Know the Requirements for Submitting Sleep Study Claims to Avoid Denials
Published on Fri Sep 01, 2000
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). [...]
