I want to welcome everyone. I am Dr. Rosemary Rojofsky, the moderator for this evening's Medicare question and answer webinar. I'm joined by our panel of speakers, Ashley Ducotto and Cindy White from Noridian, Judy Roan from CGS, and Dr. Kenneth Mogel. To comply with antitrust laws, we are unable to discuss or address questions about fees or insurance reimbursements amounts. And finally, the AADSM does not endorse any services, products, devices, or appliances. The use, mention, or depiction of any service, product, device, or appliance during this webinar should not be interpreted as an endorsement, recommendation, or preference by the AADSM. Any opinion expressed or communicated regarding any product, device, or appliance during the webinar is solely the opinion of the individual expressing or communicating that opinion and not that of the AADSM. Our first question, does Medicare require sleep studies to be 12 months or newer? And I'm happy to have any of you answer first. This is Judy Roan with CGS. And there's never been a published requirement that a test be within 12 months. There's actually no published requirement. So, a delay in obtaining the oral appliance would be understandable. Anything over a year would be harder to justify because a lot of things change with the beneficiary over a year, particularly with OSA. So, their condition could have changed. They could have had surgery. They could have lost weight. Various things could have happened within that year. So, it is good to get additional documentation from the physician to substantiate that if it has been that long. And to add to that, Judy, this is Ashley with Meridian. Currently, I think there's different interpretation for this requirement. So, I know our medical directors are working together to come to a conclusion. Like Judy said, it would be hard to justify anything over 12 months. And currently, we're waiting on clarification from our medical directors because at this point, we would not accept a face-to-face in lieu of an older sleep study. Okay. Anyone else want to add to that? If not, we'll go to the second question. Can I bill for oral appliance therapy if I'm not credentialed with Medicare? No. So, to bill any item of demipost, durable medical equipment, prosthetics, orthotics, or supplies, which oral appliances fall into, to bill any of those items, you must have a national provider enrollment number to be able to bill the DME-MAX. Okay. Third question. What does it mean to be a non-participating provider for Medicare? Who would like to take that question? I was looking for my mute button. I can take that one. Okay. All right. Thanks, Ashley. So, a non-participating provider is one who can choose to accept assignment on a claim-by-claim basis, except for in those cases where CMS requires mandatory assignment. Okay. Fourth question. Can a dentist file a claim with Medicare Part B? So, are you referring to an office visit, or are you referring to the DME-MAX for the oral appliance? Let's talk about both. Okay. So, a dentist can absolutely file a claim with the DME-MAX, but again, refer to the previous question where they must be enrolled to do so, to provide those items and to bill the DME-MAX. If it's an office visit, that's outside of our purview. So, any office services or clinic services would need to be referred to the AB-MAX. Okay. All right. Number five. How can one become credentialed with Medicare? So, to become credentialed to bill Medicare for, say, an oral appliance to the DME-MAX, you would need to enroll with the National Provider Enrollment, or the NPE, either East or West. Okay. So, that would include completing the 855-S form, or the electronic equivalent. So, there's a form that must be completed in a process that you would go through with the NPE contractors. All right. We're going to move on to questions from our audience. If Medicare won't pay due to same and similar, and the patient is willing to pay out of pocket, do we need to fill out an ABN form? Yes. Okay. Next question. Why is the patient's name not included with a Noridian payment? I'm not too sure about that question. Why is the patient's name not included with a Noridian payment? Yeah, I'm not either. I'm not sure. Judy or Cindy? This is Cindy at Noridian as well. And, unless something's not included with a Noridian payment, This is Cindy at Noridian as well. And, unless something has changed, the explanation of Medicare benefit should have the patient's name along with their MBI. So, we might need more information related to that question. And, whoever the asker is can contact Ashley or myself. Sounds good. There's a follow-up question to that. Can a telemed meeting count as a face-to-face meeting with the MD prior to a sleep study instead of an office visit face-to-face? Yes, it can. However, it does have to be a valid telehealth visit that's billed to Medicare by that practitioner. Okay. Okay. Next question. Please outline the guidelines that Medicare uses to certify or deny an oral appliance. So, that information is in our local coverage determination. So, there is a policy that anyone can access. It is available from the CGS as well as Noridian's website. And, you want me to go through the whole criteria? Is that what they're asking? You know what? I think we have… AADSM had just mentioned that they would answer via live, I think. Okay. And, I can copy and paste it if you want. Okay. Yeah. We have a question here. Please clarify again previous question one to confirm. There is currently no published guidelines requiring a sleep study within 12 months. That's a question, I guess. There is no published guidelines requiring a sleep study within 12 months. Just for clarification for an attendee. There is nothing in the policy that identifies that the sleep study must occur within 12 months prior to providing the device. That is correct. Thank you. Next question. Does Medicare require appliances be hinged like a HERPS appliance? Does Dr. Mogel want to take this one? It's pretty obvious. Yeah. Medicare does require that. I think the question that most of the practitioners are really trying to develop is, when is PDAC or Medicare going to recognize the K1027 and have that published so we can use non-fixed heating appliances? Okay. I'm not sure these are the ladies to answer that question, but I think that's a question a lot of us have, is the K1027 question. It's obvious. It's very well spelled out that any device E0486 you do with Medicare has to be a mechanical extension. Right. Yeah. As far as the K1027, we don't have any note yet of that being added to the oral appliance policy for one without that fixed mechanical hinge, so it would be considered only on a case-by-case scenario. Okay. With that added, there could be a reconsideration of the LCD submitted with documentation to substantiate the non-hinged device. You're talking about in case somebody has a mental allergy, possibly? Is that what you're referring to, something like that? Any clinical documentation that's available, I would strongly suggest including all of that in your LCD reconsideration. Okay. So that's a good example. Great. Our next question is, if I, as a dentist, out of the goodness of my heart, want to order and pay for a sleep study and interpretation, will that qualify as the Medicare requirement? That technically would not, no, meet the requirement. The oral appliance policy does require a Medicare-covered sleep study. Okay. Next question. Since the retirement of the public health emergency waiver, are face-to-face required for encounter before sleep study? If encounter was during the public health emergency timeframe, is tele, tele meaning like I think telehealth appointment, allowed if oral appliance delivered after public health emergency? Okay. So there is some confusion about telehealth, even with suppliers that bill the DMV max all the time. Telehealth was acceptable prior to the public health emergency, and it continues to be acceptable, but again, it must be a valid telehealth. So yes, that would be acceptable. The face-to-face encounter is also required. So it can be through telehealth, but it is a requirement that it occurs, and it has to be a valid telehealth visit. Okay. Can you define what you mean by valid? Billable, billable to the AB max. So when you would deal with that physician, that you would confirm that they actually billed that visit to the DMV, to the AB max. We don't process those claims at the DMV max. It does have to be a valid telehealth visit. So there are still some waivers going on with telehealth, but that would all have to be billed and a valid telehealth visit. You would confirm that with the physician, the other physician. Okay. Next question. I have not yet submitted a case with K1027. Can you explain how this would be processed? Does anyone have any comments on that? I'm thinking about that. I'm not sure I know what they're looking for. Judy or Cindy, feel free to hop in. So this is to be my take on it, is I would expect a denial. And then you would have to appeal with whatever clinical documentation you have that shows, and I think Dr. Mogel mentioned, you know, the possibility of a mental allergy or something like that. Obviously, we can't guarantee that one would be approved since the policy requires a fixed mechanical hinge. But that would be the avenue that you would need to take. And as I was listening, I just want to provide one clarification too. I think we jumped to reconsideration of an individual claim when Judy was talking about it. And I think she was really trying to make the point of an LCD reconsideration. So you as a professional organization can submit to the medical directors a request to have the LCD reconsidered to include that K1027. You would have to provide current literature and support. And remember always that for DME, we're looking for something that can stand repeated use for the five-year reasonable useful lifetime. So I just wanted to provide that clarification. I'm trying to stay in the background and listen, but it's not my nature. You're doing great, Cindy. Okay, the next question. Why does the same and similar prevent Medicare from covering an oral appliance within five years of paying for CPAP yet will pay for Inspire after paying for CPAP? I don't know. Go ahead, yeah. I was going to say, I can say from a DME perspective, it's not going to pay for the oral appliance if there's a CPAP on file because it sees it as there's already a device on file to treat the OSA that's expected to last the five-year RUL. So you would have to take that through an appeal to show what's changed with the medical condition in order for that to be considered for coverage. As far as the Inspire device, not something that falls under the Part A or Part B benefit is not covered under the DME benefit. So I'm not sure on that account. Right, she's absolutely right because it's covered under the Part B benefit. It's an implantable device, and we can't address how they would process their claims. Got it. Thank you. Next question. If the patient takes possession of the appliance but decides they want one made of a different material, can the patient be billed for the cost difference in the new appliance? So the beneficiary received the initial device, and then they wanted a completely different device created? Yes, that's what it sounds like, yes. In that circumstance, can the patient be billed for the cost difference in the new appliance? I would suggest in that scenario obtaining an ABN because technically if two were billed, it would be considered as same and similar. You could obtain that ABN and bill the beneficiary for the difference. Just be clear in your reason on the ABN. Cindy or Ashley? I agree, Judy, 100%. Okay. Next question. Where can a DME supplier find documentation that, sorry, there's a typo, opted-in non-PAR provider may charge up to charged amount, parentheses, unassigned? Where can a DME supplier find documentation, sorry, they removed, oh, there it is. Where can a DME supplier find documentation that an opted-in non-PAR provider may charge up to charged amount, in parentheses, as unassigned? So it's most likely published in one of the manuals. We can definitely research that and provide information that you cannot bill more to a Medicare beneficiary than you would to any other patient for a non-assigned claim. Okay, Rosa, I have a question to ask. Sure. So a couple questions. One, being that our population tends to be a little older and occasionally we will see a patient and go ahead and process an EO486 and they die. Is there a recourse for us because we've had to put out money there? That's one. Go ahead and answer that. I'll come to the second one in a second. Okay. For custom devices, there is currently a policy where you can bill for items that were created and not provided. The DME MACs, CGS DME MAC, I don't want to speak out of turn, CGS DME MAC does have that information on our website. I believe it's also in the claims processing manual. And can you make an abbreviated statement of what the process is? Sure. For custom made items and incurred expenses, it is actually in CMS Internet Online Manual 100-2. That's the benefit policy manual if you'd like to look it up. It states that you would use the date of service of the date you were notified of the beneficiary's passing and you would include all of the information regarding what was created and anything that cannot be reused. And for the same similar, not somebody passing away, but we occasionally will have patients who go through the process and we have an appliance made and they just decide they don't want it. Is that the same process we go through? Absolutely. If the order is canceled, you would use the date of service as the date of you received notification of the cancellation and include all of that information. And any idea how will we get reimbursed on that? Are we going to get at least our covered amount of money that we spent on the laboratory process? That would be individually priced. So it would depend on if you can reuse any of the items or not and what the services are. So I can't give you an actual fee schedule amount. and based on the disclaimer, I couldn't give it to you anyway. Is there a fee schedule on that? No, there's not. It's individually priced. Yeah, that's what I figured. Did you have a follow-up, Ken? No, that was it. That was it. Thanks. All right. Our next question. We do not participate in Medicare in any form. My billing company is offering to prepare certain documentation for the patient to submit a claim to Medicare to get reimbursed. Is that possible? How do we go about that? We are in Florida. Thank you. So the question again was, we do not participate in Medicare in any form. My billing company is offering to prepare certain documentation for the patient to submit a claim to Medicare to get reimbursed. Is that possible? The beneficiary can submit a 1490 form for reimbursement with all of that documentation. We do strongly suggest that those beneficiaries go to providers or suppliers that participate in Medicare just for the claims processing piece of that, and it's really in the beneficiary's best interest, but they can submit a 1490 form with documentation. Okay. Next question. If you are not a provider with Medicare, do you still have to use the ADN form? I think if that means if they're not a participating provider, yes, the ADN would still be required. Right. Next question. We have a patient coming to see us. Patient has an existing oral appliance Medicare history 2020. Existing appliance non-serviceable. First, the hinge broke off and states a screw missing. Two, recent dental treatment, a crown replacement. Office that made her appliance will not remake the appliance even if there is a new letter of medical necessity from the MD. Will this appliance be replaced by Medicare in less than five years? So, possibly. If it's been less than five years, up front, if it's replaced, it's going to deny for same and similar, but if there's been some kind of change in condition, something happened with the recent dental treatment, it looks like crown placement, documentation of that and what's changed could be submitted through appeals, and you might have a good case if there was a change that caused the need for a new one. Okay. Next question. The 2015 guidelines from Noridian define RDI incorrectly. Quote, RDI does not include RERAs, unquote. Has that been corrected? Do we know, or are you familiar with that? This is Cindy, and I'll just say that, you know, you're talking to the education team, neither Ashley nor I are clinicians, and our clinical team has evaluated it, and they have chosen to leave it as it is. Okay. Okay. Next question. I work at a dental office, and I'm wondering if I need to include the sleep study doctor's NPI and the dentist's NPI on the claim form? That's an excellent question. It should be the ordering physician, so whichever physician is on the actual order, that's the same physician that should be on the claim form. Okay. Thank you, Judy. How do you get Medicare to cover an appliance if the patient has already been using CPAP covered under Medicare and the patient has mild or moderate OSA? This would be similar to the previous question. That would up front deny, because there's already an appliance on file to treat the OSA, so if it's been within the five years, it's going to deny same or similar more than likely, and there need to be documentation showing why the previous treatment was ineffective or if there's been some kind of change in condition to cause it to no longer be effective. Right. Next question. The Palmetto website shows a prosomnus appliance that is not hinged that is listed as E0486. However, the CGS website shows appliances must be hinged. No, go ahead. I was just going to say there's no question, but I'm just trying. You get what the question is. Good. I do. I do. So per the LCD for the item to be considered for coverage, it does have to be hinged. Okay. Specifically in the policy. Next question. Do you have to have a prescription from a sleep doctor? That's all they said. They didn't say specifically. It doesn't necessarily have to be from the sleep doctor, whatever physician. It could be their practitioner that ordered the sleep study who's treating them for the OSA, or it could come from the sleep doctor. Either way. Next question. With Medicare, are there codes that can be billed for the initial examination, possible panorex, and follow-up visits, or are they all included in the Medicare fee for the oral appliance? So none of those codes are billable to the DME-MAX. Again, for office visit services, you would want to confirm with the AB-MAX if any services can be provided and billed to Medicare. Great. If a patient returns their CPAP, then gets an oral appliance, would the appliance be covered? Yes, it can be. As long as there's documentation of the pickup slip, we would need all that information to identify that the previous device was returned. So it very well may deny a same and similar if that pickup information is not on file. And you can request an appeal in that circumstance. How often does Medicare allow for replacement of the oral appliance? Every five years, unless it's needing replacing cases of loss, theft, or if it's been irreparably damaged due to a specific incident. Okay. I have a question, Rose. Can I ask a question or a follow-up on that? With the five years, if a person was, say, 66 years old, covered by Medicare, get an oral appliance, and then they turn on their 70th, their first birthday, and desire to get an oral appliance, it's worn out, do we have to go through the whole get another sleep study, get another prescription, get before and after notes? If it's the same physicians covering. Right. So is the question, you cut out a little bit there for me. If they've had their oral appliance for five years, and then it's worn out, they're ready for a new one, you're asking if they have to go through the whole process again of the sleep study. And the oral appliance policy does not have a requirement for a repeat sleep study or a new evaluation following the five-year RUL, so long as therapy has been continuous. So they've continued to use their oral appliance to treat their OSA for the five years. There would need to be documentation, or excuse me, there would need to be a new standard written order to reaffirm medical necessity. But it would need a new prescription from you. Correct. Yep. But other than that, that's it. Okay. That's what I thought it was. Yep. Good question. Okay. Our next question is, is there a way to check oral appliance frequency for coverage of a new oral appliance? I know it's five years frequency, but if the patient can't remember where they received their previous one, can Medicare give the date they covered it? So you can utilize myCGS, as well as the Naradia Medicare portal to check for same and similar, to see what's in history, to see if there's a PAP device, to see if the beneficiary is perhaps on RAD, or if there's been another oral appliance. And you can sign up on both of the contractors' websites. Great. Are there any requirements for a qualifying dentist for the Medicaid enrollment? We are in Maryland. They wrote Medicaid. We can't comment on Medicaid at all. Right. We're not them. Yeah. We're only, we are looking specifically at Medicare in this webinar. Next question, could you please further elaborate on the 12-month rule for sleep studies? Medicare's standard documentation requirements state that timely documentation is defined as a record in the preceding 12 months. The way I read that is all documentation should be within the past 12 months. Is the sleep study not included? So when you're reviewing that documentation and it identifies timely documentation, it's actually talking about continued medical need. It is not discussing initial medical need in that section of the documentation requirements policy article. So that particular reference is actually talking about continued medical need and timely documentation. Okay. Thank you. Will Medicare cover a home sleep study? That would be under the Part B benefit. Dr. Rahaki, this is Cindy. Can I go back to the sleep study issue? Ashley explained this very good from the get-go, but I'm imagining that many people on the call have heard me speak about that 12-month requirement. And it is currently in the Meridian's position that the sleep study must be within the previous 12 months. And I just want to make sure that we don't provide any confusion for the listeners on the call today. We do have that discrepancy with the medical directors for all four jurisdictions. And at such time as we get possibly a different response or get clarification, that will be shared with this group. But I don't want, certainly for those who bill Meridian in specifically jurisdictions A and jurisdiction D, I don't want to have you led down a path that might cause you problems in the future. Judy is correct in what she's saying, but Meridian's interpretation is that it must be within the previous 12 months. Okay. Thank you for clarifying. And just to be clear, CGS does not have that same must-be requirement. We both have different answers available on our websites. And as Ashley stated earlier, we are currently working with all four DMDs to get a consistent response. And as soon as we receive that response, we will send it out to you, ADSM, and it can be distributed to the members. Okay. Thank you for the clarification. Next question. My previous question was misunderstood. Our office charges all patients the same amount for devices. My question is, as a non-PAR DME supplier, it is my understanding we may bill the patient up to our charged amount as opposed to accepting the Medicare allowed amount. Some patients have questioned this. Where do I find documentation that non-PAR DME suppliers may bill patients up to a charged amount? Go ahead, Ashley. We may get the same answer. I was going to say, we have information on that. I believe it's in the supplier manual. Judy, you can speak to CGS. Okay. Next question. Do I file a claim to Medicare Part B for code E-0486? That code is a HCPCS code that would be billed to the DME-MAX, which is technically Part B as well. Okay. But that's not for the office visit. That's for the oral appliance itself. Correct. Okay. Thank you. If I clearly understood a previous question and answer, a patient using a CPAP covered under Medicare, and it is within five years, the patient could have an oral appliance covered as long as the CPAP was returned? It could be. Again, it would have to occur through appeal, though. On the front end, it would most likely, unless there was already documentation of the return of the PAP device, our system would still see it as same and similar. So, it would deny a same and similar, and you would have to go through the redeterminations process, the first level of appeal. Okay. Will Medicare consider reimbursement for combination therapy, oral appliance plus CPAP, if ordered by the sleep physician? No. Both won't be paid for at the same time. Next question. What is PDAC, and how does that determine the appliance you deliver? So, the PDAC is the Pricing Data Analysis and Coding Contractor, and they provide all of the codes to CMS, as well as the DME MACs for processing. They identify, say, a new hinge device was to come out, they would identify if that item is considered as an EO486, or if there's a new device that falls under a different HCPCS code. So, they handle all the coding. Great. In my state, what are the rules for when we must use a PDAC appliance? He didn't, this is an anonymous attendee, but did not give me which state he's in. So, for Medicare purposes, regardless of the state, it makes me wonder if that might be a Medicaid question, they all have to be PDAC verified. Next question. I was under the impression that if we are non-par, we can only bill up to Medicare fee plus a certain percentage, not the UCR fee. I am in New Mexico, if that matters. No, as I stated, I'm not in New Mexico, but I am in New Mexico, if that matters. Now, as I stated earlier, you can bill the beneficiary, the state, you do not have to bill the Medicare allowable for that item. You can bill your usual customary charge. Okay. Thank you. Rose, can I ask another question? Absolutely. Just regarding, so, and I don't know if any of you can answer this. I'll try to get this answered, and you can get it, but why are the four different jurisdictions wide varying amounts on EO486? I mean, just why differences? There's actually different state to state. So, when the fee schedules are created by CMS, that's where that occurs. So, it actually occurs in CMS, it's for all DEMI post items. I haven't found that to be state to state. I found it to be jurisdiction to jurisdiction that everybody in, I mean, my experience has been everybody in C gets the same amount, you know, for the, you know, the allowable amount. But the differences between A to C is obscenely ridiculous. And we all pay the same amount for the appliances. It just, I've always been looking for an answer, and it'd be nice to be able to get one. You're muted out. Oh, yes. That would be a question for CMS to determine why those amounts vary so widely between those states. I know Cindy has a quick answer to that. No, I was going to say, I know, and we would love to give you an answer because we've had this conversation many, many times. And my response is kind of, you know, oftentimes people are looking for a fee schedule. And I always say, be careful what you ask for, because that might not turn out the way that you had hoped. And we've also talked about the gap-filling methodology a lot. And that takes into consideration billed amounts by all practitioners. It takes into consideration the cost of living in different geographic areas, and a multitude of other data factors when they determine what the allowable will be duties right. It is done state by state, but you probably do see some similarities in states who are near one another, certainly. Thank you. Next question. What is an estimated turnaround time for appeals? I know we have a limited time to get all paperwork completed, but just for peace of mind, is it a lengthy amount of time for turnaround for appeals? For appeals, I'm not sure if they're asking the amount of time they have to submit. I don't think that's what they're asking. But for the first level of appeals, they have 120 days. And then the MAC in turn has 60 days to complete the request in order to get a decision back to them. And there is information in the supplier manual for both, well, I can't speak for CGS, but on the timeline for the next level of appeals. So that's just for redetermination. But if they're out of reconsideration, our website would have that, and our webinars as well. We do have webinars for appeals. Same for CGS. Okay. Next question. If I don't participate in a medical insurance plan, and the patient has Medicare Advantage, and they only allow approximately $900, can I balance bill the patient for my regular fee? We cannot comment on Medicare Advantage plans whatsoever. Yeah. Sorry. Next question. For how long are you obligated to do follow-up visits after delivery of an oral appliance without charging, without charging Medicare for the patient? Does anyone want to answer that question? I'm going to defer to Cindy or Judy. I'm not sure how I'm on. Cindy, did you want to comment? Well, I'll give my standard response. Cindy, you're breaking up the middle. Is the DME still in good working order for the full file? Well, I'll try stating it again. Did you get it, Ashley? I think you gave the answer I was going to give. And I'm assuming you said that they would need to make sure that it stays in good working order for the five-year reasonable useful lifetime. Yes. OK. All right. Can a dentist file a claim with Medicare Part B? I think we already answered that earlier. And the follow-up is, can evaluation and management codes be filed? Again, that's a question for the ABMAX, not the DMEMAX. DNM codes aren't built to us. Correct. Next question, are all PDAC-approved appliances covered? That's all he wrote. PDAC approval would be a guarantee of coverage. That's part of it. But the rest of the coverage criteria, of course, is part of that. OK. If a patient has a commercial plan, but the insurance company follows Medicare guidelines, does a PDAC-approved appliance have to be used? I live in Illinois, Chicago. Again, we can't comment on any other insurers. So it's really based on what even Medicare Advantage plans, which are supposed to follow Medicare guidelines, sometimes they have some flexibility. So you would definitely want to check with that plan. Will a patient get benefits for a sleep study provided by a dentist that is a non-PAR provider? The dentist is doing the sleep study? Yeah, I think they're trying. That's an interesting practice. Does anyone want to comment on that? Yeah, that question may need some clarification. Yeah, I think we do. I think it's very clear that dentists, according to Medicare, I'm sorry. I think it's very clear that as a dentist, we're not allowed to administer any type of sleep study, HSATs, except when you're a person. Pretty clear. I agree. All right, next question. I am a dentist credentialed to Medicare, and I bill for oral devices, E0486. Does the referring MD also need to be credentialed to Medicare for oral appliance? They don't have to be credentialed for an oral. They don't have to be specifically credentialed to order an oral appliance. But for example, a podiatrist couldn't order, just like a dentist couldn't. They couldn't order an oral appliance. So that physician needs to be able to order that item and a valid physician in our PAYCO system having a valid MPI. OK. Do all Medicare patients need an ABN before oral appliance therapy, or are there any specific guidelines? Please do not obtain an ABN for every Medicare beneficiary. That is considered a blanket ABN or a general ABN, and it is strictly prohibited. When you should be obtaining an ABN is if you believe the item is not going to meet the coverage criteria in the LCD. If there is same and similar equipment in history, such as the PAP device, you want to be very specific and review those ABN guidelines to confirm when you should provide an ABN, but do not provide one to every beneficiary unless none of them meet coverage criteria, which would be unlikely. Yeah, sounds good. Next question. Could you please provide a link for documentation for jurisdiction B regarding the 12-month rule? What is an appropriate time frame? Again, we'll be providing that information as soon as we get clarification from all four medical directors once we're all consistent on our response. Thank you. The timely documentation of 12 months, again, referring to continued medical need, is in the policy article if you'd like to reference it for standard documentation requirements for all claims. But again, we'll provide that as soon as we get it. We expect it'll be the relatively near future. Thank you. Next question. If I have not submitted a DME claim in over a year, will I have to reapply to Medicare for DME status? You would want to check with the NPE contractor to confirm that you are still eligible to bill for Medicare. OK. Next question. Is there a taxonomy code for dentists that treat sleep apnea on the Medicare application? That's for the 855S form. I'm not quite sure if that's what they're referring to. I think they are referring to that. You would have to look at the form. Again, that's so the DME MACs don't cover enrollment. That's a separate contractor. So that's the NPE contractor, and that's where you would definitely want to take a look at the form or contact the NPE contractors. Great. OK, next question. I'm looking at an Aridian website under PAR versus non-PAR, last updated April 28, 2023. It states the non-PAR supplier may bill the beneficiary no more than the limiting charge for covered services. I don't have a question with this, but it's just a comment. That's not the fee schedule. Limiting charge is not the fee schedule. Just to be clear. Yeah. And limiting charges are applicable to practitioners only. Limiting charges do not apply to DME items. OK, thank you. Next question. They wrote, this might be a silly question. What are the options for, he wrote, he or she wrote that. I didn't say that. What are the options for submitting claims? Any pointers for faster process? Email, fax, et cetera. Sometimes the sleep studies are hard to read when sent via fax. So what are the options for submitting Medicare claims? First and foremost, the sleep studies don't have to actually be submitted with the claim. So if you're currently submitting paper claims, you can obtain a free billing software for the DME-MAX through CEDI, or Common Electronic Data Interchange. That's an option. It's not super robust, but it'll give you the opportunity to submit claims. You can't email claims to the DME-MAX. You definitely, if you can submit paper claims, that's still an option. But I would suggest utilizing that free software from CEDI. Electronic claims process, I believe, within 14 days. And paper claims have 30 days to process. Next question, what about dentists offering home sleep tests with an MD reading the results and prescribing the devices? I'm still wondering what that one's meaning. I mean, home sleep tests are acceptable to qualify for an oral appliance. But it would need to be a Medicare-covered home sleep test. OK. What are the current Medicare guidelines for an oral appliance? I think I'm going to go with Judy's answer on this one. They're in the LCD listed on both of our websites. Yes. Next question, does the face-to-face chart note prior to sleep study also have to be within 12 months? Sometimes there is a delay between the face-to-face encounter and the sleep study being done. So does the face-to-face chart note prior to sleep study also have to be within the 12 months, is what she's asking? Noridian is going to say yes for now. Again, the clarification will be coming. I'll follow that one. And you're talking about between the face-to-face evaluation and the sleep test, correct? That's the question. That's the question you're referring to? I think that's what she's referring to, the attendee. OK, next question. Well, this person says, let me rephrase my previous question. Should an appliance break after four years and it is out of the lab warranty, will Medicaid pay for the repair, or can I bill the patient for the repair? He's saying Medicaid, but I'm not sure if he's meaning Medicare. Medicare will consider repairs to the item if you're talking about Medicare. I can't comment for Medicaid. And I just want to just be sure that the attendees realize that Medicare and Medicaid are two separate entities, totally, completely different. Next question, what is the NPE provider? NPE provider, that's all I have. What was that? NPE is the National Provider Enrollment. That's where they would go to enroll to obtain their billing privileges, excuse me, for Medicare. The West, I believe, is through Palmetto. And for the life of me, I can't remember who East is. Novitas. Thank you, Judy. You're welcome. Next question, could you please repeat the site for dealing with paper claims? What was the site again? I think. It's through CEDI, or Common Electronic Data Interchange. You can just search CEDI. It's PCACE Pro 32 is actually the name of the software. But you can just go to CEDI's website, and it'll be on that. OK. Next question, when submitting a claim where the patient returns CPAP and now trying oral appliance, is there a way to submit? Oh, OK, it's gone. Hold on. I'll move to the next question that probably got answered by AADSM. Most carriers use Medicare rates. E-0486 is custom and not subject to allowables. Where can we find this in writing so I can use this when negotiating rates and credentialing? I know that you can look and see that it's not on the fee schedule. That's probably the best resource. It's not, I don't believe it's going to be published anywhere saying that E-0486 has no fee schedule. I don't think that's going to be actually published anywhere that it is gap filled and individually priced. Ashley or Cindy? No, I would agree. And if you look on PDAC, like Judy said, it will show that there's no fee schedule amount associated with it. OK. Next question. When submitting a claim where the patient returns CPAP and now is trying oral appliance, is there a way to submit proof of return with the claim? I use APEX to submit claims. So is there a way to submit proof of return of the CPAP with the claim? So you could include a narrative on the claim. I'm not sure if the audience could answer this differently, but you could include a narrative on your claim identifying that the previous item has been returned. I think we would absolutely be looking for that documentation to substantiate that change in redeterminations. So it would most likely have to go through the appeals process. Ashley for Narudian? I agree. It would more than likely have to go through appeals. It would deny out similar. For replacing lost appliances, is there a protocol to have coverage authorized? There is no prior authorization. If the item is lost, stolen, or irreparably damaged, as Ashley had mentioned earlier, Medicare will consider replacement. Again, you'd want to include a narrative on that particular claim to identify the item was lost, it was stolen, whatever occurred, and have documentation in your records to substantiate, again, whatever occurred, and append the RA modifier to the claim. Next question. Oral devices, sleep apnea, do they require a pre-auth? And if not, do I need to send medical records with the claim? It does not require a prior authorization, and there should be documentation available in case of review. What is considered a covered Medicare home sleep study, HST? Covered, meaning it's covered under the Part B benefit. So Medicare would need to cover it. Did anyone else want to add anything? OK. Next question. If the claim does not need the sleep study attached, would it need to be submitted if an appeal is needed? I have been sending the sleep study with the claims. So if an appeal would be needed, I would strongly suggest that you include all of your documentation with your appeal request, just to make sure something isn't missed or there's no issues. OK. Thank you. Does CPAP have to be returned in the 90 days for the E-0486 to be paid? Didn't want to let me unmute. I don't know that the 90 days is going to have any bearing on how the claim will process. I can see that there may be cases where they've had the CPAP for 90 days, didn't meet compliance, they return it, and the oral appliance is ordered. I can see that still hitting up for same or similar and denying, but that could be taken through appeals. And since such a short time for mid-pass, I don't think you'd be hard pressed to find documentation to show that the CPAP was not effective and an oral appliance has been ordered. OK. Next question. If Medicare paid for a CPAP and within five years the patient wants an oral appliance and the CPAP has been returned, will Medicare cover an oral appliance even if the appeal is filled and all documentation is supported? Medicare has already paid for the CPAP. Will they pay for the oral appliance? You did say if the CPAP was returned, correct? Yes. Yes. So once that CPAP is returned, then yes, we would consider coverage of that oral appliance in that scenario. But again, it would most likely deny a same and similar unless it's been removed from our system through a pickup or return information. And it would need to be appealed with documentation to substantiate everything, the pickup slip, the coverage criteria being met, and everything. OK, next question. For AHI less than 15, will the oral device be covered or does the patient need comorbidity? Need to have comorbidities, that's what the criteria call. If you're under 15, you have criteria that you must need comorbidities, cardiovascular disease, cognitive disorder, it's pretty clear. Correct. OK. And again, I would strongly suggest that anyone's providing these items, definitely take a look at the local coverage determination because it does identify the comorbidities and other scenarios in the actual LCD. OK. Next question. Could you review the modifiers for the claim form, specifically NU-KX-RA? Does anyone want to take that question? I do. I'm sorry, I'm having a really hard time with my mute button. So I'm not sure if they're looking for what those modifiers mean. Yeah, so the oral appliance LCD will list the required modifiers. But to go into the ones that they listed, NU is required for purchase. You want to use a KX only if they've met the requirements and you expect it to be covered. If not the KX, you want to make sure you have the GA or GZ modifier, depending on whether or not you have an ABN. And those are also indicated in the policy. And then the RA, as Judy mentioned, is used for replacement. I'm sorry, what was the RA used for? Replacement. Oh, your replacement, OK. Next question. Is there a way to check oral appliance or CPAP history for the patient? I think we answered that earlier. OK. We did, and myCGS or the Noradia Medicare portal can be used to check history. Thank you, Judy. Next question. When filing the claim, do I include the dental claim along with the claim being submitted with Medicare? So the dental claim wouldn't come to the DME MAC. For any covered dental services, those would be covered under Part B. But for those that are covered, they're not covered under the DME MAC. OK. Next question. If a patient got their CPAP taken off the record with Medicare because it was returned, is an ABN still needed? Yeah, if they're same or similar equipment on file, I don't know, at least for Noradian, that it would be taken off file with a pickup ticket. So yes, definitely still obtain an ABN if they're same or similar equipment. I agree for CGS. All right. How does E-0486 coverage work in a federally qualified health center, FQHC? Can I bill for E-0486 in a federal quality qualified health center? Do you know what that place of service code is? Is it considered a facility? You know what? I do not. I don't have any other information. Cindy, looks like you're off mute. Did you want to take that one, or no? No, I'm just going down the same track you are. I was thinking about saying something, but without knowing what kind of skill level that facility would have, I wouldn't know the answer either. We have two more questions. Oh, one last question. We have two more questions. Oh, one last question or two. Oh, OK. Here, hold on. I'm sorry. The person said federally qualified centers are actual offices, but that was just a comment. We are down to our last question. How does E-0486 coverage work in a federally qualified? Shoot, sorry. It keeps changing on me. I understand. We're familiar. I think that was our last question, and we've answered 70 questions, so I appreciate your time. That's all the time we have for this evening. I'd like to thank our speakers for their participation. We all appreciate your generosity in participating in tonight's webinar.

webinar

Medicare coverage

sleep apnea devices

billing

oral appliance therapy

telehealth visits

coverage criteria

LCDs

healthcare providers