Oral Maxillofacial Prosthesis (A53496)

by  Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
December 6th, 2016

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 non adjustable, prefabricated (E0485) or custom fabricated (E0486). These devices are typically used to treat obstructive sleep apnea. Both codes include all fitting and adjustment. These are codes 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/ management CPT code and other appropriate CPT codes for diagnostic tests. At the time of the decision to order/provide the OSA appliance all fittings and 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 Evaluation & Management (E&M) services to the A/B 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.


Oral Maxillofacial Prosthesis (A53496). (2016, December 6). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/oral-maxillofacial-prosthesis-a53496-31578.html

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