Neurology & Pain Management Coding Alert

Caution: Don't ignore previous G codes for some payers.

If your physician orders home sleep studies, you've seen a lot of code changes in recent years. Brush up on the different study types -- including knowing when to use new codes 95800 and 95801 -- with the help of this quick update.

Differentiate Between Various Study Types

Sleep studies fall into four types:

• Type I is an overnight sleep study at a sleep disorders center that detects obstructive sleep apnea (OSA) and other sleep disorders. Technicians record at least 12 channels of information during the study.
• Types II, III, and IV studies are home sleep tests to detect OSA. A Type II study records seven or more channels of information; a Type III study records 4 to 7 channels of information; and a Type IV study records 1 to 3 channels of information.

Explanation: Using more channels for testing and recording leads to more detailed data capture and a more accurate diagnosis. Type III is most commonly used for home testing.

Tips: Your equipment might dictate how many channels the physician can monitor, and the payer might dictate your reimbursement. "Some payers do not pay for Type IV studies, so be sure to research your major payers," advises Jill Young, CPC, CEDC, CIMC, of Young Medical Consulting, LLC, in East Lansing, Mich.

Follow Code Transitions Carefully

Since 2009, CPT has introduced codes for home sleep tests (or HSTs) ranging from G codes to Category III codes to Category I CPT codes.

CPT 2010 included a new Category I code for Type 2 unattended portable polysomnography: 95806 (Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort [e.g., thoracoabdominal movement]). CPT 2011 completes the transition with new codes for Type 3 and Type 4 studies:

• 95800 -- Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis (e.g., by airflow or peripheral arterial tone), and sleep time
• 95801 -- Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation, and respiratory analysis (e.g., by airflow or peripheral arterial tone).

Details: Note the slight differences in descriptors. For example, 95800 includes recording sleep time and 95801 includes recording the patient's minimum heart rate. Code 95800 carries 6.05 RVUs (relative value units) for facility or non-facility tests and a national fee schedule rate of $205.56. Code 95801 carries 2.85 RVUs and a national fee schedule rate of $96.83 for facility or non-facility.

You'll notice that codes 95800 and 95801 include a # symbol in the CPT book. The symbol indicates that the codes are out of numeric sequence in the listing.

The following chart illustrates the introduction of HST codes since 2009.

Check Which Codes Your Payer Wants

The new codes and reporting strategies apply to Medicare patients, but not all payers. Some private insurers (such as Blue Cross) consider 95800 and 95801 non-covered by their contracts. For payers taking that stance, you might need to submit the original G codes of 2009:

• G0398 -- Home sleep study test (HST) with type ii portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation
• G0399 -- Home sleep test (HST) with type iii portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen saturation
• G0400 -- Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels.

"HST testing is relatively new -- within the past three years," Young notes. "As payers consider coverage for studies, the codes they select for payment might depend on when they implement coverage. For example, they might select codes that are in effect at that time and retain them even though new codes have been released or whether they follow Medicare's guidance and utilize the G codes." The G codes have no relative value (RVU) assignment, which possibly allows a payer more discretion in deciding payment.