3 Random Things You NEED to Know About DSM Billing

By Lesia Crawford for March, 2019 DSM Insider

1. Digital Impressions

Medicare had some dentists and dental labs with their knickers in a twist again. The questions being asked are:

• Are you allowed to scan for digital impressions to fabricate an appliance on a printed model?
• Or, are you required to use PVS or alginate impressions and poured stone models as the only methods approved for manufacturing Oral Appliances?

If you have a scanner and are using it for your Medicare DME patients, great! Keep it up. The current Medicare DMEPOS Quality Standards specifically outlines the use of CAD-CAM technology as acceptable and there is no issue with advanced technology for your Medicare patients. The Medicare supplier standards state:

“Custom Fabricated: A custom fabricated item is one that is individually made for a specific patient. No other patient would be able to use this item. A custom fabricated item is a device which is fabricated based on clinically derived and rectified castings, tracings, measurements, and/or other images (such as x-rays) of the body part. a. Molded-to-Patient-Model: A particular type of custom fabricated device in which one of the following techniques is used:

• An impression (e.g., by means of a foam box impression, a plaster or fiberglass cast) of the specific body part is made directly on the patient, and this impression is then used to make a positive model of the body part from which the final product is crafted; or

• A digital image of the patient’s body part is made using Computer-Aided Design-Computer-Aided Manufacturing (CAD-CAM) systems software. This technology includes specialized probes/digitizers and scanners that create a computerized positive model, and then direct milling equipment to carve a positive model. The device is then individually fabricated and molded over the positive model of the patient.”

2. Aetna Requirement Update

Aetna will deny claims for a 3% scoring on sleep studies.  If you are submitting a claim to Aetna, double check your sleep study.  Aetna will deny your claim if the sleep study is scored at 3% or a study scored at 4% and the AHI is below AASM scoring guides are recognized by most commercial plans, United Health Care and Cigna for example and will accept a sleep test scored at 3%. When referring your patients to the sleep physician ask for all your tests to be scored using both the 3% and 4% desaturation measurement. Aetna has also given a 2-year time frame for the age of the sleep study.

3. Cigna Requirements

If you receive a request from Cigna asking for the date of the sleep study and it’s been over a year, you will need to send the full medical file. If the sleep study is less than a year old, they usually do not request additional documents and pay the claim without an appeal.

In short,

1. Use your digital scanner for impressions
2.  Request sleep studies to be scored with both a 3% and 4% desaturation benchmarks
3. Consider changing your sleep practice protocol to include requirements for a new HST or PSG if it has been over a year since the last test.

Would you like medical treatment prescribed and dispensed without current testing. Do you crown a tooth with a 1-year old x-ray? We service our patients the greatest when we do what is best for them and not necessarily cheaper or easier.