Neurology & Pain Management Coding Alert

Heads up: Get ready for increased audits of these procedures.

The Office of Inspector General (OIG) published a report for CMS in late 2013 that could really shake up your polysomnography billing. Every neurology practice should know what the “Questionable Billing for Polysomnography Services” study determined and recommended, because your practice may now be on the OIG “watch list.”

Background: The OIG’s mission is to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as the health and welfare of program beneficiaries. HHS OIG is the largest inspector general’s office in the Federal Government and is dedicated to combating fraud, waste, and abuse, and to improving the efficiency of the HHS programs.

Get the Scoop on the Study Background

Increased spending on polysomnography (a 39 percent increase from 2005 to 2011) and concerns about fraud and abuse led OIG to conduct the study. The group analyzed claims for 2011 from hospital outpatient departments and non-hospital providers (such as physician-owned sleep labs and independent diagnostic testing facilities). They used the following three measures to identify polysomnography claims that did not meet Medicare requirements:

• Inappropriate diagnosis code
• Same-day duplicate claims
• Invalid NPI.

In addition, the study looked for providers who had patterns of questionable billing, based on eight measures:

• Shared beneficiaries
• Unbundling a split-night service
• Double billing for the professional component
• Repeated titrations
• Missing professional component
• Titration with no corresponding treatment device
• Missing visit with ordering provider
• Repeated polysomnography services.

The results: OIG found that Medicare paid nearly $17 million for polysomnography services during that time that did not meet one or more of the three Medicare requirements. Most of the inaccurate payments stemmed from inappropriate diagnosis codes. Other problems the study discovered included patterns of questionable billing for polysomnography services, especially with providers who submitted a high percentage of claims for beneficiaries with more than one polysomnography on the same day. The OIG questions this because beneficiaries can only undergo one polysomnography service in a day since the test requires an overnight stay.

What it means: OIG is conducting audits of polysomnography claims for selected regions to determine whether the claims complied with Medicare requirements and were paid accurately. As part of these audits, OIG will review MAC safeguards for the selected regions. OIG is also evaluating MACs’ use and evaluation of local edits.

Work Toward Having Clean Audits

Knowing what the OIG will be looking for in polysomnography claims means you can check your providers’ work to ensure any future audits will be as pain-free as possible. Focus on the following three areas to help make that happen.

1. Choose your codes: Physicians bill for most polysomnography services using three CPT® codes. Report diagnostic services using either 95808 (Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist) or 95810 (Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist), depending on how many parameters of sleep are measured. You should code for both full-night titration services and split-night services using 95811 (Polysomnography; age 6 years or older, 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).

2. Connect the correct diagnosis: Verify the diagnoses your local payers accept as medically necessary for polysomnography services. Depending on the test your physician conducts, supported diagnoses could include 307.48 (Repetitive intrusions of sleep), 327.23 (Obstructive sleep apnea [adult] [pediatric]), 327.42 (REM sleep behavior disorder), 347.xx (Narcolepsy), 780.51 (Insomnia with sleep apnea, unspecified), 780.57 (Unspecified sleep apnea), and more.

3. Don’t unbundle services: The OIG study found that many providers with patterns of questionable billing had an unusually high percentage of diagnostic polysomnography claims with a titration claim for the same patient the next day. The physicians might be performing split-night services, but submitted separate claims for the diagnostic and titration portions. Unbundling the services and reporting them separately inappropriately increases the provider’s reimbursement. The OIG stated that unbundling could lead to non-hospital providers receiving $1,186.79 instead of the correct amount of $618.03.

Coming next month: While you’re focusing on polysomnography claims, ensure that you know the difference between these tests and sleep studies.