Correct Coding of Oral Devices

An oral device is considered durable medical equipment (DME) which:

• Can withstand repeated use
• Is primarily and customarily used to serve a medical purpose
• Is generally not useful to a person in the absence of an illness or injury
• Is appropriate for use in the home

The oral device is an oral appliance that may be prefabricated or custom fabricated by a dentist. The beneficiary is usually referred to the dentist by the treating physician for fabrication of an oral device to be used in treatment of obstructive sleep apnea. An oral device/appliance is billed by a dentist to the DMAC contractor using the HCPCS code(s) E0485 (oral device/appliance used to reduce upper airway collapsibility, adjustable or nonadjustable, prefabricated, includes fitting and adjustment) or E0486 (oral device/appliance used to reduce upper airway collapsibility, adjustable or nonadjustable, custom fabricated, includes fitting and adjustment).

The use of HCPCS code L9900 (orthotic and prosthetic supply, accessory and/or service component of another HCPCS L code) is incorrect coding for an oral device/appliance as it does not meet the definition of an orthotic (rigid or semi-rigid device that is used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body). Additionally, CPT code 21089 (unlisted maxillofacial prosthetic procedure) should not be submitted on claims for oral devices because oral devices are not implanted, but are manually removed by the individual patient. The oral device does not replace a body part there by not meeting the definition of a prosthetic.