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December 8, 2016

Oral Appliances Not Used For the Treatment of Obstructive Sleep Apnea – Correct Coding

DME MAC Joint Publication

Oral appliances are used for the treatment of many conditions related to the mouth, teeth and jaw. Most of these items used to treat these conditions do not fall within the jurisdiction of the Durable Medical Equipment Medicare Administrative Contractors (DME MAC).

Only oral appliances that meet the requirements to be classified as DME are eligible to use HCPCS codes E0485 and E0486. The Oral Appliances Used for the Treatment of Obstructive Sleep Apnea Local Coverage Determination (LCD) excludes devices coded as E0485 from reimbursement. Only products reviewed by the Pricing, Data Analysis and Coding (PDAC) contractor and included on the Durable Medical Equipment Coding System's (DMECS) Product Classification List may be coded as E0486.

All other oral appliances are classified by HCPCS "D" or "S" codes. HCPCS "D" codes are used for dental items and procedures. HCPCS "S" codes are not used by Medicare. HCPCS "D" and "S" codes do not fall within the jurisdiction of the Medicare DME MACs or PDAC.  PDAC does not provide coding advice for these HCPCS codes. Questions about "D" codes should be directed to the A/B MAC contractors. Questions about HCPCS "S" codes should be directed to the non-Medicare payer to whom a claim will be submitted.

For additional information about coverage and coding of oral appliances classified as DME, refer to the Oral Appliances used for the Treatment of Obstructive Sleep Apnea LCDExternal Website and related Policy ArticleExternal Website.

Questions concerning HCPCS code classifications should be directed to the Pricing, Data Analysis and Coding (PDAC) contractor – Contact Center at (877) 735-1326 during the hours of 8:30 a.m. to 4:00 p.m. CT, Monday through Friday, or email the PDAC by completing the DME PDAC Contact Form located on the PDAC website https://www.dmepdac.comExternal Website.

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