Neurology & Pain Management Coding Alert

Sleep apnea commonly is diagnosed using sleep studies. But getting reimbursed for these studies can be challenging. By using the appropriate procedure and diagnosis codes, however, neurologists can ensure that insurance carriers will not deny claims for such testing.

In recent years, there has been a growing recognition of the significance of sleep disorders and the grave impact these conditions have on a patients overall health. Among the most prevalent of these disorders is sleep apnea, which is a respiratory dysfunction resulting in the cessation or near cessation of respiration for 10 seconds or longer.

In reponse, many neurology practices are operating sleep centers that provide testing for sleep apnea. The testing takes several forms, and neurology coding professionals who understand the various studies and their appli-cations are better able to assign the most applicable codes.

Once the sleep test has been completed, the neurologist interprets the results. The interpretation, however, is bundled into the code for the study.

Coding the Primary Testing Procedure

According to Medicare, the most common nocturnal (during sleep) symptoms for these conditions include snoring, abnormal motor activity (flailing or getting out of bed) and nocturia (urinating at night). Diurnal (during wakefulness) symptoms associated with sleep apnea involve excessive daytime sleepiness, poor memory and personality changes.

Paul Blackman, BS, RPSGT, RCP, CPFT, chief technologist at the Atlanta Center for Sleep Disorders, says most patients are referred to his facility because they suffer from sleep disorders of unknown origins. They may be snoring excessively, waking up tired or sleep-walking. Most of these patients have seen their primary- care physician and have been referred to a neurologist for these problems.

The initial study to determine the cause of the disorder, he says is polysomnography95810 (polysomnography; sleep staging with four or more additional parameters of sleep, attended by a technologist).

Polysomnography is an all-night study that should be used if more than five observed apneas or hypopneas occur during each hour of sleep for at least six hours of nocturnal sleep.

This study bundles in a number of monitoring activities that allow us to identify neurological conditions that may be interfering with sleep, Blackman says, adding that polysomnography (or PSG) is defined to include a one-to-four lead electroencephalogram (EEG), an electrooculogram (EOG) and a submental electromyogram (EMG).

Additional parameters of sleep measured during a polysomnography also may 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 tumescences; gastroesophageal reflux; continuous blood pressure monitoring; snoring; and body positions.

PSG, Blackman says, generally is conducted on adults and children older than one year. Infants, whose sleep disorders are less likely to be neurologically based, typically undergo simple sleep studies95806 (sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, unattended by a technologist) or 95807 (sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist).

The sleep staging component of PSG, Blackman adds, allows technicians to monitor different stages of sleep like REM (rapid eye movement, often called dream sleep, or delta (slow-wave sleep when the mind and body regenerate). This allows us to study the architecture of a patients sleep. Some stages of sleep are more prone to apnea, so this helps us pinpoint the disorder.

Second Test Helps Determine Treatment

If apnea is diagnosed based on PSG, patients usually undergo a second full night of sleep testing. A continuous positive airway pressure (CPAP) study is ordered, and neurology coders correctly would assign 95811 (polysomnography; sleep staging with four or more parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist) for this test.

During this study, the patient wears a mask that forces air into his or her airways, according to Blackman. Throughout the night, at various stages of sleep, we test which air pressures are most effective to sustain the patient through the whole night. Once the correct pressure is determined, CPAP becomes a treatment, with the patient using a CPAP device in his or her home.

Medicare allows for follow-up PSGagain coded 95811under the following conditions: to evaluate the response to treatment (CPAP, oral appliances, surgical intervention); after substantial weight loss in patients on CPAP to ascertain if the treatment is still needed at the previously titrated pressure; after substantial weight gain in patients previously treated with CPAP successfully, but who are again symptomatic despite continued use of CPAP, to determine if pressure adjustments are needed; when clinical response is insufficient or when symptoms return despite a good initial response to CPAP treatment.

One other sleep test is used often, says Blackman. Following the initial PSG, patients may undergo daytime testing to determine if their condition is better defined as narcolepsy (347), rather than apnea. This study should be coded 95805 (multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness). This test includes 20- to 30-minute napping periods, followed by one-and-a-half to two hours of wakefulness to determine how quickly a subject falls asleep and how soon he or she enters REM sleep.

Correct Preliminary Diagnosis Codes

To be properly reimbursed for these testing procedures, neurologists should submit the test code with the correct diagnostic code. According to Vera Charlot, CCS, AAS, data quality supervisor with Hackensack University Medical Center in Hackensack, N.J., three major diagnosis codes within the 780.5-series (general symptoms, sleep disturbances) are assigned most appropriately to describe sleep apnea.

Most often, we see the patients with a diagnosis of 780.51 (insomnia with sleep apnea), 780.53 (hypersomnia with sleep apnea), or 780.57 (other and unspecified sleep apnea), Charlot says. We rely on these to help us conduct
an effective sleep study that will provide more specific information that will allow the physicians to decide upon the correct course of treatment.

Dahlia Gordon, medical recorder with the Atlanta Center for Sleep Disorders at the Atlanta Medical Center, agrees that these are the preliminary diagnosis codes seen most frequently. She adds, however, that their practice regularly sees one additional code.

Often, the physician cant categorically diagnose apnea before the sleep testing. We frequently simply assign ICD-9 code 786.09 (symptoms involving respiratory system and other chest symptoms; dyspnea and respiratory abnormalities; other) to indicate snoring, which is often what the doctor has documented on the report. Sometimes, it is necessary to code the symptom until the results from the sleep testing can be reviewed.