Neurology & Pain Management Coding Alert

If you're frustrated with the payment you're receiving (or not receiving) for sleep studies and polysomnography, pay special attention to your diagnosis coding and documentation verifying place of service and the physician's attendance during testing. Failure to follow payers' strict guidelines for these services can lead to a nightmare of unpaid claims.

According to CPT, "Sleep studies and polysomnography refer to the 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." Although similar, sleep studies and polysomnography are separate diagnostic tests performed at different times to assess various physiological parameters of sleep, and you may report them separately if the patient's symptoms or diagnosis supports medical necessity, says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver.
 
CPT includes three primary codes to describe sleep studies:
 

95805 Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep
 during multiple trials to assess sleepiness

 

95806 Sleep study, simultaneous recording of ventilation, respiratory effort,
 ECG or heart rate, and oxygen saturation, unattended by a technologist
  

95807 ... attended by a technologist.
 
You may report 95805 for studies on asleep or awake patients. "The code [95805] applies to multiple sleep latency testing during periods of napping to assess sleepiness," as explained by the Coders' Desk Reference.
 
Code 95807 describes a standard sleep study. These studies are attended by a technologist and include monitoring of all parameters as specified in the code descriptor. A physician must interpret and report the results and generally documents the patient's position while sleeping. The physician may also use such studies to evaluate a patient's response to therapy such as nasal continuous positive airway pressure (NCPAP).
 
Note: Most insurers, including Medicare, will not reimburse an unattended sleep study, 95806 (see below).

2. Include Sleep Staging in Polysomnography

According to CPT, polysomnography differs from sleep studies by the inclusion of sleep staging, which is defined to include a one- to four-lead electroencephalogram (EEG), an electrooculogram (EOG) and a submental electromyogram (EMG), says Susan Turney, MD, FACP, medical director of reimbursement at the Marshfield Clinic in Marshfield, Wis. In addition, polysomnography involves overnight recording of data, and the physician (or technologist) monitors the patient throughout the night.
 
CPT also specifies three codes for 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.

"Additional parameters of sleep" as defined by descriptors 95808-95811 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.

3. Choose a Diagnosis With Care

Sleep studies and/or polysomnography are routinely indicated for the diagnosis of sleep-related breathing disorders, Hammer says. Potential diagnoses codes for these breathing disorders include insomnia with sleep apnea (780.51), hypersomnia with sleep apnea (780.53), and other and unspecified sleep apnea (780.57) (see sidebar on page 51 for a more complete list). Sleep apnea occurs if the patient stops breathing for 10 seconds or more during sleep. The apnea may be obstructive, meaning a physical obstruction (for example, the tongue) blocks the upper airway; central, in which the respiratory muscles do not move due to a malfunction of the brain; or mixed, Turney says. Other sleeping disorders for which the physician may use 95805-95811 include narcolepsy, nocturnal myoclonus, and hypersomnolence, as well as daytime somnolence, reports of sleeping/napping during the day, falling asleep at work or when driving, and witnessed apneic episodes.
 
Payers differ as to the exact ICD-9 codes they will accept to establish medical necessity for 95805-95811. National Medicare policy, for instance, allows coverage only for diagnoses related to narcolepsy, sleep apnea and parasomnia (which may include symptoms such as sleep walking, sleep terrors and REM sleep behavior disorders), while specifically prohibiting use of sleep studies/
polysomnography for chronic insomnia.
 
Note: In limited circumstances, Medicare and other payers will allow sleep studies to diagnose impotence of organic (607.84) or psychogenic (302.72) origin. Although impotence is not a sleep disorder, diagnostic testing must occur during sleep. Ordinarily, testing is covered only when necessary to confirm the necessity of surgical, medical or psychotherapeutic treatment. These tests are usually reported using 54250 (Nocturnal penile tumescence and/or rigidity test) rather than the sleep study/polysomnography codes listed above.

4. Attendance, Place-of-Service Matters
 
 Nearly every insurer dictates that sleep studies and polysomnography be "professionally attended" to qualify for reimbursement (that is, unattended study 95806 is not payable, and you must specifically document physician or technologist attendance for all other tests) and that the tests must take place "in an approved sleep center," as defined by the Medicare Carriers Manual (MCM), section 2055. Such sleep centers may be directly affiliated with a hospital or a freestanding facility under the direction and control of a physician(s). Patients are generally considered outpatients, even though the test may require an overnight stay. As the MCM further argues, "Portable sleep studies (95806), sleep studies that are performed without professional attendance in the home setting, and sleep studies that only measure and record limited characteristics of the patient's sleep are considered experimental/investigational" and are therefore not covered.
 
All sleep studies, including polysomnography, must last a minimum of six hours, Turney says. If the test is less than that, you must report the appropriate code appended with modifier -52 (Reduced services). The payer will reduce reimbursement to reflect the diminished time and effort.