Neurology & Pain Management Coding Alert

Question: We perform sleep studies in our sleep disorder center; the physicians perform and read all studies on site. Our Medicaid carrier denies our claims with 95810 and 95811, though the other payers reimburse without any problems. Am I billing correctly, or do I need to split bill or submit something different to Medicaid?

Colorado Subscriber

Answer: When reporting polysomnography, select the appropriate code from 95808-95811 based on the staging and provider involvement:

• 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.››

Polysomnography codes have separate technical and professional components, but your question indicates that your staff performed the sleep study in a physician-owned sleep study center. If you bill with the "11" place of service designation (Office), report the diagnostic study as the global service rather than separating and billing individual components.

Denials can stem from a host of reasons including medical necessity, no authorization, frequency utilization, or more. Each state has its own Medicaid program that can have its own coverage policies. Because Medicaid seems to be the only carrier denying the claims, check with your local policies to ensure you're following current guidelines.