Neurology & Pain Management Coding Alert

Stick with attended studies to ensure payment

If you're reporting polysomnography (95808-95811), be sure the physician's documentation indicates that the patient's sleep was staged to distinguish the procedure from a standard sleep study (95807).
 
Take a look at three sure-fire ways you can bolster your sleep testing and polysomnography coding success.

1. Call on 95805 for Wakefulness Testing

You should claim 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 neurologist orders a daytime test following polysomnography to measure sleepiness, says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting, a reimbursement consulting firm in Denver.

The physician or technologist records the time it takes the patient to fall asleep during a course of four to five 20-minute nap opportunities.

Clarification: During testing as described by 95805, the patient may not necessarily fall asleep. This does not affect coding.

Bonus Tip: Document Location and Time

Don't leave your sleep study and polysomnography vulnerable to denials by not documenting where the tests occurred and who attended them, coding experts say.

For instance, tests must take place "in an approved sleep center," as defined by the Medicare Carriers Manual, section 2055. A sleep center may be directly affiliated with a hospital or a freestanding facility under the direction of a physician.

Time matters: All sleep studies  must last a minimum of six hours, says Susan Turney, MD, FACP, medical director of reimbursement at the Marshfield Clinic in Marshfield, Wis. For tests of fewer than six hours, you must append modifier -52 (Reduced services) to the appropriate sleep study or polysomnography code. The payer will likely reduce payment for a truncated study.

2. Choose 95807 for Sleep Studies

For a basic sleep study, which includes monitoring of respiratory effort and heart rate, you should use code 95807 (Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate and oxygen saturation, attended by a technologist). Your physician should interpret and report the results and document the patient's positions while sleeping.

Typically, neurologists order sleep studies for diagnoses of narcolepsy, sleep apnea and parasomnia (which may include symptoms such as sleep walking, sleep terrors and REM sleep behavior disorders), says William J. Conner, MD, physician at Meridian Medical Group, a multi-specialty practice in Charlotte, N.C.

Don't Bother With Unattended Studies

For most insurers, you shouldn't bother to bill for unattended sleep study 95806 (Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, unattended by a technologist).
 
Medicare and many private payers dictate that sleep studies must be "professionally attended" to qualify for reimbursement.

Remember: Because payers will only reimburse for attended studies, you should specifically document physician or technologist attendance when claiming 95805/95807 or 95808-95811 for polysomnography.

3. Look to 95808-95811 for Staged Studies

Before reporting polysomnography, note that Medicare requires the neurologist or technologist to stage the patient's sleep and to record the results throughout the night.

Sleep staging includes a one-to-four-lead electroencephalogram, an electroculogram, nasal and oral airflow, ventilation, and respiratory effort.The physician may include other tests, such as a submental electromyogram, Turney says. 

You can choose from three polysomnography codes, depending on the number of sleep parameters or other tests: