Question Somnogard device

[DTATRO]

We are using CPT code 21085 for the Somnogard device. We order the guards and our physicians shape and fit the appliance . Do you think the description "This code should only be used when physician actually designs and prepares prosthesis , ie not prepared by an outside lab." There is also a HCPS code E0485 which looks like a better choice.
Does anyone have any experience with coding these? Thanks in advance for your help.

 

[jackjones62]

Correct, you cannot bill 21085, it is specific to a specialist who designs and manufactures these types of prosthesis. You should bill E0485 for the Somnogard - Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, prefabricated, includes fitting and adjustment

E0485 - This code represents an adjustable or nonadjustable oral appliance that helps improve the upper airway patency during sleep in a patient with obstructive sleep apnea. These devices have a standard size and design.

Clinical Responsibility
An oral appliance or device is a prefabricated jaw positioning or tongue retaining device that a provider recommends for a patient with obstructed sleep apnea, a sleep disorder where the walls of throat relax and narrow, and the tongue falls back against the soft palate during sleep causing cessation of breathing. These devices enlarge the upper airway and improve upper airway muscle tone. This code includes the fitting and adjustment of the item.

 

[LoftisX4]

E0485 is for a pre-fabricated device, whereas E0486 is for a custom-device. Is your Somnoguard device custom-fabricated from impressions of the patients dentition?

I have a related question. Can a provider use 21085 for impressions/fabrication of an obstructive sleep apnea device, if 1) the provider takes the impressions in office and 2) sends the materials to an independent lab for fabrication, for a patient who 3) does not require any open-cutting or surgical procedures?

Based on my CPT book, it seems an anatomical deficiency needs to exist. Barring a co-existing cleft or something of that nature, I don’t know if an argument could be made that patients with obstructive sleep apnea all have anatomical deficiencies. However, it seems crystal-clear (to me) that the criteria regarding an outside lab means the provider should not use this code. Any thoughts?

What about 21110 for retainers? These are not permanently affixed to the teeth/jaw. They are used daily and inserted/removed by the patient.

Was 21085 or 21110 ever appropriate for sleep apnea DME? Did the advent of E0485/86 make these codes obsolete for this service?

 

[jackjones62]

E0485 is for a pre-fabricated device, whereas E0486 is for a custom-device. Is your Somnoguard device custom-fabricated from impressions of the patients dentition?

I have a related question. Can a provider use 21085 for impressions/fabrication of an obstructive sleep apnea device, if 1) the provider takes the impressions in office and 2) sends the materials to an independent lab for fabrication, for a patient who 3) does not require any open-cutting or surgical procedures?

Based on my CPT book, it seems an anatomical deficiency needs to exist. Barring a co-existing cleft or something of that nature, I don’t know if an argument could be made that patients with obstructive sleep apnea all have anatomical deficiencies. However, it seems crystal-clear (to me) that the criteria regarding an outside lab means the provider should not use this code. Any thoughts?

What about 21110 for retainers? These are not permanently affixed to the teeth/jaw. They are used daily and inserted/removed by the patient.

Was 21085 or 21110 ever appropriate for sleep apnea DME? Did the advent of E0485/86 make these codes obsolete for this service?

E0486 is a custom device where impressions are made and then sent to a lab to have the device made. E0485 are a pre-fab. In order to bill for something like 21076 thru 21089 (Head Prosthesis) you have to specialize in making custom prosthesis and have your own onsite lab to produce them. As the descriptions states, these codes are only used when the physician or other QHCP actually designs and prepares the prosthesis (ie, not prepared by an outside lab). Also, these are prosthesis for oral, facial, or other anatomical defects, not for sleep apnea. 21110 are actually metal arches that are cemented for support following an Maxillary Mandibular Advancement procedure for sleep apnea, although it is not widely performed these days due to the advancement of surgery and other sleep apnea treatments.