Neurology & Pain Management Coding Alert

Neurologists often perform a sleep study for patients who have high blood pressure (401.1) and a tendency to doze off during the day. Studies have found a link between hypertension and sleep disorders, especially if the patient also is obese (278.00). Coders need to be aware of the problems with reimbursement due to the varied requirements by Medicare and many third-party payers to establish medical necessity for testing, and that sleep study results must meet particular levels of severity to establish grounds for reimbursable treatment.

Proving Medical Necessity

Mary Ellen Mascio, assistant director of business development for National Sleep Dynamics Inc., in Woodstock, Ga., a collection of sleep centers that perform diagnostic sleep studies all over the state, reports that her company provides a screening questionnaire for neurologists to document the medical necessity of the sleep testing. To decide whether a patient needs to have a sleep study, neurologists are looking for excessive daytime sleepiness, snoring (786.09), obesity, high blood pressure and morning headaches (784.0). Mascio is quick to point out that insomnia (780.52) alone is not a severe enough condition to require a sleep study because not being able to fall asleep is not considered the same as having disrupted or restless sleep. Mascio recommends that coders stay away from using the unspecified diagnosis codes as well as from circadian rhythm disorder (780.55) because these will not be reimbursed by most insurance carriers.

The most common diagnosis for a sleep study is sleep apnea (780.53). An apnea occurs when the patient stops breathing for at least 10 seconds during sleep. In extreme cases, the patient will wake gasping for breath. It helps if the doctor can document that the apneas were observed by a spouse, Mascio reports.

There are two types of sleep apnea: obstructed sleep apnea, where there is a physical obstruction of the upper airway causing the patient to not be able to breathe, and central sleep apnea, where the brain forgets to breathe but there are no physical obstructions; the respiratory muscles simply do not move.

CPT Coding for Sleep Studies

The correct CPT code to use for a sleep study greatly depends on how many parameters are being monitored during the study and if a technologist is present. If the study is for asleep or awake patients, then it should be coded using CPT code 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 sleep study is unattended by a technologist, then it would be coded using 95806 (sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, unattended by a technologist).

Larry Sieden, MD, assistant professor of neurology and director of the University of Maryland Center for Sleep Disorders reports that most neurologists want information about the patients positioning when sleeping that cannot be obtained unless a technologist is present. For that reason, and because insurance carriers fear an abuse of this code and will not reimburse for unattended sleep testing, unattended studies rarely are performed. The neurologist must be careful not to code 95806 when the sleep study is indeed attended.

A regular sleep study is coded using 95807 (sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist). According to CPT 2000, sleep studies also need to include recording of six or more hours of sleep with physician review, interpretation and report. In the rare event that less than six hours of recording is made or in other cases of reduced services, report the testing with a -52 modifier (reduced services).

Performing Polysomnography

If the neurologist requires additional information from the sleep study, then polysomnography can be performed. Neil A. Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at the University of Pittsburgh Medical Center at Shadyside in Pittsburgh and president of the American Association of Electrodiagnostic Medicine (AAEM), reports that polysomnography is distinguished from sleep studies by the inclusion of sleep staging, which is defined by CPT 2000 to include a 1-4 lead electroencephalogram (EEG) and electro-oculogram (EOG), and submental electromyogram (EMG). Additional parameters of sleep can include: 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; etc. Busis also states that for a study to be reported as polysomnography, sleep should be recorded as well as staged.

The neurologist can choose between the following CPT codes for polysomnography, depending on how many additional parameters are being recorded: 95808 (polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist) or 95810 (polysomnography; sleep staging with four or more additional parameters of sleep, attended by a technologist). Please note that CPT code 95811 (polysomnography; sleep staging with four or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist) should be used for polysomnography with continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BIPAP) only. Busis recommends not combining 95810 and 94660 (CPAP, initiation and management) for this procedure because 95811 now exists for this purpose.

Tests That Prove the Diagnosis for Sleep Apnea

Mascio reports that anything above the respiratory distress index of five is considered abnormal and positive for sleep apnea, but carriers disagree about the definition of mild, moderate and severe sleep apnea. According to the American Association of Sleep Medicine, a score between six and 15 is considered mild, between 16 and 25 is considered moderate, and more than 25 is considered severe sleep apnea. Previously, a score had to be higher than 40 for severe sleep apnea. But depending on the insurance carrier, the sleep study results that verify a diagnosis of sleep apnea vary, and this can cause difficulties in getting reimbursement for treatment and the additional sleep studies that may be required.

For example, one major insurance carrier instructs providers that if the patient has a low respiratory distress index, then the oxygen desaturation level also needs to be fairly low, or they will not approve a CPAP titration study (95811). Upper airway resistance syndrome (UARS) is another possible diagnosis that may be drawn from the results of sleep study testing from patients who display a great deal of sleep fragmentation and snoring but actually do not stop breathing (as in sleep apnea). The treatment for UARS is the same as it is for sleep apnea: a CPAP machine keeps the patients airway open during sleep. Getting coverage for this portable unit the patient will use at home may be extremely difficult, unless a carriers exact criteria has been met. Many Medicare carriers will not pay for a CPAP machine or for additional sleep studies unless the sleep study results indicate that the patient has had at least 30 apneas per hour during the sleep study. Meanwhile many third-party payers expect to see at least 20 apneas per hour.

Sieden notes that in some cases, the carriers sleep apnea criteria has not been met but other indicators for CPAP treatment are in place, such as very high respiratory distress. In some instances, he has filed grievances with the Maryland Insurance Commission and has won the CPAP treatment for his patients.

Documentation Requirements

Sieden reports that along with the claim form, neurologists should include the following information to ensure proper reimbursement:

statement that the patient was referred to the sleep clinic by an attending physician;
statement that patient has signs/symptoms of a covered medical condition, for example, sleep apnea
statement that the sleep testing is being performed to diagnose or rule out a condition; and
sleep testing results.