Complimentary Wi-Fi is available: Connect to HYATT-MEETING or MEYDENBAUER WELCOMES PNDC. Use Password: PNDC2015.

Transcription

1 Welcome to the Pacific Northwest Dental Conference! To provide quality continuing dental education programs that will promote the highest standards of patient care and professionalism in the dental community. Complimentary Wi-Fi is available: Connect to HYATT-MEETING or MEYDENBAUER WELCOMES PNDC. Use Password: PNDC2015. Download the PNDC mobile app and fill out course evaluations for a chance to win a $100 restaurant gift card. Search PNDC in your app store. Please silent all cell phones. There is no photography or recording of any kind allowed during the presentation. Visit the Exhibit Hall at the Meydenbauer Center. There are drawings during the lunch hours on both days which include flat screen TVs, GoPros, and more. Please support our exhibitors who support the PNDC! WSDA members may have your WSDA membership card scanned by the room ambassador and CDE verification forms will be available at the END of the course. Sign up for the Seattle/King County Clinic at Key Arena, October For more information visit seattlecenter.org/skcclinic. Dental Assistants are especially needed. x 1

2 Medicare and Dental Services Presented by Noridian Provider Outreach and Education. Durable Medical Equipment and Enrollment Team

3 DISCLAIMER This information release is the property of Noridian Healthcare Solutions, LLC (Noridian). It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents. The information is provided as is without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and the Centers for Medicare & Medicaid Services (CMS). The most current edition of the information contained in this release can be found on the Noridian website at and the CMS website at The identification of an organization or product in this information does not imply any form of endorsement. CPT codes, descriptors, and other data only are copyright 2015 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.

4 Introductions Tammy Ewers Noridian Provider Outreach and Education Representative Cindy White-Noridian DME Outreach and Education Consultant Donn Robertson- Noridian Provider Enrollment Education Representative

5 Agenda Overview General outline Medical Services and Coverage Exclusions Durable Medical Services and Coverage Oral Appliance Devices for the treatment of OSA Enrollment Opt out vs limited enrollment

6 Objective The objective today is to provide you with regulations and guidance about the Medicare program in the context of your specialties.

7 Overview

8 Statutory Dental Exclusion Section 1862 (a)(12) of the Social Security Act states: Where such expenses are for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth. Except that payment may be made under part A in the case of inpatient hospital services in connection with the provision of such dental services if the individual, because of his underlying medical condition and clinical status or because of the severity of the dental procedure, requires hospitalization in connection with the provision of such services

9 Medical Necessity Coverage is not determined by the value or the necessity of the dental care but by the type of service provided and the anatomical structure on which the procedure is performed. Place of service has no bearing on coverage.

10 Definition Structures directly supporting the teeth means the periodontium, which includes the gingivae, periodontal membrane, cementum of the teeth, and the alveolar bone (i.e. alveolar process and tooth sockets).

11 Services Excluded under Part B The following two categories of services are excluded from coverage: A primary service (regardless of cause or complexity) provided for the care, treatment, removal, or replacement of teeth or structures directly supporting teeth, e.g., preparation of the mouth for dentures, removal of diseased teeth in an infected jaw.

12 Exclusions cont. A secondary service that is related to the teeth or structures directly supporting the teeth unless it is incident to and an integral part of a covered primary service that is necessary to treat a non-dental condition (e.g., tumor removal) and it is performed at the same time as the covered primary service and by the same physician/dentist. In those cases in which these requirements are met and the secondary services are covered

13 Coverage

14 Medicare Coverage Medicare will pay for dental services that are an integral part either of a covered procedure or for extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw Example - reconstruction of the jaw following an injury from an accident

15 Medicare Coverage There is no payment for the cost of dental appliances or for the preparing for them. Such as dentures, even though the covered service resulted in the need for the teeth to be replaced, The cost of preparing the mouth for dentures, or the cost of directly repairing teeth or structures directly supporting teeth (e.g., alveolar process).

16 Example 1 -Not Payable The reconstruction of a ridge performed primarily to prepare the mouth for dentures is a noncovered procedure.

17 Billing for Exactions CPT codes or In item 19 narrative tooth extraction and number of teeth removed. Diagnosis- a cancer that involves either a region of the head or neck i.e. jaw, tongue Service must be performed prior to radiation.

18 Coverage Cont. Coverage of administration of anesthesia, diagnostic x-rays, and other related procedures are dependent upon whether the primary procedure being performed by the dentist is itself covered. Payment may also be made for services and supplies furnished incident to covered dental services. Ex: Services of a dental technician or nurse who is under the "direct supervision of the dentist or physician are covered if the services are included in the dentist s or physician s bill.

19 Dental Splints Dental splints used to treat a dental condition are excluded from coverage under 1862(a)(12) of the Act. Exception if the treatment is determined to be a for a medical condition (i.e., dislocated upper/lower jaw joints), then the splint can be covered.

20 National Coverage Determinations Dental Examination Prior to Kidney Transplantation (260.6) Such a dental or oral examination would be covered under Part A of the program if performed by a dentist on the hospital's staff, or under Part B if performed by a physician. (When performing a dental or oral examination, a dentist is not recognized as a physician under 1861(r) of the Act.)

21 Noridian Web Site

22 Resources Noridian Healthcare Solutions Jurisdiction F A/B MAC Center for Medicare and Medicaid Services Pub 100.Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, "Definitions," 70.2, Pub Medicare Benefit and Entitlement Manual, Chapter 15, "Covered Medical and Other Health Services," 150.) Pub Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Noridian Jurisdiction D DME MAC

23 Durable Medical Equipment Presented by Cindy White Noridian DME Outreach and Education Consultant

24 DMEPOS Enrollment DMEPOS enrollment is separate Resource information Noridian DMEPOS Supplier Manual, Chapter 2 pics/enrollment#enroll National Supplier Clearinghouse (NSC) Palmetto GBA

25 Custom Fabricated Mandibular Advancement Oral Appliance (E0486) Used to treat OSA Must have approval from the Pricing, Data Analysis and Coding Contractor (PDAC) Requires the following to be met: Face to face clinical evaluation by the treating physician prior to a sleep study Medicare covered sleep study AHI/RDI > 15 events per hour; min. 30 events AHI/RDI > 5 and < 14 events per hour; min. 10 events and documentation of additional symptoms If AHI > 30 or RDI >30 one of the following: Beneficiary unable to tolerate PAP Treating Physician determines PAP contraindicated Noridian Jurisdiction D DME MAC

26 Custom Fabricated Mandibular Advancement Oral Appliance (E0486)(2) The device is ordered by the treating physician following review of the report of the sleep test The device is provided and billed for by a licensed dentist Refer to the LCD and Policy Article policies/lcd/active/oral-appliances-for-osa Noridian Jurisdiction D DME MAC

27 Coding E0486 Product must have written coding verification made by Pricing, Data Analysis and Coding (PDAC) contractor Contact PDAC for guidance Noridian Jurisdiction D DME MAC

28 Coding E0486 (2)

29 Coding E0486 (3)

30 Modifiers NU - purchase KX - required if all coverage criteria met GA - criteria not met, ABN executed GZ - criteria not met and no ABN Noridian Jurisdiction D DME MAC

31 Repair and Replacement Repair Fix or mend Covered when needed to make the item serviceable Cannot exceed the price of a new item Replacement 5 year reasonable useful life Lost, stolen or irreparably damaged as a result of a specific accident or disaster Normal wear and tear not replaceable Statutorily non-covered Noridian Jurisdiction D DME MAC

32 Resources Noridian Healthcare Solutions Jurisdiction D DME MAC Noridian Supplier Manual ucation/supplier-manual Oral Appliance Device LCD and Policy Article cies/lcd/active/oral-appliances-for-osa Noridian Jurisdiction D DME MAC