Neurology & Pain Management Coding Alert

Physician will recommend routine changes, OTC meds as initial treatments.

Managing one’s sleep health is a crucial aspect of overall bodily function. A patient’s health and overall well-being can be greatly affected by poor sleep.

This can stem from unrecognized habits or something deeper like an unidentified illness or disorder.  

In this article, we will identify healthy sleep habits that providers should recommend to all patients. We will also review different ways your physician can help treat sleep disorders — including devices, therapies, medicines, and procedures. 

Sleep Problems Affect All Areas of Life

Inability to manage sleep can lead to moodiness, lack of concentration, anxiety, and depression. Long-term sleep issues can even cause heart problems, obesity, and diabetes. Physicians should encourage patients to speak about their sleep patterns, to see if the quality or quantity is inadequate.

Although sleep issues can be frustrating, there are solutions. The provider can guide the patient through the use of any medications or home remedies for sleep issues. Although resolving chronic insomnia might require a longer timeframe, a prescribed treatment regimen allows patients to directly address their sleep problems under the supervision of a skilled professional.

The first step in treatment of sleep issues is to guage the extent and severity of the problem with an evaluation and management (E/M) service. This E/M will probably occur in the office, so you would report a code from the 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.) code set for the service, depending on encounter specifics.

During the initial E/M for a patient with sleep problems, the physician might recommend the following tips to the patient to improve sleep hygiene:

• Ensure their bedroom is cool, dark, and quiet.
• Avoid screens before bed that give off blue light, such as televisions and cell phones, as this can affect your body’s natural circadian rhythm.
• As often as possible, make sure they go to bed and wake at the same time every day. 
• Avoid napping unless necessary.
• Stay away from caffeine, nicotine, and alcohol while winding down. While they may help a patient fall asleep, they can also cause lighter sleep, leading to more nighttime waking.
• Get regular physical activity during the daytime (at least five to six hours before going to bed). Exercising close to bedtime can make it harder to fall asleep.
• Review the patient’s over the counter (OTC) and prescription drugs to ensure they aren’t disrupting sleep.
• Avoid big meals before bed as they may cause indigestion.
• Reduce fluid intake before bed as this can cause frequent urination, rousing the patient during the night.
• Adhere to a low-stress wind -down routine. Read a book, listen to relaxing music, take a warm bath or shower.
• Start relaxing an hour before your expected bedtime, at a minimum.

OTC Meds Come First

When a provider treats a patient with sleep disturbances during an initial E/M, they might first recommend OTC medications that can be taken without a prescription from a provider (for those over 18 years old). These often contain antihistamines, which are frequently used to treat allergies, but they also can cause drowsiness.

A subset of OTC medication, available without a prescription, can be more “natural” remedies such as melatonin or valerian. Melatonin is naturally occurring in the body and valerian is an herb that boosts relaxation.

Provider Might Prescribe These Sleep Meds

Depending on the physician, medications may be prescribed to help patients fall asleep or stay asleep.  Providers need to be sure patients review the potential side effects, as most of the medications should not be taken long-term. Those with liver or kidney disease may be the most at risk for these side effects.

Here’s a look at some prescription medications your provider might suggest for patients with sleep issues:

• Barbiturates, which are often used for seizures and anesthesia induction, are now being used for extreme cases of insomnia.
• Benzodiazepines (benzos) work by stimulating a chemical in your brain called gamma-aminobutyric acid (GABA), which lessens a nerve cell’s ability to receive, create, or send messages to other cells.
• Antidepressants such as amitriptyline, mirtazapine (Remeron), and trazodone may be taken in lower doses to treat insomnia.
• Z-drugs, such as zolpidem and eszopiclone, slow the activity in the brain, and are sometimes used for insomnia as well.

These Therapies Could Come in Handy

Light therapy is helpful for seasonal affective disorder (SAD) and those with shift work changes; this treatment is also known as phototherapy. There are dawn simulators that can be purchased online that gradually increase in brightness over a period of time to simulate the sunrise. Physicians can also prescribe a light visor that is worn on the head and emits a bright light upon waking.

Orofacial therapy is a treatment for orofacial myofunctional disorders, or disorders of the face and mouth. These therapies are exercise-related to help regain proper posture and function of the tongue and mouth, which can impact the quality of your sleep.

Cognitive behavioral therapy (CBT) can be approved for insomnia treatments. This is a type of psychotherapy that can change negative thoughts and behaviors, such as depression, anxiety, and post-traumatic stress disorder (PTSD). Improving mental and emotional health can frequently improve sleep quality.

Devices Can Also Aid Sleep

A continuous positive airway pressure (CPAP) mask is a device worn at night for the treatment of sleep apnea. This mask fits over the nose and mouth and blows air to ensure adequate oxygen is being pushed in the lungs during breathing breaks while sleeping.

When your physician fits a patient with a CPAP mask, report 94660 (Continuous positive airway pressure ventilation (CPAP), initiation and management). During the initial CPAP encounter, the physician will  introduce the patient to CPAP treatment, explain how the device operates, and adjust the strap’s tension to obtain a comfortable and secure fit on the head.

Home Testing for Sleep Apnea? Use These Codes

If a patient’s symptoms are related to sleep apnea, the physician may prescribe a home sleep apnea test. These are often devices that are worn on the head while sleeping to monitor breathing patterns, heart rate, and respiratory effort.

According to the American Academy of Sleep Medicine, the most commonly used HCPCS codes for these services are the following:

• G0398 (Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: eeg, eog, emg, ecg/heart rate, airflow, respiratory effort and oxygen saturation)
• G0399 (… minimum of 4 channels: 2 respiratory movement/airflow, 1 ecg/heart rate and 1 oxygen saturation)
• G0400 (… minimum of 3 channels).

Payer issue: Even though the above G codes might be recommended by professional societies, you should check with private payers to determine if they accept these HCPCS codes. If a payer doesn’t accept these codes for sleep studies, then you’ll opt for the following CPT^® codes:

• 95800 (Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis (eg, by airflow or peripheral arterial tone), and sleep time)
• 95801 (… minimum of heart rate, oxygen saturation, and respiratory analysis (eg, by airflow or peripheral arterial tone))
• 95806 (Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort (eg, thoracoabdominal movement)).

Jessica Sullivan, CPC, COBGC, COSC, Consultant, Pinnacle Enterprise Consulting Services (PERCS)