Neurology & Pain Management Coding Alert

Stick with attended studies to ensure payment

If you-re reporting polysomnography (95808-95811), be sure the physician's documentation indicates that the patient's sleep was staged to distinguish the procedure from a standard sleep study (95807).

Take a look at three sure-fire ways you can bolster your sleep testing and polysomnography coding success.

1. Call on 95805 for Wakefulness Testing

You should claim 95805 (Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness) if the neurologist orders a daytime test following polysomnography to measure sleepiness.

The physician or technologist records the time it takes the patient to fall asleep during a course of four to five 20-minute nap opportunities.

Clarification: During testing as described by 95805, the patient may not necessarily fall asleep. But this does not affect coding.

Bonus tip: Don't leave your sleep study and polysomnography vulnerable to denials by not documenting where the tests occurred and who attended them, coding experts say.

For instance, tests must take place -in an approved sleep center,- as defined by the Medicare Carriers Manual, section 2055. A sleep center may be directly affiliated with a hospital or a freestanding facility under a physician's direction.

Time matters: All sleep studies must last a minimum of six hours, says Susan Turney, MD, FACP, medical director of reimbursement at the Marshfield Clinic in Marshfield, Wis. For tests of fewer than six hours, you must append modifier 52 (Reduced services) to the appropriate sleep study or polysomnography code. The payer will likely reduce payment for a truncated study.

2. Choose 95807 for Sleep Studies

For a basic sleep study, which includes monitoring of respiratory effort and heart rate, you should use 95807 (Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist). Your physician should interpret and report the results and document the patient's positions while sleeping.

Typically, neurologists order sleep studies to diagnose narcolepsy (347.xx), sleep apnea (780.5x or 327.2x) and parasomnia (which may include symptoms such as sleep walking, sleep terrors, and REM sleep behavior disorders), says William J. Conner, MD, a North Carolina physician.

Unattended note: Medicare and many private payers dictate that sleep studies must be -professionally attended- to qualify for reimbursement. Because of this, some coders say you shouldn't bother to bill for unattended sleep study 95806 (Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, unattended by a technologist) with most carriers.

Why this is: -According to the introduction in the CPT manual, just because there is a code for something doesn't make it reimbursable,- says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, CodeRyte Inc. coding analyst and coding review teacher. -CPT was originally designed to track what physicians did, not for billing purposes.-

Remember: Because payers will reimburse only for attended studies, you should specifically document physician or technologist attendance when claiming 95805/95807 or 95808-95811 for polysomnography.

3. Look to 95808-95811 for Staged Studies

Before reporting polysomnography, note that Medicare requires either the neurologist or technologist to stage the patient's sleep and record the results throughout the night.

Sleep staging includes a one- to four-lead electroencephalogram, an electroculogram, nasal and oral airflow, ventilation, and respiratory effort. The physician may include other tests, such as a submental electromyogram, Turney says.

You can choose from three polysomnography codes, depending on the number of sleep parameters or other tests:

--95808 -- Polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist

--95810 -- ... sleep staging with 4 or more additional parameters of sleep, attended by a technologist

--95811 -- ... sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist.

-Additional parameters-: When reporting 95805-95811, the neurologist must document that he has included one-three (95808) or four or more (95810-95811) -additional parameters of sleep.- According to CPT guidelines, these could include:

--electrocardiogram (ECG)

--airflow

--ventilation and respiratory effort

--gas exchange by oximetry, transcutaneous monitoring or end tidal gas analysis

extremity muscle activity, motor activity-movement

--extended EEG monitoring

-penile tumescence

--gastroesophageal reflux

--continuous blood pressure monitoring

--snoring

--body positions.

Remember Modifier 26

When reporting a service such as 95805-95807 or 95808-95811 in a facility setting, you must append modifier 26 (Professional component). The only exception occurs if you are conducting the sleep study/polysomnography in your own approved sleep facility, and you are supplying the necessary equipment and attending technologist.