Neurology & Pain Management Coding Alert

Hint: Confirm the stage of sleep and parameters recorded. You can improve your sleep study coding accuracy by watching three key areas. Here are some handy tips to help you to report these services and make your claims hassle free. 1. Differentiate Sleep Studies from Polysomnography Understanding subtle differences between sleep studies and polysomnography (PSG) will aid your code selection. "Sleep studies and polysomnography refer to a continuous and simultaneous monitoring and recording of various physiological and pathophysiological parameters of sleep for six or more hours with physician review, interpretation and report," says Mary Mulholland, MHA, RN, CPC, with the University of Pennsylvania Health System in Philadelphia. These studies will help your neurologist assess the patient for sleep disorders and the response to certain therapies (such as CPAP) initiated to overcome these disorders. Staging is your key: Note that polysomnography tests will usually require your neurologist to stage sleep with a number of parameters. These can include:

• Frontal, central, and occipital lead electroencephalogram (EEG)

 

• Left and right electrooculogram (EOG)

 

• Submental electromyogram (EMG)

 

• ECG

 

• Airflow (nasal and/or oral)

 

• Respiratory effort

 

• Oxygen saturation (SpO2 -- pulse oximetry)

 

• Extremity muscle activity (bilateral anterior tibialis EMG)

 

• Body positions.

"Body position is not one of the allowed CPT ® coding parameters of polysomnography," says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver, CO. Sleep studies such as multiple sleep latency test (MSLT) or the maintenance of wakefulness (MWT) testing are generally performed to assess day time sleepiness. MWT involves patient being instructed to remain awake for as long as possible during several 20 or 40 minute sessions while sitting in low-level light. The neurologist can perform these tests the day after he performs PSG. "The MSLT objectively assesses the patient's sleep tendency by measuring the number of minutes it takes for the patient to fall asleep, as well as the premature occurrence of rapid eye movement (REM) sleep," says Mulholland. "In order to ensure the validity of the MSLT, interpretation should only be made following the PSG performed on the preceding night." "The MSLT is a standardized objective test of the tendency to fall asleep," says Hammer. "MSLT is used to measure the time elapsed from the start of a daytime nap period to the first signs of sleep with its main purpose is to discover how readily a person will fall asleep in a conducive setting, how consistent or variable this is, and the way they fall asleep in terms of REM sleep and other brain patterns." When your neurologist performs MSLT or MWT, you report 95805 ( Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness). PSG? Choose from 3: When your neurologist performs a PSG, you have three coding choices, depending on the number of parameters that your neurologist has opted for to record and stage sleep:

• 95808 (

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

• 95810 (...4 or more additional parameters of sleep...)

• 95811 (...4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation...)

  "The codes differ based on the number of parameters of sleep that are monitored as well as if the neurologist initiated either of the obstructive airway treatments," says Hammer. "The neurologist's documentation would need to clearly identify the different parameters monitored as well as any therapeutic treatment introduced." You may however anticipate changes soon. "Now, in 2012, the coding is based on number of parameters of sleep monitored and obstructive airway management BUT in 2013 there will be an added separation of the codes based on patient age -- age 6 years or older OR new CPT ® codes for patients younger than 6 years." Example: A 55-year-old male patient reports to your neurologist with complaints of restlessness during sleep, frequent arousal from sleep due to a gasping or choking sensation, and recent episodes of daytime sleepiness, one incident that almost caused an accident while driving an automobile. Your neurologist performs a comprehensive evaluation of the patient and suspects obstructive sleep apnea. He decides to perform a PSG that records EEG, EOG, submental EMG, ECG, nasal airflow and oxygen saturation followed by a MWT the next day. Code: You report the PSG with 95808, as your neurologist recorded 3 parameters above the standard parameters (EEG, EOG and submental EMG) and the MWT with 95805. 2. Home in on 95806 for Home Sleep Testing Medicare allows home sleep testing (HST) to diagnose a patient for obstructive sleep apnea (OSA). "HST is covered for diagnosing OSA if the HST is reasonable and necessary for diagnosing the patient's condition, meets all Medicare requirements, and the physician performing the service has sufficient training and experience to reliably perform the service," Mulholland says. Single payment: The HST recording should be done over a period of three consecutive nights, but Medicare considers the multiple recordings as one study and will only reimburse it once. Remember the HST must be performed using FDA approved devices and the patient should receive training and instructions on the use of the device. You report unattended HST for commercial carriers using 95806 ( Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort [e.g., thoracoabdominal movement]). You need to understand how to select the right code for unattended sleep studies. Check if the respiratory effort is being monitored or a respiratory analysis is done. For respiratory analysis, you report codes 95800 (Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis [e.g., by airflow or peripheral arterial tone], and sleep time]) or 95801 (Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation, and respiratory analysis [e.g., by airflow or peripheral arterial tone]) depending upon whether or not sleep time is also being recorded. "The CPT® section guidelines provide definitions of respiratory airflow & respiratory effort (part of 95806) versus respiratory analysis (95800 or 95801)," says Hammer. "Likewise 95800 requires documentation of sleep time whereas 95801 does not include that requirement." If patient is covered under Medicare, choose from one three G codes based on the number of parameters recorded:

• G0398 (Home sleep test [HST] with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort, and oxygen saturation)

• G0399 (Home sleep test [HST] with type III portable monitor , unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen saturation)

• G0400 (Home sleep test [HST] with type IV portable monitor, unattended; minimum of 3 channels).

  Sometimes sleep studies are performed in a lab and attended by a technologist. In that situation, report 95807 (Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist). 3. Don't Forget Modifier 52 for Reduced Services You need a minimum of six hours of interpretable data before you can report a sleep study. "CPT® 95808-95811 procedure codes require six hours of data monitoring," says Mulholland. "Report them with modifier 52 (Reduced services) for reduced polysomnography or sleep study services if less than 6 hours of recording were obtained." "Going further in 2013, physicians would also append modifier 52 for less than 7 hours of recording for polysomnography for patients younger than 6 years," says Hammer. Use modifier 52 when less than four nap opportunities occur during MSLT/MWT services. Also, you may be clear on the recording time even though the codes also include interpretation and report creation. "The documentation will need to include the recording time to support billing the diagnostic study with or without modifier 52," says Hammer.