Local Coverage Article Billing and Coding

Billing and Coding: Oral Maxillofacial Prosthesis

A53497

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Contractor Information

Article Information

General Information

Article ID
A53497
Article Title
Billing and Coding: Oral Maxillofacial Prosthesis
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
01/01/2023
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2022 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2022 American Dental Association. All rights reserved.

Copyright © 2022, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

N/A

Article Guidance

Article Text

Implants, which could be considered dental but are being inserted to secure, attach, or support the maxillofacial prosthesis, will be covered when the prosthesis is to be used secondary to maxillofacial surgery or repair of traumatic injury. Use CPT® code 21299 to bill the implants with an explanation of the intended use. Please note dates of trauma or tumor biopsy/resection, dates of radiation treatment and other pertinent medical history.

E0485 to E0486: Oral Devices for Obstructive Sleep Apnea

HCPCS codes E0485 and E0486 describe oral devices or appliances used to reduce upper airway collapsibility, adjustable or nonadjustable, prefabricated (E0485) or custom fabricated (E0486). These devices are typically used to treat obstructive sleep apnea (OSA). Both codes include all fitting and adjustment. These codes are reimbursed as Durable Medical Equipment by the Durable Medical Equipment Medicare Administrative Contractor (DME MAC). The initial assessment and diagnostic services to determine whether an OSA appliance should be used are billable to the Part B contractor up to the time of the decision to order/provide the OSA appliance using the appropriate Evaluation and Management (E&M) CPT® code and other appropriate CPT® codes for diagnostic tests. At the time of the decision to order/provide the OSA appliance, all fittings, adjustments, supplies, and services to provide the appliance to the individual patient is inclusive. Medicare claims related to the fitting, subsequent adjustments and repairs of an oral device should be submitted to the appropriate DME MAC and not as E&M services to the A/B Medicare Administrative Contractor (MAC). Additionally, any radiological or other services performed in order to guide the adjustments of the oral device should not be submitted separately to the A/B MAC, as the Medicare Program payment associated with HCPCS Codes E0485 and E0486 already includes any required adjustments to ensure a properly fitted device.

Coding Information

CPT/HCPCS Codes

Group 1

(1 Code)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
21299 UNLISTED CRANIOFACIAL AND MAXILLOFACIAL PROCEDURE

Group 2

(2 Codes)
Group 2 Paragraph

N/A

Group 2 Codes
CodeDescription
E0485 ORAL DEVICE/APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE OR NON-ADJUSTABLE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
E0486 ORAL DEVICE/APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE OR NON-ADJUSTABLE, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT

CPT/HCPCS Modifiers

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ICD-10-CM Codes that Support Medical Necessity

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

N/A

ICD-10-PCS Codes

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

N/A

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
01/01/2023 R9

Under CPT/HCPCS Codes Group 1: Codes the description was revised for 21299. This revision is due to the 2023 Annual/Q1 CPT/HCPCS Code Update and is retroactive effective for dates of service on or after 1/1/23.

07/01/2021 R8

Punctuation was corrected throughout the article. Acronyms were inserted and defined where appropriate throughout the article. CPT® was inserted throughout the article where applicable.

10/24/2019 R7

This article is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs and incorporate into related Billing and Coding Articles.

02/26/2018 R6

Annual Validation performed with no revisions made.

 

02/26/2018 R5 The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. The notice period for this article begins on 12/14/17 and ends on 02/25/18. Effective 02/26/18, these three contract numbers are being added to this article. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.
01/29/2018 R4 The Jurisdiction "J" Part A Contracts for Alabama (10111), Georgia (10211) and Tennessee (10311) are now being serviced by Palmetto GBA. The notice period for this article begins on 12/14/17 and ends on 01/28/18. Effective 01/29/18, these three contract numbers are being added to this article. No coverage, coding or other substantive changes (beyond the addition of the 3 Part A contract numbers) have been completed in this revision.
05/04/2017 R3 Annual validation
05/05/2016 R2 Under Article Text multiple acronyms were defined and punctuation and grammatical revisions were made.
10/01/2015 R1 Added CPT/HCPCS Codes from Article Text to the CPT/HCPCS Coding Sections.

Associated Documents

Related Local Coverage Documents
LCDs
L33428 - Cosmetic and Reconstructive Surgery
Related National Coverage Documents
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
01/11/2023 01/01/2023 - N/A Currently in Effect You are here
06/22/2021 07/01/2021 - 12/31/2022 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Oral Maxillofacial
  • Prosthesis
  • Sleep Apnea
  • Oral Devices