2022 Billing/Coding Q&A-2022 Billing/Coding Q&A Recording

2022 Billing/Coding Q&A Recording

Video Transcription

go ahead and give us a little bit of background to us and introduce themselves to us.  I guess I'll go first.  I'm Belinda Postal. I'm actually a registered nurse and I handle the sleep apnea medical billing for my husband's practice. Currently we're about 50-50 dental sleep medicine  and general dentistry.  I'll hop in here. So my name is Alex Vaughn. I'm an oral facial pain specialist in Richmond, Virginia. I've got a practice that's a full service  kind of sleep and oral facial pain practice.  And then in my prior life, let's say I was at,  did some coding and billing as a staff member. So my background to this kind of field is I'd like to call myself a coding lay expert.  I don't really know what I'm doing, but I think I do. It is kind of where I sit. And then I am faculty along with Belinda in the mastery program for coding and billing.  Okay, well, I'll go next. My name is Angie Cooper and I'm a senior provider relations analyst with CGS administrators. We are the durable medical equipment,  Medicare administrative contractor for jurisdiction B and jurisdiction C. I have about 30, a little over 30 years of experience with Medicare.  And I started in provider outreach and education on the part B side, and now I am with the DME.  Pleased to be here, thank you.  And I guess that leaves me. So my name is Cindy White and I am a supervisor of operations for Noridian Healthcare Solutions in the provider outreach and education team.  We at Noridian serve the durable medical equipment,  administrative contracts for jurisdictions A and jurisdiction D. And I too am a lifer in this industry. I have about 25 years of experience.  I personally worked on the DME supplier side  prior to joining Noridian about 10 years ago.  All right, I guess that leaves me actually for last. I'm Janet Hunter from Novitas Solutions. I guess I'm the oldest one from also being last.  I've been with Medicare for over 35 years. I won't tell you how many, but definitely over 35 years. We are traditional Medicare. We started out fee for service.  We're the original Medicare. We do part A and part B services. So glad to be a board on the panel. Thank you so much.  Well, thank you all. I guess we can jump directly into the questions. So I'm gonna read the questions and anyone can answer.  If another person has some more information by all means do tell us. So the first question is,  how does a dentist who is a diplomat of the ABDSM get credentialed with Medicare payers for DME or provide oral appliance therapy and related services?  I'll start on this one, I guess.  So how do you get credentialed with medical payers? I'm gonna give you the annoying answer first. You ask, which by that I mean, you go to Google,  you type in the payer you care about. So you type in their name. So UnitedHealthcare, type in UnitedHealthcare, put a space in there and then say, join the network  or join or provider site or I want to join or something like that. And every insurance is gonna have their own system. There's really no universal system  for requesting credentialing. There is a fairly universal system for keeping your credential file in order. So that website is CAQH,  which is the Commission on Affordable and Quality Healthcare or something like that. And in that site, you'll list all of your, and this is partnered with the ADA as well.  So if you're an ADA member, you can link straight to the CAQH site. You're gonna list all of your history, schools you went to, first child's name,  the girl you dated in high school, everything. Everything about you is gonna get listed in the system. And basically what that does, that allows all these insurance companies.  So when you say, I want to join you, they go to one single website and get all your info.  Well, all the insurance except for Medicare. Medicare has got their own system that you run in through, which you're doing the exact same thing.  It's just, you're putting it on Medicare forms. But realistically, have your CAQH up to date first, then you're gonna search the insurance company  you want to join, join their network. The other thing I will tell you that has worked well for me is go into this knowing that you're an expert  and don't ask questions as much as telling answers. And what I mean by that is don't call the insurance and say, hey, I'm a dentist and I want to join your network.  Do you let dentists? How do I do it? No, it's you send, you fill out the form and you tell them, I want to join your network.  If it asks your specialty and dentistry isn't an option, usually other is, and you can define it. But most states have a law that says a dentist  is a physician when operating within the scope of practice. So an insurance company can't say we credential, well, rephrase that. Insurance companies aren't supposed to say  we don't credential with dentists, we only credential with physicians and oral surgeons, but many will say that. And you can usually compete that with just saying,  so within scope of practice, it's covered under medical and the state law requires it, that you allow me to be evaluated. Now, if they let you in network or not, that's up to them,  but going in with kind of an attitude of, I will be in network, this is the form you asked me to fill out has a much better response I found  than calling and asking questions or whatnot. Just assume you know what you're doing and do it.  I think I'm gonna kind of add on because I took this question as getting credential just to be able to bill, not necessarily be in network.  So if that's the case, your first step is, I'm assuming you would have a patient and on the back of the card, there's gonna be a provider service number  and you're gonna call that provider service number and ask for the codes that you're calling about,  which for an oral appliance is gonna be the E0486. And they're gonna ask you for your tax ID and NPI numbers. And then you kind of get through it that way.  I agree with Dr. Vaughan though, the CAQH, if you have that all done, it's gonna make your process easier. And they'll ask for your malpractice insurance  and all the documents, the insurance carriers are concerned that you have up to date,  but just call the provider service number on the back. Again, remember that when you call, you're speaking to a person that receives calls of thousands of different codes a day.  You know what the codes are that you're dealing with. So you can kind of ask the questions to guide them to where you need them to go. Meaning I'm out of network,  I just need to get this authorized. What do you want me to send and where? That kind of thing.  They may not know anything about your particular code because they are dealing with thousands of codes every day.  But just call the provider service number and that'll help you.  Okay. Ladies, you got anything to add?  Well, I think this is Cindy at Meridian. I think for Medicare, for the DME portion for the oral appliance itself, we better add that in order to provide the oral appliance,  you have to be registered as a durable medical equipment provider. And you do that through the process that Dr. Vaughn alluded to, the National Supplier Clearinghouse,  fondly referred to as the NSC. And if you Google the National Supplier Clearinghouse, it will direct you to Palmetto GBA's website where that website will walk you through  how to become a provider to bill durable medical equipment.  So our next question is,  as a routine procedure along with a custom oral appliance, we provide a custom made AM aligners slash morning repositioner by the appliance manufacturer.  What is the billing code for the AM aligner? Does the letter of medical necessity have to include the necessity for an AM aligner along with the oral appliance?  Okay, so Belinda, do you wanna take it or do you want me to? Well, do you know what pops into my head? It's just because you can, it doesn't mean you should.  There's a mentor of mine that says that all the time with his little Southern drawl. The first thing I would tell you is that the oral appliance code  for different insurance companies includes different things. So for instance, Medicare, everything I have to do for my patient to give the E0486 is included in the E0486.  I don't get to submit different things. It's what I need to do for that code.  And so you need to know which insurance you're dealing with and what those requirements are. So we never bill for a morning repositioner. We assume that's part of our service.  That's how we operate because we don't wanna keep track of which insurance it's clumped into, which one it's not. It just makes it more streamlined for us.  And I'm not sure if you actually read the code that there's actually a designated code for the AM aligner. There's not. Yeah, I can tell you what code it's not. Yeah.  It is not 21085 or 21110. It is not those codes. Although that is what often is recommended. Yeah. Those codes are A, you're likely billing those codes wrong.  So a big important thing on the codes, the 21 series of codes.  Now this is not in the number code itself. So if you look up the details for 21085 or 21110, the code itself, you're gonna see it's a very brief description.  But if you look up the coding series, so that series of oral surgical splint codes, there is a little thing. And now all these things, CPT codes, just like CDT codes,  the name of the code, you can get for free. All of the details for the code you have to pay for. The American Medical Association or the American Dental Association  own the rights to the materials. So they charge you for those. But if you buy the coding books and you buy the coding series info on CPT codes, and you look up the 2100 codes,  you're gonna see that there's a requirement in there that the appliance delivered must be made by the provider.  So that means you can't use an outside lab, first of all. So if you're billing one of those codes and using an outside lab to make your morning prepositioner, then that's a miscode.  Now, if you're talking about the little wafers you boil and bite,  if you're using those for an oral surgical procedure, you can use the 21085. But if you're using those for a morning repositioner, I would use a miscellaneous code.  Realistically, I would expect most insurances to deny a miscellaneous code for that service. If you bill a 21085, this is the biggest difference between medicine and dentistry,  as far as billing is concerned. Dentistry billing, the billing companies, the insurance companies assume you're an absolute idiot and have no trust or faith in you  and require you to submit all your details for your codes. So in dentistry, we're used to submitting x-rays when we do molar endo, or submitting x-rays when we do a crown  to explain and prove why. Medicine trusts you. You're a doctor. You went through school. You've earned some trust. So in the medical world,  you're trusted and assumed what you're doing is legal. Just like the IRS. The IRS trusts you until they audit you and find out what you did wrong. So medical trusts you.  So if you bill 21085, they will pay you. But just because you got paid didn't mean that it was correct. And then what will happen is on audit, they'll take that back  and they'll take back all of your other payments over the last five years or however long they'll retroactively pull back.  So should you submit a letter of medical need? Absolutely. If you submit a miscellaneous code, you have to submit a report with it.  If you submit a report and insurance pays it, you're pretty good then. You're pretty golden. But if you submit a report and they deny it, then fight it if you want.  But in my mind, it shouldn't be approved personally. It shouldn't be medical need.  Sounds good. All right. So our next question is, I want to file my own electronic claims. What clearing house or houses do you recommend?  Are we, or weren't it supposed to be? We're not gonna be able to recommend specific companies. That's not kind of our role here isn't to necessarily vet and recommend companies.  We don't wanna put the ADSM out there  saying this company is good and then they're bad and you get angry at them. They're all the same. Google it. They're all the same.  Realistically, like everything in the United States, there's consolidation. So we've gone from 1,800 clearing houses to like three.  And so the clearing houses are all condensing down. They're all buying each other up. There's gonna be one or two. Your software that you use realistically  is gonna be the one that determines the clearing house.  They'll probably just change healthcare. I'm not recommending change healthcare, but that's the largest one in the U.S. right now.  So our next question is for Medicare. Are we allowed to bill Medicare Part B for consult or any follow-ups after E0486 is billed?  That's a Part B question, right? Yes, I can go ahead and fill that one. For Part B, Part B does not cover consults at all or any provider. So no, definitely cannot bill a consult.  Can I add one modifier to that question?  Just because we're talking about billing and coding and, Dennis, we sometimes use the wrong words. Let's change that from consult to a new patient E&M,  like a 99203. Can I bill that to Part B prior to determining if I should need an appliance for the patient? And then can I build a follow-up to 99213s following that?  And still the answer is no. Okay, I'm just saying, because- Those are not favorable services. So if I can add one thing to context on that,  Palmetto GBA, so these would be for regions, what is that, A, they're jurisdiction J and M.  They do have a policy article in LCD published. It's LCD A53497.  Now, again, this is a local coverage determination.  Or whatever they change the names to now, or local coverage article.  Applying to just two jurisdictions. But in there specifically, there's a line that says, a line that says specifically, the initial assessment and diagnostic services  to determine whether an OSA appliance should be used  are billable to the Part B contractor up to the time of the decision to order or provide the OSA appliance using the appropriate E&M or evaluation management CPT code  and other appropriate CPT codes for diagnostic tests. At the time of the decision, all fitting adjustment supplies and services related to it are inclusive in the E0486.  Now, again, that would only apply to one contractor.  I'd also add to that, it does have to meet medical necessity too. Correct. But in other words, it's, yep, absolutely. Medical necessity needed. But just out there to highlight,  LCDs apply to a specific region, not to universal. NCDs apply to universal.  Absolutely. There's an extension to this question, which is once you have delivered the appliance and you're supposed to monitor the patient on an annual basis,  how do you get compensated for your annual visits? Because that doesn't fall under DME anymore.  You don't. Cindy's shaking her head. Medical need based off of the contractor determination  on that one.  So if the contractor determines it fits medical need, then it fits medical need. If they determine it doesn't, it doesn't. And that's up in the air somewhat  just because there's no published guidance on it. Although it'd be great for someone to send a request. Maybe the AADSM can send a request for a new LCD or NCD on that.  Okay, so our next question is, does insurance require the sleep study to be 12 months or newer? And is that from the date we first see the patient or date of device delivery?  Well, if you're delivering a device, or if you're doing an E0486, it's durable medical equipment. You cannot submit the claim until you deliver the equipment to the patient.  So it would be from the delivery date.  As far as whether or not it's a year, that depends on the insurance carrier because some of the carriers don't have a designation, some of them do.  So when you're calling to get your benefit information, that's one of the questions that you should ask is does the age of the sleep study matter?  And they'll look it up and they'll be able to tell you that.  And that does change periodically.  And I'll tell you that every rule has an exception. Every single rule on the planet has an exception. Whether or not you're given the exception is different, but you can always ask.  So in other words, if an insurance company says we require a sleep study within 12 months, you're gonna be two days off of that 12 months at delivery date,  ask the insurance for an exception to that policy. And you do that literally just write up a letter, say the title it requests for exception to policy and explain the scenario  and a physician on the other end will evaluate and determine if it's appropriate or not.  Your patient is homebound and can't do it. I mean, if there's a real extenuating circumstance, but the safest answer is get a study within a year  because every insurance will accept that. Kind of like 4% versus 3%. Every insurance accepts 4% desaturation, everyone. Not everyone accepts 3%.  So just get a 4% desat and you're safe. Same thing on this. Get it within a year and you're safe. Okay.  All right. So our next question is, I see that there are three new CDT codes related to oral appliance therapy. Great first step by ADA. Does that mean that medical payers,  including Medicare are not going to pay for those codes? If so, will a simple claim, dental claim form do?  Okay. So my first thing is I would love to know who thinks this is a great step  but because I don't know if you've looked at your dental insurance, but they all have maximums and you would use up your maximum on delivering an oral device  and not be able to give your dental patients any care for the rest of the year covered by insurance. So I'm going to have to disagree,  but those codes currently are not billable insurance  reimbursement codes to dental insurance.  Although I did hear that one state does have that in place. I'm not mistaken, Rhode Island,  but no one else to my knowledge is reimbursing those codes. The ADA put those out as supposedly tracking codes to kind of keep track of what was going on  but that would require them were submitting those codes. I'm submitting to medical. I'm not going to turn around and submit to dental also.  So the answer is, we don't know it's too new and we'll have to see what happens. And realistically, I always remember that billing, coding and payment are three separate things.  They're related, but they're completely separate things. Coding is a language. That's all it is. Okay, it's French versus English. It's nothing different than that.  It's you communicating to essentially a computer on the other end, realistically, I mean, a human may touch it, but most of the time it's a computer and it's just the language.  So all that is doing is allowing you to communicate in another language, okay? And dental codes fall under this category of what we call HCPCS codes.  So CMS publishes HCPCS codes and they've leased or licensed the dental series CDT codes as the D series of HCPCS codes. So if the ADA creates a code,  it automatically becomes a HCPCS code for the most part and all insurances except, in other words, they will receive HCPCS codes.  Whether they will pay them is up to the individual medical payer.  So you can certainly submit it. It's a valid code, but yeah, I'm not aware of any medical insurances that are covering that code and dental insurances are gonna be up  to each dental insurance, whether or not they wanna cover it. They might not cover it, but realistically, how's that gonna get used in real life?  It's, like Melinda said, it's a tracking code. It's something you can put in. Instead of having to use a miscellaneous code or create a dummy code in your software,  it'll have that code as an option, but I would not suggest billing that code anywhere other than internal.  So our next question is, can I charge different fees for different appliances, different fees for cash patients versus insurance?  Alex, do you wanna take this one first? So the caveat, I think we all, well, I forgot.  I'll give it for everyone. None of us are lawyers, so none of this is legal advice. Can you do it and should you do it are two different questions.  So again, this is a general lay understanding of this is not legal advice, but fraud would be when you're using a similar situation  in two similar scenarios, but two different results. Let's put it that way. So in other words, if I'm treating a patient  for sleep apnea, they both have the exact same sleep studies, exact same health histories, all that. They just have different appliances  and I build different codes on the exact same day. That is questionable for a different rate on the same code in the exact same scenario. Now, if you're doing it based off of payer,  almost guaranteed to be illegal,  but if you're not doing it based off of payer, there's ways to do it, but it's a very specific way and specific scenarios. And again, that goes way out of the scope of this,  but in general, no, don't bill a different fee for the same service, especially if it's the exact same service in the exact same scenario.  And again, if you're billing different based on payer,  well, if it's a commercial payer, you got to deal with your state and state law. If it's a federal payer, I hope you enjoy federal penitentiary because it's a fun place to be.  But on the back of the CMS claim form, right? The CMS 1500 form you send and send in on your claim. CMS on there does not stand for like anything other  than Center for Medicare and Medicaid Services. That is who published the form. If you flip it over, you'll see what you're signing and you agree on there to follow CMS policy  and federal law. So submitting that claim form with inaccurate information, in other words, if you charge Medicare a higher fee, let's say than everyone else,  because you were told that you get reimbursed higher that way, or, you know, they may have a plan G supplemental that pays your full fee. So I'm going to bill out 12K to Medicare,  but 4K to everyone else. That when found out, not if, but when found out gets you in a lot of trouble. That's called Medicare fraud. That's not a good thing.  Okay. So our next question is kind of wordy, just, and it has lots of small questions in there. So I'm going to go ahead and get started.  We're starting to get many Medicare patients who are either completely or partially edentulous, have moderate to severe alveolar atrophy.  Some wear their removable dentures and some don't because of lack of stability, retention, or pain when they wear them. And because they're either edentulous  or have fewer than four teeth per quadrant  or unilaterally edentulous, don't technically qualify for management of their OSA with MAD. And they refuse the use of, or are CPAP intolerant.  If we wanted to install two or four dental implants per arch and any hard and soft tissue grafting needed to accomplish that and place locator abutments,  what would be used to retain? Oh, that would be used to retain MAD. What all documentation do we need to provide the payer for them to consider payment  to help us manage this patient's OSA? What ICDs and CPTs do we use? So this is a little bit of dentistry and a little bit of innovation and a lot of billing.  I like the thought. I've tried this scenario a little bit on my end with the VA, but I mean, I don't place implants, but I've tried to get the VA to place implants for my patients.  Let me, I'd like to explain it this way. Medical necessity determines all payments, right? Interns pays off of medical need.  So they're gonna ask you, why is this necessary to pay for? And now work through this scenario in your head, right? You're the medical insurance company.  You're trying to save money. You're paid by saving money. That's how you're paid. And someone comes to you and says, hey, I have this patient with a non,  I'm sorry, but mild or moderate apnea is non-life-threatening in the general sense. Okay, we're not talking about a stroke or major, severe apnea, sure, we're a different scenario,  but mild and moderate in general, we're not gonna classify this life-threatening major problem. So I've got this moderate condition.  There are two first-line therapies. Patient doesn't want to do one of them.  The second one of the first-line therapies is hard for us to do, and we need $30,000 to allow us to do it.  There are also five or three or four second, third-line therapies that are cheaper.  The insurance company is gonna tell you, great, they're not a candidate for oral appliance. Go to Inspire, go to MMA, go to something else first.  Now, the scenario where this might work, where you might be able to make this argument, every other treatment on the planet is contraindicated.  I don't know what that patient looks like, but they're contraindicated for Inspire because they weigh too much. They're contraindicated for MMA  because they've got a clotting disorder, although how are you gonna justify doing the implants? But let's just go with that scenario. Every other alternative is contraindicated.  Now, maybe with a lot of letters and a lot of phone calls to the medical directors and fighting, you might get to a point where they're gonna justify it.  As far as what codes you'd use, you'd use the CDT codes. You just use dental codes. Again, those are valid billing codes. They're HCPCS codes.  And the ICD-10, I don't know, go to Google ICD-10 Edentialism and use that ICD. But realistically, the hard part is medical need.  I don't know if anyone wants to add any more, but that's kind of my long-winded explanation.  I just think it's asking for some trouble. So you, yeah, you better have- I mean, you're going about the right approach, right? You justified it and you're asking,  how do you get it covered?  You get it covered through exception to policy and requesting medical need review and giving a good detailed explanation of why, including why everything else is contraindicated,  why nothing else will work. Now, you can do this with anyone but Medicare. Unfortunately, Medicare is a little harder to get predeterminations done on these  because they're not required predeterminations. You're gonna have to fight after the fact, which, good luck on that one. A lot of times, and I don't mean that negative  towards Medicare, a lot of times you can fight after the fact, but that one after the fact, I ain't touching with a 10,000-foot pole because that's a lot of expense on your end  to hope it gets covered in the backend. Well, although you're talking about Part B interplay because it's not DME, I don't know. It's complex. But again, I've done this.  I've gone down this route with my VA when the VA sends patients to me and I say, hey, this patient would be a great candidate for an appliance, I just need implants.  Can you, the VA, place the implants? I don't want the implant money. I just want you to place the implants. And even then they said no.  But. Hmm. Okay.  All right, so our next question is, if a patient wants an appliance that Medicare does not cover and is willing to pay out-of-pocket, what paperwork do we need to submit?  Medicare ladies, you're up.  Well, if it's one of the,  you know, if it's under the local coverage determination for the oral appliances and it's a medical need,  if it's a medical necessity denial, then you would provide them with an advanced beneficiary notice. You would have to explain that it's not reasonable and necessary for whatever.  And basically there's just two codes. There's the EO485, which always is denied, is not medically necessary. But your custom appliance, you know, there's coverage criteria,  so you would need to be specific on why it's not reasonable and necessary. And then that claim would be filed to Medicare with the GA modifier. And then you would be,  you could be asked to provide a copy of that ABN.  And that has to be delivered before you ever provide the item, so.  Cindy may want to fill in if I left anything out.  When we have a patient that wants an appliance that's not on the Medicare PDAC approved list, that's their, they don't care. That's what they want. Then we'll put on the ABN  that the device does not meet Medicare's criteria  and that the patient is responsible. And we've not had any issues with that because it's not, they're selecting something not on the PDAC approved list for whatever it is.  Right, and you can do a voluntary ABN for things that are non-covered or, you know, are outside of the coding. Because I'm not sure,  Cindy, does the coding deny with the medical necessity? I can't, I don't remember if that one's a specific medical necessity or reasonable and necessary denial message, but.  I'm talking about for EO485? For the coding, the code, if it's something that's not been verified through PDAC? We have to submit it under an A code, the A, what is it, 9270,  which is an automatic denial because it's non-covered. Right, that's the non-covered, yeah. And you can provide a voluntary ABN in that situation, yeah.  Right, because to build the EO486, it has to be one of the manufacturers that has been approved as providing an E0486. There are other codes out there.  In fact, there's a new K code, but that's not covered by Medicare. Yeah, I want to caveat two things on here or agree with you on two things.  One thing to add in, a reminder on ABNs, the patient is the only one who can fill out box G. So box G is the instruction of what the patient wants you to do. And as a supplier,  you need to follow that request of the patient. So their options on that are either A,  they want it and they realize that, you know, they may be asked to pay now, but they also want Medicare billed for it. So in other words, they're saying,  hey, I'll pay you, but I also want you to build Medicare. Medicare may then tell you to pay me back. Option two is that they want it listed by all, but don't bill Medicare.  I'll pay you all right now and I'm responsible for it. And then option three is they don't want it and they understand that the choice, they're not responsible for payment  and cannot apply to Medicare. But the point is the patient has to fill that section out. You cannot have that pre-filled for them.  You need to allow them to be the determining factor on that. And then the other thing I'll, sorry, go ahead. Oh, no. Yeah, I was just going to point out  that there's quite a bit of education on completing that ABN. It can get detailed. There's a lot of instructions with it. You know, we could do a two hour webinar over just the ABN.  I think you guys, do you have a webinar? I'm sure you guys have something in the can that you can go to.  We do have webinars and we do have self-paced tutorials, but Angie's absolutely right. And we don't want to frighten people, but an incomplete ABN is the most common reason  for a denial in a review of documentation if you're billing with the GA modifier. So if you're going to use ABNs  and certainly the scenario that Melinda mentioned is an appropriate use of an ABN, just make sure that you clearly understand the detail with which it has to be filled out.  Because just having a piece of paper with one of those boxes marked is probably going to ultimately get you a denial in the event of a review. So it is a very detailed process.  That's a really good point, Angie. And the denial will be a contractual denial or a forced write-off. Not a patient, you know, not a patient owes you this.  And so if you fill out the ABN wrong, even though the patient agreed that they are going to pay for it, but you filled out the ABN wrong  and you are registered, par or non-par, whatever, you are legally billing Medicare, you are legally required to follow what is on the EOB for Medicare.  So if they come back and say, you need to write it off, you need to write it off. And if your patient paid you, they can go to Medicare. Medicare will gently tell you to do it.  And if you still don't do it, they'll sue you for it.  Do things correctly with Medicare. Do things correctly with everyone, but just get that Medicare is federal government, right?  It's IRS level of, they tell you what to do and you do it, or you face a local attorney.  Yeah, do it the right way. They said we didn't want to scare them, Dr. Vaughn. I'm not scaring you. I'm just, I've been doing it the right way. It's just like the IRS.  If you're honest on your taxes, there's nothing wrong with the IRS. Or orange may be the new black, but we don't necessarily want to all be in orange gym suits. You got it.  Good analogy. You got it.  These are words of wisdom.  All right. Our next question is, has anyone tried getting insurance approvals for dual therapy with CPAP and an oral appliance, both covered by insurance?  Any help or advice would be greatly appreciated.  Oh, you know, some of the insurance companies will pay for both treatments. So when you're making that benefit call to the private payers, when you're making the benefit call,  that's one of the questions that we ask. If we know that the patient has recently gotten a CPAP or, you know, we always ask, are there any issues? Do they have to return the CPAP?  Those are things that we ask. Medicare pays for one option and there are some different guidelines on that, but it's five years unless there is a physician documented reason  that there's been a change in the health condition that directly affects the patient's inability to use a CPAP. So again, it all goes down to the documentation,  but we do have patients with private payers that their insurance will pay for both modalities. If you're not sure, err on the side of caution with your patient,  go ahead and get all the correct documents and submit the claim and see what happens. But some of the private payers are still doing that.  And again, always an exception to policy, always. So if you have an insurance that says, again, commercial is a little bit easier to get these exceptions than the DME max  only because of the pre-review versus post-review phase. But on a medical insurance, commercial insurance, pre-review, I've had plenty where we've gone down this route.  Best route to do with that is you and the physician each write a letter. Again, this is assuming that they have a policy limitation says you can't do it.  Write a letter, both of you explaining why it's necessary.  And most of the time, if it's just a, and you're not, this isn't, you don't need a 30 page letter with all this research. Just you're a doctor, you got two doctors,  you're writing to other doctors. You're gonna explain the scenario, the history, why it's necessary. As long as it's a reasonable argument, most insurances will approve it.  Okay.  So now this question has multiple sub questions. We would like to do compliance monitoring with compliance chip embedded in all of our OAs.  We are also trying to do follow-up visits remotely as much as possible and would like to give the patient the reader at the time of the oral appliance delivery  so they don't have to come to the office for the data to be downloaded.  What are the billing codes and approximates fees  for the following? One, compliance chip embedded in the oral appliance. Two, the compliance chip reader. Three, collection and interpretation of compliance chip.  Four, reading of compliance data by the doctor. Five, reading of compliance data by the staff. And six, compliance monitoring counseling.  And what is the frequency for each of the above for billing?  That's a big question. Here's how I'm gonna answer this. This is, again, by itself, an entire topic. Okay, so this landscape changed dramatically  the last couple of years, and especially this year. So there are now codes for remote patient monitoring and remote patient therapeutic monitoring.  So we're talking about two different things. One, remote patient monitoring is basically  using vital signs the patient provides to you to help direct care, and then you've got this therapeutic effectiveness monitoring, or sorry, there's remote physiologic monitoring,  remote, basically, therapy monitoring. How well is the therapy working? So the two different treatments, or two different codes, code series, and lots of rules over,  basically, only one physician can bill them for that code. So it's kind of whatever physician bills it first gets to keep billing it. There's monthly requirements.  There's documentation requirements. But all that to say it's a whole field has been developed in the last few years regarding this. The best thing you can do is to go to Google,  type in remote patient monitoring reimbursement or systems, and you're going to find plenty of websites that sprung up for this exact thing.  Now, not for sleep, but for wearing a Fitbit and sending your Fitbit data to your doctor, or wearing a Holter monitor.  So this is a whole industry. Software is developed to do it. Which codes to bill, that's going to be all there. And again, it's kind of outside the scope  to go through every single code, but that'd be what you want to look for is remote patient monitoring, remote therapeutic monitoring. And-  Can I ask an extension to that question, Dr. Vaughn? Yeah. When patients that are referred from, obviously, all our patients are referred from physicians,  many of them sleep physicians,  wouldn't there be a bit of an issue because they would want to monitor these patients? Hey, I'm not going to tell you how to run your business, but you got to make sure  you're not ticking off your sleep docs, or work out an agreement with who's going to bill it. I mean, there's it, how you want to run your practice,  how you want to run your practice, and there's benefits and risks to any decision you make. But I'll tell you again, the whole industry about it. And then, yes.  If...  I would suggest you speak, especially if you are referral-based and you work closely with your sleep physicians, I would strongly suggest you discuss it with them  because they may want to do it. Now, we're not talking,  it's still significant, but it's, let's say, $10 to $30 a month per patient. So, decent amount if you've got a large volume of patients, but they may want that money too.  And if you're... Again, I'm not saying you're exchanging services for fees, that would be illegal. But certainly, if you are providing them  with a billable option that is perfectly legal, and they choose because of that to work with you because you're providing that service to them,  that is not a violation of Stark or Sunshine because that is just a normal... You didn't pay them for this patient. It's just, if they refer to you, they happen to make more money  because they can monitor the patient.  Maybe that's going to be a referral generator. Again, that's kind of how the referral system works. You refer to get refers.  Okay.  Is there a way to collect fees upfront as fee for service, but submit the claim on behalf of the patient so they can get some reimbursement? If so, do you advise connecting  with insurance companies directly or working with a billing service? Well, I mean, of course you can collect the full fee upfront and then send a claim on behalf of the patient,  but you should probably still be contacting the insurance carrier and doing your due diligence on what needs to be done and providing that information.  Otherwise, you're going to have some unhappy customers and it won't take long before you won't be getting any customers.  So yes, you can absolutely bill as a fee for service. You can mail it. You can do an electronic claim on behalf of the patient. The difference is where the payment goes  and there's the little check box. The payment goes to you or the payment goes to the patient. And so if the patient's paying you,  then you would check, send the payment to the patient. I would encourage you to continue to follow that claim on behalf of your patient, because it's overwhelming to patients  that never done this, what to do. So just giving them the paper seems like a little bit of a disservice. I think you should probably at least make sure  the claim got there and is being processed so that the patient knows what's going on. Yeah. Also, and to clarify, sorry, go ahead.  Well, we can argue it over, Dr. Vaughn, but for Medicare, I want to make sure that we talk about the caveats for fee for service Medicare. There are some rules surrounding  whether or not you can bill the patient first. So what I'd like to explain is the difference between participating and non-participating first.  So when you enroll as a Medicare supplier with the National Supplier Clearinghouse to provide the oral appliance, you get to choose whether you're participating  or non-participating. Either way, you can bill the Medicare program for the oral appliance. But if you're participating, you are agreeing to accept assignment on every single claim.  If you are non-participating, you can make a determination on whether or not you want to accept assignment. So then when you bill the claim,  the difference between an assigned claim and a non-assigned claim is that with a non-assigned claim, because you're non-participating, you can now collect the full amount upfront.  And when Medicare pays, they will pay directly to the beneficiary.  But you can't collect the whole amount upfront if you are participating with Medicare.  Speaking of breaking rules. Yeah, I assume when they were talking about fee-for-service, they were not talking about Medicare, but that is correct. Yeah. And two things.  The fee-for-service. Sorry, we keep interrupting. But the fee-for-service. See, we talk about, for Angie and I, working with the DME-MAX, that is fee-for-service Medicare.  The difference between that in an Advantage plan. So that's why fee-for-service to us was, oh my gosh, we've got to make sure we're clear with that. So good clarification, Belinda.  Okay, Dr. Bond, we'll let you talk now.  Well, no, you're good. That was going to be one of my clarifications, which fee-for-service Medicare is the original name or the original concept. So if you think fee-for-service,  that means not Advantage and not Supplemental. It means original Medicare, Medicare Part B, whatever you want to call it, that's fee-for-service Medicare.  What I was going to clarify is box. Sorry. No, you go ahead.  I can clarify. Box 27 on the CMS-1500 is the assignment form or option. So that's what Belinda was talking about. It's sent it to the patient or you.  Accepting assignment means it goes to you as the provider. You're accepting assignment of that benefit to you, which means you do have some more requirements of that.  And then box 29 on the CMS-1500, which is incredibly rarely used. But that box, and I promise you don't have these boxes memorized. I've got it up on my screen.  Box 29 is amount paid. That you can indicate if the patient has paid you any amounts. What insurance does with that is going to be different on the insurance carrier.  But I have some carriers that I've worked with in the past, especially before I did this often, where if you put patient paid you $500 on that line  and the claim came out to be worth $1,000, they'll send you a $500 check and then they'll send the patient a $500 check, right? To reimburse the patient for what they paid you  because of that difference. Again, they may also just then submit it to you and then the EOB and tell you to pay the patient $500 back. But just note, you can indicate on that form  how much the patient paid,  99% of people won't put that on there just because it can get messy with the math, but there is a spot to indicate on there if the patient paid you anything.  But the safest, assuming that you mean fee for service, meaning non-participating with all insurances,  Medicare requires that you be registered in order for the patient to have any sort of benefit. So if you've not at least filled out your form  to register with the National Supplier Clearinghouse as non-participating, patient gets nothing ever, period, is my, please correct me if I'm wrong,  but if you're a, because dentists don't have to opt out, but if you're not registered at all with Medicare, there's no option for patients to submit claims  on their own, is that correct? Well, that's what I was going to touch on is the fact that if you're seeing a Medicare patient, you are required to file that claim to Medicare.  If you've not enrolled in Medicare, then you're not gonna be able to charge the patient because you have to provide them with an advanced beneficiary notice in order to charge them  if you haven't met your enrollment requirements. So, yeah, and you have a year to file the claim. As a non-lawyer, again, non-lawyer, vet this through your healthcare attorney,  the one caveat I will give is that dentists are statutorily excluded from the requirement to enroll in Medicare or opt out.  If you want to use that new D code, that new CDT code, and claim that you are doing dental services,  you may be able to get around that opt out requirement. Again, check with your healthcare attorney, but that's just like our exams. We don't have to bill our exams to Medicare  because it's statutorily excluded. But you're enrolling with the DME as a supplier. Oh, no, no, I'm saying if you're unenrolled, completely unenrolled.  Not, no, have no relationship with Medicare. And then you're claiming you're a dentist providing dental services.  Check with your healthcare attorney on that one. The better answer, just enroll with Medicare is non-par and choose to not accept assignment,  make your patient pay you full A, B, and all of the legal things on the Medicare side. On the commercial side,  that you don't have to register most states. I can't say all, but most states by law require medical insurances to accept a claim from a provider  that has not ever billed them before. They still have to accept the claim. You don't have to have registered with a commercial. Now, once you send the claim,  they'll probably ask for, or they will ask for a W-9. They're gonna ask for some details before they pay the claim. But you don't have to pre-register  with a commercial insurance if you're fee-for-service. It's good to, but you often don't have to. Medicare is the exception where you do have to be registered.  Michelle, can you take this? Please correct me.  Yeah, and the non-participating part of it, I just want to be clear on that. Non-participating means you are enrolled in Medicare and you do still file the claim for the patient.  You have one year from your date of service to file the claim, even if you're non-participating and the payment's going to the patient.  Yep, unless the patient on the ABN says option what to  do is don't bill Medicare. Right, yeah. Yep, but otherwise, yeah, bill it to Medicare. And then, but the non-assignment means that the claim's gonna go to the patient.  The other difference, two to highlight here, I think, and again, please, Medicare, both Part B and DME, please correct me on this. Part B has what's called a limiting charge,  which applies on these scenarios, where if you are registered with Medicare, enrolled as a non-participating provider, you do still have to follow the limiting charge,  which is what, 15% over the published, you know, physician fee schedule minus the 5% reduction for non-PAR, something like that. But you do have to follow the limiting charge,  whereas DME does not have a limiting charge for non-PAR. Is that correct?  That is correct.  For the DME side. Right, on the Part B side, though, you are, if you're registered with Medicare, you are required to only collect up to the limiting fee.  Is that correct, the limiting charge? That is correct. Yes, on the Part B side, that's correct, yes. So just be aware, if you do register Part B as non-PAR  so that you can accept assignment or not, you do have to start following limiting fees, which are, again, what, 115% less 5% or something like that,  isn't the, you know, that's not what we're talking about. Something like that isn't the, it's some weird funky math, because if it's the non-PAR, you'd lose a portion,  but then you can only charge 50% above your allowable or something weird.  I don't know. It's been a while since I looked in that, because I participate.  Well, it just needs to- I confused everyone that's listening, but just know that there are rules. Follow the rules. Yes. Our next question is an extension of this.  How do I decide if it's better to be participating or non-participating with Medicare?  My advice would be develop a business plan and a business model based off of how many patients you're going to receive or expect to receive on referral basis.  Speak with your physicians and ask them what they would prefer. This is a business decision. This is kind of like saying, which appliance should you select over another?  There are benefits to both routes. Non-participating with Medicare involves more of a, well, participating is the most common way to get a referral,  but non-participating with Medicare well, participating is the most straightforward. It's no different than any insurance. You submit a claim, you get paid,  you follow what the insurance tells you to do as far as patient portion, and you have to follow the rules. Very, very straightforward. Easy transfer back and forth.  Lowest amount of administration outside of just straight fee for service.  But the downside is you're beholden to every single rule and the whims of the insurance companies. Non-participating,  you can do a model where the patient receives the check. You can do a model where you selectively participate occasionally. You can do a model where  you charge the patient the full fee and they just get whatever Medicare pays them. You can do a model where you submit on their behalf and you allow them to reassign,  to pay you with the Medicare check that comes in the mail from them and wait for them to receive their check.  So multiple models on a non-par side, all involving probably the most administrative burden. Um, so it's a hard answer to give you. I will tell you that we are non-par on DME  and we are participating in Part B,  is how our company is set up.  I'm not saying it's the right way to do it or best way. You should keep in mind, and again, it goes back to your business model, is Medicare can change their fees  based on what's going on. And if you're a participating provider, you're bound by those fees.  There's a process that you can go through to remove yourself, but if you've already submitted the claim, you're in. So those are some things to think about.  How many Medicare patients are you seeing? Are you a referral-based practice where your physicians are referring to you because you're a Medicare provider?  To be honest, I don't know that the physicians pay a lot of attention to whether or not you're participating or non-participating as long as it seems reasonable  of what their patients are paying.  So we're non-participating also. We've not had any issues, but some things I do want to, as long as this is coming up and the Medicare ladies can join in on this,  your fee is what you still submit to Medicare. That fee should be your fee. So just keep that in mind. And the other thing is I've run into some offices  where they're like, oh, well, we offer less for cash fee. Oh, that's less than your Medicare fee. That's a bad no-no. And I don't look good in orange. My fee is my fee.  That's my fee. So just kind of keep that in mind.  Even if you're non-participating, you still have a set fee. It doesn't get to change just because you're non-participating and you can balance bill that patient.  That's not a good idea.  So our next question is an insurance payer is requesting we submit claims with our group NPI number. We use a group NPI number for billing,  but they want us to also use the group NPI in their rendering provider box number 24J.  Is this possible? Can a rendering provider use a group NPI?  Medicare versus commercial. Medicare DME, you're registered, the supplier that's registered is the company itself, not the individual physician.  And part B, it's the individual physician that's registered and then they reassign their benefits to the company.  So Medicare confuses this a little bit or makes it more confusing. Commercial insurance, the provider who gave the service to the patient is the rendering provider.  That's the physician or dentist in this scenario. Unless that commercial insurance maybe has a system where they have a specific DME arm that you registered with or something funky.  But for Medicare, again, correct me if I'm wrong, but Medicare, it's the DME supplier, which is the company that is registered with Medicare DME.  And in part B, it is the physician that is registered. As far as the billing NPI, that would be the entity that's actually billing the claim  and expecting a check to come back to them. In box, what is it, 33 or 32? That NPI is the business, but the rendering provider should be the...  And to clarify, because there are some groups that are recommending you put a physician NPI in there. If you partner with a physician and they're gonna sign off on your claim forms  as the rendering provider. No, the rendering provider is any individual that is entitled to have an NPI, which is a dentist, physician, healthcare provider.  If they rendered that care to a patient, they are the ones whose rendering provider goes there  with the caveat of Medicare.  But I believe, correct me, please.  You are correct on the part B side, yes.  The group is gonna go down in the bottom. 24J is the rendering physician, the individual.  Correct.  So our next question is, billers are stating providers must be credentialed as out of network, even if they are fee-for-service. So a patient can get reimbursed.  Does this sound right? Caveat of commercial versus medical or Medicare. Medicare, yes, you have to be registered if you want patients to get anything out of it  or credentialed or whatever, again, term for the non-par. Commercial insurance, again, it's gonna be state by state. Commercial insurance is run by the state  unless it's, all these caveats, unless it's an ERISA plan and then it's run by the government, federal government, or if it's for ACA, Obamacare, market insurance,  for ACA, Obamacare marketplace plan, then that's run by the government or follows federal law.  But most states have a law on the books that says insurance cannot require you to pre-register to bill them. For them to pay the claim to the provider,  yes, they'll ask for a W-9, but to submit the claim, no, they are not supposed to require you to be credentialed to submit a claim in most states to commercial payers.  If that's clear as mud. Again, please correct me if I'm speaking incorrectly over the government side.  So we're back to the ABN form now. Is an ABN form needed for the amount balanced, billed by a non-par Medicare provider to be paid out of pocket by the patient for an appliance?  I guess I'm a little confused by this question.  The advanced beneficiary notice is for when you believe something is not going to be paid, you're advising the patient in advance that Medicare is not gonna pay for it and why,  is kind of how I've always understood it. So for instance, the example I gave earlier is if my patient says, no, I don't want any of those PDAC approved appliances,  I want this appliance, then we notify them on the paper that says, Medicare is not going to pay for the appliance you selected because it's not a Medicare approved appliance,  this is how much it is. And so you're notifying that patient in advance. So I guess I'm a little- I think they're asking though, if it's a Medicare approved,  you deliver a HERPS that's on the PDAC list, it's all approved, but you want a balanced bill.  Do you need an ABN for the balanced bill portion?  Or are you as a non-par just allowed to balance bill just because? Do you need a signed document from the patient acknowledging that they will be balanced billed  is essentially how I interpret this question. There's not a limiting charge with DME. So if Medicare approves the item and we have an approved amount,  then the supplier can bill the patient for their charge.  And the patient's not required to acknowledge that prior. Right. Now, again, it's a business practice, but good customer service would lead you to believe  that maybe you should explain that to the beneficiary because somebody down the road might have an oral appliance and you know how they talk.  And if they pay twice as much than their friend did, then you're gonna have to explain that. So it's a good practice to explain it, but you don't have to have a piece of paper  unless like Belinda said, you're non-participating with Medicare and the patient still doesn't qualify because the rules for an ABN are the same  whether you are participating or non-participating, that's irrelevant. So if they don't qualify, you do need the ABN, but if they do qualify and you're billing non-participating,  you don't need a special piece of paper to address that.  But you cannot use the ABN to bill for things that are wrapped up into the payment for that device. I know we get that question a lot for other items.  So the ABN cannot be used to bill for something that is outside of what you're able to charge the patient for if it's a bundled top service, if that makes sense.  Great clarification. Yeah, I appreciate it. Absolutely, no, that's a critical piece. Yep, yeah, so in other words, you're saying you can't ABN for the 90-day global  and say, well, I'm providing an adjustment, so here's a separate ABN for $60 for the adjustment of your appliance because the code is inclusive of 90 days of adjustment.  Yep.  Great clarification. So our next question is, are there any medical EHR systems slash billers folks recommend?  Again, not gonna recommend any specific companies. Go to Google, look up a bunch of different ones. There's a lot.  Okay, fair enough.  What are best practices and possible examples of documentation that is sent with patients to have them file their own medical insurance?  The patient presents for OAT. You collect full free service, but you help the patient gather appropriate documentation to submit to the insurance. Depending on the insurance,  does the patient file pre-authorization? Just curious as to what are the best practices with this model? Okay. Go to Google. Well, I'm gonna say,  if you're really concerned about best practices, then you're not gonna make the patient do it.  They're not gonna, I mean, as a physician, I always, I recommend to the dentist when you start this to make a couple of calls yourself. Number one, it's good for you to understand  what happens on those calls. Number two, it's really good for you to understand how long it takes your staff to complete these calls. Because when your staff member says,  it took me an hour, you're like, I don't understand how it would take that long. When you make a couple of these calls, you understand how that happens. And it's medical jargon  and your patients have no idea what that medical jargon is. And so if you're really worried about best practices, you wouldn't be making your patient call  for pre-authorization, you would do that for them. Yeah. The one caveat, I can see where this is going though, from the doc's perspective. I mean, if you wanna provide  and you think that you provide a $7,000 service and you know that their insurance isn't gonna cover that $7,000 and part of your service fee  is collating all this information for your patient so that they're gonna come to you and you're gonna give them a packet that basically they just sign three spots,  put it in the mail to their insurance company. I think that's an honorable and good thing to look at. But every insurance company is gonna have a different policy  as far as how patients can submit their own claims. A CMS 1500 is universal for providers submitting the claim, but many insurances allow patients to submit claims  from non-participating providers to see if they can get a reimbursement, but that's gonna be insurance specific. And so for that, again, you'd go to Google,  you type in the insurance name, you type in, submit patient claim or something like that. Maybe type in, I'm a member, right? Because patients are called members  of their insurance company and you'll find the member submission process and there's gonna be a special form they want filled out. It's gonna be, where did you go see?  Who did you see? What date did you see them? How much did they charge? You're gonna need to submit a copy of your bill. You're gonna need to submit a copy  of all the referral information, the sleep study, your notes documenting what you did.  Again, I don't necessarily think this is the best way to go about it. I would say if you wanna be fee-for-service, just be fee-for-service  and just charge cash. But if you wanna help your patient out with that, I can see it, but it's a challenge.  Okay, so our next question is, as you may know, cone beam scans using CPT code 70486 is not payable to dentists. What code could be used when rendering this procedure  with Medicare and other medical insurance plans who may also follow Medicare rules? And so that question itself is unfortunately not the correct necessarily.  There may be an assumption or something they've been told in the background. 70486 is the code for a cone beam CT scan. Now, some insurances are denying it,  stating it doesn't say cone beam in the definition of the code. My usual response to that is to give them a different CT code and ask them where it shows in that, the code fan CT.  Because if they're talking about a medical CT, that's a fan CT, the traditional, versus a cone beam that a dentist uses. You'll notice that medicine  also doesn't define a fan CT anywhere. Often when you point that out to insurances, they all of a sudden approve the cone beam CT because that is the appropriate code,  the CT of the maxillofacial region.  As far as billable, payable, more likely than not, you ran into a medical necessity denial. And that's because it is extremely rare for a CT scan to be necessary  for the treatment of anything dental sleep medicine related. I would go as far as say it's,  I don't use absolutes. 99.9% of the time, it is not medically necessary to take a CT to treat a sleep patient. To treat a patient where you suspect  there's an osteoma growing in their TMJ, yes, that's medically necessary, and that's how you bill it. You bill under osteoma. You don't bill under sleep.  So just remember that the diagnosis and the billing code have to match. And there's almost no insurance that's going to determine that there's a medical need to bill a CT for sleep.  And to also go back to, as we said before, everything that you do for your Medicare patients is encompassed in that E0486 code. So there's no separating out  a PANO and E0486 generally.  Unless you're under palmetto in region J and M, because that LCD does specifically say that the exam and imaging, diagnostic imaging, is to be billed to Part B.  And that if Part B determines it's medically necessary, right? So there's the two caveats. One says bill it to Part B. The other is, does Part B determine if it's necessary?  But Part B, there are absolutely necessary reasons to do a CT on a patient by a dentist, billable to Medicare Part B. Again, osteoma, osteochondroma,  looking for pathologies in the TMJ based off of clinical findings is absolutely appropriate and billable.  Sleep, no.  At least CT. Pan, you got an argument there maybe.  So has insurance ever paid for oral appliance with a diagnosis of upper airway resistance versus sleep apnea when the sleep physician refers for oral appliance therapy?  Yes. Does it ever happen? Yes. Does it normally happen? No.  To clarify too, upper airway resistance syndrome doesn't have an ICD-10 code. There's a miscellaneous code of other sleep disorders. So you may see it coded under G47.8,  which is other sleep disorders that may be how you'd code it, or it could be coded as snoring as a symptom code. But there is no technical ICD-10  for upper airway resistance syndrome, which is more likely than not why you're running into difficulties with it. Also, most medical policies are gonna exclude it  because it doesn't meet the medical necessity criteria of five events or more per hour.  But again, exceptions policies exist. They exist. Make a well-reasoned argument to insurance. This patient has a medical condition that is causing a problem  with their ability to do X, Y, or Z. Can't be ability to drive. That's not a medical insurance issue, or work, but they're falling asleep  and they've fallen and broken their head three times, cracked their head open because they're so tired. Make that argument to insurance because essentially you're telling insurance,  what do you wanna pay for? Multiple ER visits due to falls or upper airway resistance syndrome. If you can make a reasonable, valid argument, you can ask for coverage.  Have I had UARS covered? Yeah, once. But realistically, it's not gonna get covered.  So you would send a pre-op letter with a letter of necessity. You got it. Either if the insurance already requires pre-author E0486, it'd be a pre-auth letter.  If they don't require it, you're going to ask for a courtesy pre-authorization or courtesy review. A lot of states require insurances to allow you to do that,  to prevent the need for a post-service review where everyone's on the line for it. Most states allow you to essentially demand a pre-service review or...  And in that case, yeah, you're going to submit a letter.  And again, you're writing to another physician for the most part when you're asking these things. Medical determination, medical necessity is always required a physician to deny.  Again, well, not always. Most states requires a physician to deny. So you're writing to another physician. Make a valid, concise medical argument,  and then it's up to them to approve or deny. Okay. So our next question is, at times the patient is undergoing dental treatment and we use a provisional oral appliance  such as Alpha from Somnomed for the duration of dental treatment and charge the patient. Most of the times the patient accepts the modest additional fee,  which is usually three times our cost. We would like to minimize the financial burden on our patients as much as possible. So is there a way to submit a provisional oral appliance  to the payer? And if so, what documentation do we need to provide them?  I am not aware that you're able to do that. I mean, there's the E085, which is a prefabricated,  but most of the policies, if they would pay for that, will not then turn around and pay for the E0486 because there's a time limitation.  So the question would be when you contact your provider, the insurance carrier, and we're talking about commercial here,  then those would be questions that you should ask them. Is there a time limit? Is there, so if you submit one code, can you submit the other?  Those are questions you're gonna have to ask the individual carrier. But to my knowledge, and if you think about it this way, the insurance companies are there to provide benefits  to their patients, but the most economical manner possible. And so they don't want to pay for the same treatment multiple times, and that's how they're gonna view that,  it's the same treatment. We don't because one's far superior than the other in our eyes. They don't look at it that way.  So I'm not aware that you would be able to do that.  Is it billable? Absolutely. Is it necessary? Absolutely not. The scenario where a temporary appliance is necessary. Necessary, not ideal, not best case scenario  for the patient, not what everyone wants, necessary, meaning there are no other better alternatives. Necessary is hard to hit. If you're talking about,  I need them to be in a temporary appliance for three months because I got to do a crown. You know what I would respond to if I was an insurance company?  Sounds like they're not appropriate for an oral appliance of any sort.  Sounds like they should wear a CPAP. Oh, the patient doesn't want to. Well, they need to. It's their choice. I mean, their decision to not utilize their care  isn't a medical insurance company problem. So that's how the insurance companies are gonna view it. And that's legally how they should view it  because I don't know why I love medical insurance companies. I don't, but I want to support them because that's how the world works.  And they do reasonably do what they're supposed to do most of the time. But by law, they have to cover medically necessary coverage, right? That's the insurance.  I'm paying you insurance company so that if I have a medically necessary thing, you pay for it. So from their perspective, they are only gonna pay for what's necessary  because by law they have to. So why would they pay for non-necessary items? And so they're gonna find a way to say it's not necessary. And I'd agree. I find very few scenarios  where a temporary dental appliance is necessary.  Yeah, not saying I don't, I'd love to use them. Okay, but necessary is very different than beneficial.  So the next question is, at times, oh, I think that's the one that I just did. I've checked that. Okay. All right. This is all overwhelming.  Is there a day long class that AADSM offers to get started from scratch regarding coding and billing? Oh, there is a moderator's response to it. So we're okay there.  I would say, I think Dr. Bragg is on the call. So she's in charge of figuring all that stuff out.  All right. So does Medicaid pay for oral appliance therapy? Medicaid. Medicaid and Medicare can be confusing, but Medicare is federal. Medicaid is state aid. It's run by your state.  So it depends on your state.  So that's, you know, for instance, my state still is not covering under Medicaid. Lots of states are. So- I would encourage you, you can almost definitely force it to be covered.  Again, because Medicaid also, by law, has to cover medically necessary procedures. So you could certainly get with the state and try and force it.  If you really want to go down that route, it's a lot of work and you're going to get, depending on your state, maybe great reimbursement, maybe awful reimbursement.  But Medicaid, like Lynn said, it's a state run thing, but it's federally, man, federal oversight. So there's, I will tell you, I've gone down that route and you can be successful  depending on which state you're in. That's a lot of work. And so you better be making a lot of money on the back end on it. Otherwise it's not worth it.  I think I skipped this question or maybe got moved up. What is the difference between being out of network versus fee-for-service? Is it just a workflow issue where a prior auth  may be needed to get paid by the insurance company as a provider who is out of network?  Network status is a status. It's in or out of network. There's only two options. As far as network status is concerned, from a commercial perspective,  you're either in network or you're out of network. Fee-for-service is a business model.  So every fee-for-service provider is out of network. Not every out-of-network provider is a fee-for-service provider, is the way I'd look at it. How you want to deal with that,  do you want to balance bill your patient? Do you not want to balance bill them? Do you accept assignment on some claims and not others? All of that is a business decision,  but you're out of network. If you're thinking about those things. If you're in network, you've signed a contract with an insurance company. And again, those are the only two options  as far as network status is concerned. Commercial. Federal, you're talking about Part B, opt-out, register or not. And then DME, you're talking about  the ability to bill them or not based off of registering with them as par or non-par.  So our next question is, Medicare has a non-duplication of benefits policy. We're getting more Medicare patients who need an oral appliance prior to their five years  or over for various reasons, but mainly that they can't wear a CPAP due to a significant change in medical history.  Under these circumstances, how should we proceed? Will Medicare pay for a new oral appliance therapy or will they pay for oral appliance therapy at this point?  Well, there's a five-year reasonable useful lifetime for the CPAP device and for the oral appliance. So in order for another device to be covered within that five years,  there does need to be documentation of a change in condition. So more than likely when the claim is submitted, it will deny as same or similar equipment.  And you can submit documentation through the appeals process to show that there is a new condition. But there's not a mechanism in place to prevent that kind of a denial,  but you can appeal that with the documentation. So there would need to be a medical record showing whatever it was that change in condition, was there a change in their weight,  different conditions that may be, or comorbidities that may be involved now that the patient didn't have at the beginning when they were first issued that CPAP.  So there's a lot of variables to that. But yes, we will pay for a replacement due to a change in condition, but you'll probably have to appeal it.  And what if the appliance is damaged? You know, they accidentally broke their appliance and it's year three.  Now, Medicare will pay for the same equipment that is irreparably damaged, but the same equipment. So if it's, you know, an oral appliance  within the five years of a,  that, you know, the stipulation is we'll pay for the same equipment if it's been irreparably damaged due to a specific incident.  So just wear and tear, normal wear and tear over the course of five years would not meet that requirement.  The other thing I would, I'd like to share is I think sometimes Medicare sounds really intimidating, but we've had cases where we knew it was going to be denied originally,  but we had all the documentation and it really has gone very well. And as long as you have what you need, we have not had any issues. So for instance, we've had patients  that had their CPAP for 60 days and were having substantial arophagia and a lot of other issues returned it. We were able to get the oral appliance covered because of the timeframe.  And for instance, I'm dealing now with the gentleman that had a traumatic brain injury, has nerve damage, which is affecting his swallowing. So he's no longer able to wear the CPAP  because of massive arophagia. So, you know, we have all that documented. We've got all the physician notes saying  this is what he thinks is going on. They've tried da, da, da, da. So I don't anticipate that we'll have any issues with it. So we've never had any problems. So don't be intimidated  about sending in that additional appeal.  Yeah. Medicare is very, I found pretty easy to work with. And again, you don't ever work with Medicare. You're working with a contractor, right?  You're working with, in the DME world, Narodian or CGS. In the Part B world, what, there's five max, four max?  I don't know. There's more max in the DME world or the Part B world. But I found in general, they're very easy to work with. But like I said, coding is a language.  Medicare is a dialect.  So Medicare does have some things that are a little funkier like commercial insurance, you file a corrected claim if you need to change something.  Medicare, you have to do a reopening first. Otherwise the corrected claim is just gonna get denied as a duplicate. So there's certainly some slight differences,  again, like a dialect would be.  But also Medicare has the, almost universally, the most relaxed filing standards.  I mean, my participating commercial insurance is I have to file within 30 to 90 days depending on the insurance provider. Medicare, it's a year.  Again, I believe, don't quote me on that one. But you got plenty of time with Medicare. So it's a good,  I found them pretty easy to work with in general, as long as you use the right words and you're okay with having to learn that dialect.  You only have four months to request an appeal though. So if you get the same or similar denial and you need to appeal it, that time limit is four months.  Are you able to do an intent to appeal?  Does Medicare have an intent to appeal or do you have to submit the full appeal? You have to, the appeal, yeah, the full appeal.  Does Medicare ever do peer-to-peer review like private payers does, I mean, for appeals?  That's a good question. That'd probably be a Part B question because DME, there is no peer, correct?  Well, technically, no. I mean, we have medical doctors on staff for DME as well, but in some cases, those medical directors  would review a claim if our appeal staff needed assistance, but it isn't the same at Medicare as it is with commercial insurance.  But on the Part B side, we do a comparative billing report that perhaps would be peer-to-peer, same locality, billing for the same services.  All right, well, I guess in the questions on the commercial side, I can force a call with a physician.  So by law, I'm entitled to a peer-to-peer, where I can call and say, as a physician, I need to speak to another physician about this.  On the DME side, of course, we're not physicians. We are, what I affectionately refer to lovingly as crutch salesmen, right? Because on the DME side, you are not a physician.  It doesn't matter that you're a doctor. It's just a weird scenario where you're a doctor that owns a DME company, but it's the DME company that's represented to Medicare DME.  But on the Part B, is there any way to get a physician response directly or no?  You can, we have an email address for medical affairs that you can write into and, you know, request that, or you want to have a discussion, you know,  and they'll, they definitely will look at it and see.  All right, so our next question is, I'm a general dentist registered as a DME MAC since August 26, 2019. I'm registered as non-participating provider.  I also have opt-out status effective 10-20 of 2014.  I have been billing Medicare for E0486, and the payment is sent directly to the patient from Medicare. The patient pays my full fee for E0486 to my office at the time of insertion.  Is this the proper way to deal with Medicare, or am I doing something wrong? And what should I do in the years to come? Also, can I bill Medicare patients for the annual visits  for evaluation of their oral appliance and have them pay my fee to my office each year?  So I'll start. This is Siddhi with Duridian on the DME side. If you are non-participating, you may bill the patient upfront, and the Medicare payment will go,  will be paid directly to the beneficiary. So you're not doing anything wrong. As long as you are non-participating, beneficiary meets the coverage criteria requirements,  and you're charging your standard fee, that is acceptable with the Medicare program.  I'll turn it over to Janet for the Part B part. I always sort of jokingly say that, you know, we can bill anything we want. That doesn't mean we're, as Belinda said,  A, it doesn't mean that you should, and B, it doesn't mean it's gonna get paid. So I'll let Janet take that,  the annual follow-up, because for DME, we pay for the device and the three-month follow-up, and it's all rolled up into the same payment, and that's it. So Janet, over to you.  Right, right. Normally from the Part B side, you know, billing for an office visit for a dentist, you know, is not a coverable service. You know, under the Part B side,  there's very, very little services that are covered for a dentist,  but no, not just like evaluation and management service.  First thing I think of when you say annual wellness is like an annual wellness visit, but no, that's not coverable on the dentist side.  And to clarify a little bit, because there's a little bit of confusion in that question, the questioner said opt out. I assume they're referencing opted out  of Medicare Part B formally.  And in that case, if you are formally opted out, you cannot bill Medicare. So it's not that you can choose to, you cannot, and you can only opt back in  or get rid of your opt-out whatever,  it's a two or three-year requirement if you opt out.  You opt out now. Yeah, I mean, you are, if you formally opt out, which is a form to fill out, which dentists aren't required to do, physicians are.  So law requires physicians to pick their Medicare status,  I believe, but dentists were exempted from that law.  But because there was a one-year period where there's this overlap of, are dentists gonna be excluded? A lot of dentists did opt out formally.  And a reminder, if you formally opt out of B, it is almost like signing a contract with Part B in that you have a time limit. You can't just jump back in whenever you want.  You are, there is a disadvantage to opting out and an advantage if you view it as a, I don't wanna bill. But if you're opted out, you cannot, under any circumstance, bill Part B.  I don't know, can you opt out of DME? Is that a requirement on the DME side? You cannot opt out of DME. You're either a supplier or you're not. Yeah. And that all comes to, again,  because the reminder that as a dentist, we are a physician for Part B and we are a crutch salesman for Part DME, right? We are your neighborhood pharmacy.  We are your neighborhood DME supplier. You just happen to have a doctorate,  but you are not a doctor. I think you undersell that, but that is part of one of the most difficult concepts to understand in that role is because you're right, you are a doctor,  but you're a doctor who's a DME supplier. And in this case, even though you're treating because you're working with the oral appliance, you are not the treating practitioner  in the eyes of Medicare. The sleep practitioner or their primary care physician who initiated the therapy for the obstructive sleep apnea evaluation  is considered in Medicare's eyes, the treating practitioner. And I don't know if it's true, but it seems to me that the sooner you make peace with that,  if you will, maybe the easier it is to go through the process of providing oral appliances under the Medicare program, at least. You got it. And I draw that distinction.  Yeah, obviously I'm being bombastic, but I draw it because it really is a contrast. And I want to draw that contrast out of your MPI is not even on the claim form.  It is a company that bills and provides the service to Medicare DME, whereas it's a doctor that provides it on the Part B side and happens to bill through a company.  So very different paradigm. But the criteria to enroll, to be able to bill this device, you do have to have that degree and you have to have those qualifications,  but it is the role of supplying the device that you're billing for. But that's also why there's a fee to apply for the DME side versus no fee for the Part B.  That's why there's medical supplier standards on the DME side that don't exist in the Part B side because some DME companies in the past may have been less than scrupulous  to require the government to create some rules and guidelines that bind them a little bit tighter. That's why there's a surety bond requirement on the DME side, right?  We're talking about company versus physician.  Not saying there are any, DME companies now are great, but maybe in the past they had issues.  There's an extension to this question. Do I have to be a Medicare provider to provide Medicare DME?  I mean, you sort of answered it, but you can formally answer it. Yes, you have to have a Medicare number in order to provide, well, I guess you could provide it,  but you won't be paid for it. So you need to have a Medicare number in order to bill Medicare for DME.  Okay. And the clarification is to remember, DME and Part B are separate. So you can be registered for just DME and not registered for Part B.  But if you're registered for Part B and not DME, you can't bill DME. So they're almost like separate companies. They are. But you do enroll through PECOS.  It's the same system for the enrollment, but it's a different type of enrollment. And with DME, there's one central contractor for enrolling you.  So the whole nation, if you're enrolling as a DME supplier to provide these devices, it's one company.  For the Part B side, and this is my old days when I was in Part B, I was in Part B and I was in Part B.  My old days when I was in Part B and I worked with Janet,  each contractor has its own provider enrollment. But PECOS will kind of steer you into that, the type of supplier or the type of provider that you're enrolling as.  It will steer you there.  So our next question is, understanding you're not lawyers, but is it considered fraud if you offer professional courtesy discounts?  In general, again, with the caveat of not a lawyer,  there's a difference between a routine discount and an individual rare specific discount. So in what I mean by that is by professional courtesy, if you're saying,  can I discount my sleep physician, for example, you're gonna run into strong Stark violation question there because you are providing a service that has value to a referral source.  So you might not have given them money, but you did give them in-kind, it's an in-kind donation basically, which is 100% illegal if both of you are Medicare  and involved in the Medicare system. So Stark only applies to government payers, but just to highlight that. So by professional courtesy, you mean treating your sleep physician  or any referral source for free,  you're definitely gonna run into a Stark violation and potentially anti-kickback statute of your state.  If you're talking about, is it okay for me to occasionally give a discount to a patient?  The scenario is gonna dictate that. So you've got a patient that is going through a divorce and they just got a cancer diagnosis and their bill is $3,000  and you decide to give them a financial hardship discount because they said, hey doc, I can't pay this right now. Can I just give you 300 bucks? Is that gonna work for you?  Document the financial hardship, document the reason for the discount and apply the discount uniquely to that scenario. You're gonna be safer.  Routine discount, the OIG, your office inspector general has come out and stated that you can offer a prompt payment discount. It has to be reasonable.  Generally 10 to 20% is gonna be the industry normal on that and that is gonna be offered to patients who pay their entire fee at the time of service.  You have to offer that universally to all patients and all payers. Now I've yet to have an insurance company pay me the day of service,  but prompt payment discounts, there are legal ways to do. Professional courtesy is the riskiest thing in this world because of Stark, because it has a very quick Stark violation  would be my non-lawyer answer. I don't know if Medicare people can probably get better descriptions there.  So our next question, oh, did I? Sorry, that was just because I just agreed. That's a good explanation.  99204, GQ modifier designates virtual.  Is that correct? What does the 02 location code mean?  So I'll just, I'll give my experience with this. Because again, you're talking Medicare versus commercial, place of service is where you rented the service.  Now there's the 02 code for place of service and then there's a new one they created this year, which is, oh, I wanna say, I don't remember now what it was. It was a new location.  I wonder if they meant one, two, which is home, one, one, office. So maybe- No, 02 is telehealth rendered outside the home and then there's another one for inside the home.  And then there's also a modifier code of 95 for asynchronous telehealth or synchronous telehealth services. GQ is asynchronous. Most insurances will not cover asynchronous.  The difference meaning asynchronous is essentially I send you an email, you respond back, right? We're not talking together. Synchronous at the exact same time.  So 95 is the modifier, 02 is the place of service. Having said that, when COVID hit, there were a lot of billing issues with the Medicare contractors  because traditionally Medicare only covered telehealth in very specific circumstances, like what was it, rural health and some other things.  But then the COVID emergency temporarily long-term kind of,  who knows, changed that a little bit. And so the modifiers, I typically will bill both the 95 modifier and the 02 service location. Initially, Medicare was denying my claims,  stating that I billed it wrong  because I had to choose basically one or the other. Then they came out, I think it was CMS that came out and said, oops, we fixed that error in our system. Now bill it.  And it also had to do with this game, like an 02 paid less than a 95, but I mean, it was a mess to start with back when COVID hit,  but now it's more straightforward and I bill 02 and 95, but they did add that new place of service this year.  And the place of service, I believe is the location of the physician, but it could be the location of the patient, but that's why it's confusing with that new code  of inside versus outside the house for telehealth services.  Is that about right, Janet? Did Part B get to have fun with all of that? Oh, yes, yes. Used to it was where would have the services been performed,  use that place of service right at the very beginning. And then they came back and said, no, use the 02 with the 95 modifier. Yeah, and that was the basis too  for changing all of the LCDs from face-to-face to in-person, correct? Correct. To line up with the law that says in-person is required and telehealth is not allowed,  which doesn't gel with the emergency declaration that telehealth's allowed.  Or whenever that expires, who knows what's gonna happen. Exactly, and if it will expire, we're in limbo.  As far as commercial payers, 02 and 95, 02 place of service, 95 for the modifier.  Mm-hmm, so our next question is, what Medicare regions can we bill my 9203 to Part B?  I think that might have been answered before, but real quick.  Billing and payment are two different things. You can bill to whatever region you saw the patient in, right, you bill to the insurance. Payment is based off of medical need.  There has to be an evaluation of was it necessary for you as a dentist to render those services and were you rendering medical services?  Were you rendering medical services as a dentist, which is 100% allowed, or were you rendering dental services to a patient which is statutorily denied?  So again, are you treating a medical condition like an osteoma, osteochondroma,  something that's medical, or are you touching the teeth, the supporting and surrounding structures? Because that's what's statutorily denied,  is my guess.  You're correct. Okay.  So our next question is, is it legal for, oh, did I cut you off, John? Sorry, I was just gonna say, I'm wondering if that question was dealing  with the LCD from Palmetto that you mentioned a moment ago. I wonder if that's what they were referring to. Well, you know what those regions were.  I will tell you in my region, which is under Palmetto,  using that LCD,  I am generally allowed to bill that and has been reviewed on audit and confirmed. Now, that is my region in my scenario, so that is not universal.  But that LCD is helpful if you're in Palmetto jurisdiction J or M.  Okay. So our next question is, is it legal for Humana, for example, to withhold funds from a claim that is clean on patient B to compensate for a claim  on patient A that they paid in error and are trying to retrieve from a doctor?  Well, unfortunately, the insurance can, I'm assuming in this scenario, it's the same doctor. It's not another doctor, but yes,  that is what they will do to try and retrieve funds.  And eventually you'll get this figured out if you consist with it, but can they do that? Yes. Look at the alternative. Essentially, the insurance has given you a statement of debt.  They've said you owe them $10,000. Let's make up numbers. They can be pulled back from future payments or they can sue you.  I don't know which you'd prefer. I personally prefer that they handle it without lawyers and just take the money away from you. I just voluntarily send them the money  or you argue it, right? Just like if a patient said, hey, you overbilled me and you owe me $3,000,  their choices in that case are to bother you or sue you. But the insurance company, because you're gonna give them future, they're gonna pay you future.  They just take from that, but yeah, it's legal. In most states, your state may have a different rule. It's gonna be state by state, but if we're talking commercial,  federal is a different story,  but if you're talking about a Medicare Advantage, Human Advantage plan, different rules, but in general, yeah. Or I mean, if you'd rather a lawsuit,  you can go that route and just never submit a claim to them and they'll sue you for it. And honestly, my biggest issue is not that they do that.  It's when they don't disclose the other patient and you have to try and figure out who that other patient is so you can make your accounting all work.  That's the bigger issue, not that they do it, it's the, because of HIPAA and other things, they don't wanna let you know who that other patient is. Generally, again, state specific,  but in Virginia, they're required to send you a notice in the mail stating that there's an overpayment on this claim and you can either choose to accept,  write them a check or pull from future payments. And if you do nothing, they'll pull from future payments or you dispute it, right? Again, it's a debt letter.  It's a business that informed you of a debt. You can dispute it or allow it to be confirmed.  You know, it's business.  So our next, oh, someone has someone to put input.  All right, so our next question is, we billed E0486 with modifier KX to a Medicare Advantage plan. It is being rejected, quote,  procedure code or modifier not payable to the fee schedule. This is a very vague reason. We have been disputing the rejection, directing them to refer to chapter 10  on pricing and gap filling and for similar items. Any suggestions?  Every Medicare Advantage plan has their own set of rules.  I think we all get thrown off because it's Medicare, but they still don't, they're not Medicare.  They're basically replacing Medicare and they get to make their own rules. So if you have filed the claim with the KX modifier and they're coming back and saying that doesn't work,  then send a corrective claim without the KX modifier because that particular policy doesn't require that. Also, you missed the NU modifier.  I'm assuming you have it on your claim form, but if you just put KX as the only modifier, that's a great reason to deny it because it's required to know is it new  or is it rental or used, which aren't appropriate for this, but you still have to put the NU modifier on for most insurances. I put NU KX on every single claim form we send out.  All of my insurances that don't care about the KX just drop it when they adjudicate it. I've yet to have an insurance company deny because of the KX modifier.  Based off that denial reason, I'm gonna guess what that insurance company did is they probably went to the handy dandy physician fee schedule or DME fee schedule  for the national level, looked at B0486, and this is the biggest pet peeve I have with Medicare. They don't list it as an IC code. They say it is worth $0.  Now, Medicaid will list it often as IC, meaning individual consideration, meaning we have not set a fee nationally,  and that's what Medicare, when they put in the national, the only published available fee schedule for it as $0,  that gives insurance companies a very easy way to say, well, Medicare reimbursement is $0 on it.  You can challenge that, but it's an uphill battle.  What I would suggest with gaps, the best way to do it is like all things. I mean, I've had insurance companies where they gave me $40 and they said, Medicare allowable is zero,  They don't have to pay you, and that's because the best way, right? Alzheimer's prevention is worth a pound of something, I don't know, whatever the phrase is,  but a gap exception is a guarantee from the insurance  to the patient that they will be processed under in-network guidelines. It is not an agreement between you and the insurance company. A single case agreement is,  and so ask that insurance company, anytime you get a gap, ask them also for a single case agreement. What that is is that's a contract between you and the patient  where you set the fee on the front end.  So you prevent that issue on the back end.  Unfortunately, that doesn't fix your scenario. If the situation is like Alex is mentioning and they are not recognizing the fee, we have taken an EOB from a Medicare patient  and blacked out all pertinent information showing the allowed fee for our area and sent that in and we have gotten reimbursed.  But you don't keep doing the same thing expecting you're gonna get a different answer. You're gonna have to try something different to get a different answer.  Single case agreements are the best way because you've set the fee up front, you've done all the work on the front end, you just send that in, you get paid.  Unfortunately, yeah, when you're in this scenario, you're at the mercy of the medical insurance company. You can try. And what Melinda said,  we've done and a lot of times that works. Doesn't have to though. They can simply say no. And you're in a tough spot in that case. I mean, you just built a patient ultimately,  but because if you're, I'm assuming you're non-par, which is why there's no fee set, you can always build a patient. But wow, Medicare Advantage,  you run into, again, statutory issues because I call it Medicare Plus because you've got Medicare rules and their rules. And sometimes there's, they can conflict.  So our next question is what if we bill Medicare less than commercial insurance? Is that okay?  I mean, you're not gonna get in trouble with Medicare for that, but you're getting in trouble with your commercial insurances and your patients. Because again, that's still fraud.  It's just the opposite way of fraud.  But it's not federal fraud. It's civil fraud, maybe. Or criminal, depending on how much you do it, probably.  Again, scenario matters more than, whenever the payer, whenever the question is, can I bill a payer different than another payer? Always red flags. Scenario specific.  Can I bill this scenario different than this scenario? When payer's not involved, better arguments there.  And I think that's a good question. Better arguments there.  And this is Cindy. Belinda mentioned this earlier too. Your fee is your fee. And so remember, bill consistently. Your different payers are going to have different allowables  and depending upon the circumstances, you have agreed to accept those allowables, but the fee is still the fee.  Yep. So the next question is regarding clarification for CPT code 70486. Billing this code for TMJ issues that need to be managed prior to moving over to sleep device.  Billing for the scan. So I guess I need clarification.  Respectfully, TMJ issues is not a diagnosis.  So it all depends on the diagnosis. The reason I say that, you know, you're worried about displacement. CT would be incorrect for that. You'd need an MRI.  So in that scenario, no, CT is not appropriate. If the question is, should I bill, do I need to do this in order to treat a TMJ issue before, and again, I'm just going to,  let's call them all the TMDs put together, any of them,  before treating with an oral appliance. I'll remind you that oral appliances is relatively contraindicated in temporal manipular joint disorders.  Now that doesn't mean it's absolutely contraindicated, but if the argument you're making to insurance is I have to fix this jaw pain to treat them with this appliance  that is not recommended in patients with jaw pain,  again, from a necessity perspective, insurance is going to say, then they don't need the appliance. They need something else.  So, and I'm telling you that to say, tailor your arguments correctly to insurances. When you're making a medical necessity argument,  you're arguing a necessity. So you're not treating the joint to get them to an appliance. You're treating the joint because it's a joint problem.  That's it, just stop there. You're treating the joint because it's a joint problem. Don't worry about the appliance, fix the joint problem.  So if you're concerned over a joint problem, treat the joint problem. If it resolves, then you can get to an appliance, then treat the appliance.  But they're just two separate issues completely. But can you bill it for joint issues? Yeah, absolutely, if it's appropriate to bill for. What I mean by that is a condition  that requires ACT to aid in the diagnosis and treatment of that patient. So as an orificial pain specialist, I will tell you it is rare that that is necessary.  Again, useful, wonderful, what we want to do, absolutely. Necessary, rare, because paying can get you most of what you need.  If you provide the oral appliance to a Medicare patient with an ABN stating  you do not have a Medicare biller number and cannot bill Medicare, then they pay you at the time of service. Any problem with that?  Yes.  And the Medicare ladies can correct me here, but if you're not a participating or non-participating Medicare provider, then you should have legally opted out.  And there's an opt-out agreement, an individual contract with the patient that you would fill out for them. It's saying, we are not a Medicare provider,  we cannot bill Medicare, you cannot bill Medicare. And you have to give that information to the patient prior to them having treatment. That's an opt-out agreement  because you're not a Medicare provider for DME. No, I'm sorry, for the DME side, there's not an opt-out option. So I believe the question was, they're not a Medicare supplier  or they weren't enrolled, right? So you can, that is a situation to provide an ABN. So if they choose not to enroll in Medicare as a supplier  and bill for the appliance to the DME MAC, or if they want, I mean, they're not gonna bill to the DME MAC, they're going to provide one of those appliances.  They would let the beneficiary know upfront that they do not meet Medicare enrollment requirements and then explain, that's why, and that would be the reason on the ABN.  And then once they have that on file, then they could charge the patient. And then if the patient came back and complained, oh, they didn't file my claim to Medicare,  then you've got your ABN that shows that you gave them the notification upfront.  So that is one of the reasons for an ABN and a DME situation.  All right, so I think this brings us to the last question of the evening. There are still some more questions. We, I think we went through quite a bit.  If there, before I ask the last question, if there are questions that are not answered, they can actually contact the Academy and we can get you some answers.  So with that, the last question is,  what is the code you use for adjustment of the appliance?  Okay, go.  So I'm just gonna add the caveat before we get into coding. Adjustment of the appliance is a loaded phrase. Are we talking about adjustment as in fitting it  to the patient to make it fit correctly to their teeth? Or are we talking about adjustment meaning aiding in titration and recommendation of advancement or less advancement?  Just because those are two very different scenarios.  As far as the coding, I'm gonna assume we're going off of actually physically changing the appliance to better fit the patient.  Not a repair and not a anything else.  Which my answer would be all of that is inclusive in the 90 day global. And by definition, this is how I think of Medicare. And again, please correct me if I'm wrong,  because this is my own crazy thinking.  Just like the IRS defines maybe a child different than someone else would define child. When you're dealing with IRS, you have to go off of the IRS definition.  So even though that might not be reality, it's the IRS definition. And that's who you're dealing with. It's federal government, federal law.  So the way I remember that 90 days inclusive, essentially what PDAC has said is that these appliances are required to be adjusted within 90 days.  If it takes you more than 90 days to adjust it,  then you build it incorrectly because it should only take 90 days. Other than, you know, barring extreme circumstances, dog chewed on or whatever.  But just if you routinely take 120 days to adjust your appliances,  then it was incorrect billing to say that you build an E0486, which is supposed to be able to be adjusted and completed within 90 days.  Is my crazy understanding of it.  All right, I guess. Is that correct, Cindy or Angie? I just wanna make sure that I'm not insane.  Well, this is Cindy at Neridian.  There's not really another way to bill it. So saying you build it incorrectly, I'm not sure that that's really where we wanna get to  because there's not really another way to bill it. You bill an E0486, it's all inclusive of all of the work that you need to do to provide that oral appliance  when you're talking about filling to the DME mat. So whatever you need to do, that work needs to be done in that 90 days.  Now, again, if you're talking about adjustment, meaning titration, saying turn the screws, you know, 10 times or whatnot,  that is a medical treatment you're providing. And then it's up to part B to determine if it's medically necessary, which, for example, that article I referenced  says the exams for a patient are necessary up until the point that you determine that an oral appliance is necessary. In other words, after you determine that,  all of your medical care is considered non-necessary and should be denied.  But ultimately, telling a patient where to put their appliance is a medical determination. That's a part B determination.  And in general, you're probably gonna get denied under medical necessity, but, you know. Yes, that's a different webinar.  Well, I think this is all the time we have for this evening. I'd like to thank all of our speakers for their participation and time. We all appreciate your generosity  in participating in tonight's webinar.

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