooth and effective billing process that will enable you to bill medical insurance and reduce costs for your patients.