Neurology & Pain Management Coding Alert

Question: May we report an E/M service on the same day as a sleep study (95805-95811)?

New Mexico Subscriber

Answer: You may be able to charge an E/M service and sleep study on the same date of service, depending on circumstances and documentation.

Medicare and other payers assume that all diagnostic services include an inherent E/M component. For example, a typical sleep study (e.g., 95807, Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist) will include a cursory examination, minor discussions with the patient, etc. If the physician provides a significant, separately identifiable E/M service beyond that usually associated with the diagnostic procedure, you may report the appropriate E/M code separately with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended. Generally, this would occur only if the patient has a new complaint at the time of the previously scheduled service that requires the physician to perform all the relevant components of an E/M service (history, exam and medical decision-making). For instance, the patient arrives for a scheduled sleep study and mentions recent numbness and tingling in one or both legs, as well as hot and cold sensations in the feet. In this case, the neurologist will perform an E/M service to deal with the new complaint, offer a differential diagnosis and determine the need for further diagnostic testing.

CMS guidelines specify that the diagnosis linked to the procedure and E/M service need not be different to receive separate payment. As noted, however, if the patient presents with a new complaint, you should link the patient's signs and symptoms to the E/M service. In the above example, for instance, link an appropriate diagnosis (e.g., 780.53, Hypersomnia with sleep apnea) to the sleep study while linking numbness (782.0), leg pain (729.5) and other relevant signs and symptoms to the E/M code.

The E/M code and diagnostic procedure might share a common diagnosis(es) if the E/M service led to the decision to perform the diagnostic procedure on the same day. This is unlikely for a sleep study (which is usually scheduled prospectively) but might occur if the physician orders immediate nerve conduction studies (95900-95903) after examining a patient with the signs and symptoms of carpal tunnel syndrome, for instance.

In any case, you can further differentiate the separately identifiable nature of the E/M service by physically separating the documentation from that of the diagnostic procedure. In this way, you clearly indicate that the service can stand on its own and meets all billing requirements independent of other services reported.