Neurology & Pain Management Coding Alert

The Office of the Inspector General (OIG) has had polysomnography sleep codes (95808-95811) on its watch list for a few years now. The popular sleep lab exam is also on the OIG's 2010 Workplan.

"Medicare reimbursement for polysomnography tests increased from $62 million in 2001 to $215 million in 2005," the OIG Workplan states.

Why it matters: The OIG wants to make sure practices are performing polysomnography properly, and for the right reasons. So if your neurologist interprets polysomnography tests or your sleep lab performs them, you'll want to pay attention now or risk a possible audit later.

The biggest reason the OIG is looking at polysomnography is that coders often misuse the diagnosis codes submitted to justify the test.

The scrutiny isn't unexpected, says Jill M. Young,CPC-ED, CPC-IM, president of Young Medical Consulting LLC in East Lansing, Mich. Medicare is seeing the rise in payments, "and they're starting to question the tests from a diagnosis perspective," Young says.

If you're unsure your diagnosis is up to snuff, there's at least one diagnosis you can rule out right away: chronic insomnia.

Medicare does not cover polysomnography (95808-95811, Polysomnography; sleep staging ...) for diagnosis of patients with chronic insomnia because it does not consider the test reasonable and necessary for that diagnosis. "Evidence at the present time is not convincing that polysomnography in a sleep disorder clinic for chronic insomnia provides definitive diagnostic data or that such information is useful in patient treatment or is associated with improved clinical outcome," CMS says. There are many other conditions that Medicare does not cover, including:

• Cases where seizure disorders have been ruled out
• Patients with epilepsy who don't have specific complaints associated with a sleep disorder
• To evaluate a preoperative patient for laser-assisted uvulopalatopharyngoplasty without evidence of obstructive sleep apnea
• Depression-related insomnia
• For the diagnosis of circadian rhythm sleep disorders (jet lag, shift-work sleep disorder, delayed sleep phase syndrome, advanced sleep phase syndrome, etc).

Young also advises a second look at the appropriate ICD-9 codes in the 327 (Organic sleep disorders) code range, especially for 327.2x (Organic sleep apnea). "There is a very narrow window of diagnosis of sleep studies. Make sure your intake of information is as good as it can be," Young says.

Reminder: If your neurologist documents daytime sleepiness, particularly with driving, morning headaches, and probable obstructive sleep apnea but the diagnostic test results don't confirm it, you can't code the sleep apnea. "If a test was negative, you would code the signs and symptoms," Young says.

A polysomnography test is not the same as a sleep study. Therefore, your coding isn't the same.

Note the differences: In a polysomnography evaluation, the patient's sleep is staged, meaning a setting is created to allow the patient to fall asleep. The exam occurs overnight, and a trained technician monitors the patient for the entire study. In contrast, sleep studies do not require the neurologist to stage the patient's sleep patterns during his interpretation of the diagnostic study data.

You'll use these codes to report polysomnography:

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.

In order to properly report the correct components of the test and avoid denials or possible audits, you'll also need to understand how the exam works and how it might affect your modifier use.

Option 1: If your neurologist or sleep lab administers the study, owns all the equipment used (such as an 1-4 lead electroencephalogram [EEG]), employs the technician(s) and then interprets and reports the findings, you can simply report the component codes (95808-95811) without any modifier appended.

Option 2: If your neurologist only receives the test results, then analyzes, formulates an interpretation, and reports the findings, you would use the appropriate CPT code, then add modifier 26 (Professional component).

Option 3: When your lab, hospital, or center operates and owns or rents out the staging area and equipment, and employs the technicians, but sends the results to an independent neurologist, use modifier TC (Technical component) with the appropriate CPT code.