Neurology & Pain Management Coding Alert

Question: A patient came for a sleep study, but couldn't complete the test (she stayed for three hours but couldn't fall asleep). What is the correct way to bill an incomplete study?

North Carolina Subscriber

Answer: Begin with the standard code for a sleep study, such as 95807 (Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist). According to CPT's sleep testing guidelines, include modifier 52 (Reduced services) "if less than six hours of recording or in other cases of reduced services as appropriate."

Choices: Coders sometimes stumble over whether to append modifier 52 or modifier 53 (Discontinued procedure) to a claim. Report modifier 52 when a service or procedure is partially reduced or eliminated at the physician's discretion (that is, the procedure started but was discontinued). Appending modifier 52 allows you to report reduced services without disturbing the identification of the basic procedure.

Turn to modifier 53, however, when the provider starts the procedure but discontinues because of extenuating circumstances or factors that threaten the patient's well-being.

Payment: Reporting modifier 52 or 53 reduces your payment. Your reimbursement depends on the payer involved and even, to some extent, how much of the procedure your provider completed before stopping. Stay up-to-date on your payers' policies to know what to expect.