Neurology & Pain Management Coding Alert

Question: We recently opened a sleep lab, and performed an overnight sleep staging study for a patient with parasomnia due to suspected nocturnal seizures. We set up the patient in our lab while a technician monitored the progress. We billed for 95806, but the claim was rejected. What went wrong?

Oklahoma Subscriber

Answer: Answer: You may have gotten a denial because you performed polysomnography, not a sleep study.

You should instead choose from three polysomnography codes, depending on the number of additional parameters of sleep that were tested:

95808 -- Polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist

95810 -- ... sleep staging with 4 or more additional parameters of sleep, attended by a technologist

95811 -- ... 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.

What's the difference? One difference between a sleep study and polysomnography is the setting in which the study took place. For instance, tests must take place "in an approved sleep center," as defined by the Medicare Carriers Manual, section 2055. Failing to include where the test occurred and who attended can leave your polysomnography claim vulnerable to denials, experts say.

For polysomnography, Medicare requires either the neurologist or technician to stage the patient's sleep and 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.

For polysomnography, Medicare requires either the neurologist or technician to stage the patient's sleep and record the results throughout the night.

Per Chapter 15 in the Medicare Benefit Policy Manual, the medical conditions for which polysomnography testing is covered are: narcolepsy (347.00), sleep apnea (780.57), impotence (607.84), and parasomnias (307.47), such as sleepwalking, sleep terrors, and rapid eye movement (REM) sleep behavior disorders.

The CPT section guidelines for Sleep Testing Procedures lists the additional parameters of sleep referenced in these code descriptions as: 1) ECG; 2) airflow; 3) ventilation and respiratory effort; 4) gas exchange by oximetry, transcutaneous monitoring, or end tidal gas analysis; 5) extremity muscle activity, motor activity-movement; 6) extended EEG monitoring; 7) penile tumescence; 8) gastroesophageal reflux; 9) continuous blood pressure monitoring; 10) snoring; 11) body positions; etc.