Neurology & Pain Management Coding Alert

Tip: Don't forget to check for add-on modifier opportunities.

Correctly coding diagnostic sleep tests depends partly on the sleep lab's credentials and physical location (or place of service, POS) and partly on the physician's ownership and service. Read on for simple comparisons and tips that will help you choose the right POS and modifier mix every time.

Base knowledge: Physicians can bill for services in diagnostic sleep testing in one of several ways. Your choices are:

• POS 11 -- Office
• POS 21 -- Inpatient hospital
• POS 22 -- Outpatient hospital
• POS 49 -- Independent clinic
• POS 15 -- Mobile unit.

Bill All Components for Office Service

Physicians providing services in their offices bill for the entire global service, including both the technical and professional components. You'll report POS 11 and the appropriate CPT® code without a modifier, such as 95810 (Polysomnography; sleep staging with 4 or more additional parameters of sleep, attended by a technologist).

Key: The physician must rent or own the facility and own the equipment used during the testing, says Catherine French, CCS-P, manager of medical economics with the American Association of Neuromuscular and Electrodiagnostic Medicine. The physician also must be paying for the physical location, sleep lab staff, etc., before you can submit charges for the complete service.

Remember -26 for Interpretation Only

If the patient has the study in a hospital-based sleep center or freestanding facility and your physician performs the interpretation of the findings, you'll need to append modifier 26 (Professional component) to the appropriate CPT® code. The modifier tells the insurance company that the physician only interpreted the results, but doesn't own the equipment.

"My understanding is that those in an office or freestanding facility may bill global or components," says Marc Raphaelson, M.D., a neurologist in Leesburg, Va. For example, the physician might bill globally from a freestanding facility or separate the fees (professional component by the interpreting physician and technical component by the freestanding facility). The arrangement could depend on meeting criteria for equipment ownership, rent/ownership of the facility, staff employment, and more.

POS change: The correct place of service designation depends on the type of facility. You might submit POS 21, 22, 49, or 15, depending on the circumstances.

Check Whether TC Applies to Facility

If you bill on behalf of a freestanding facility with a sleep lab, you might submit some claims with modifier TC (Technical component).

"The TC modifier indicates that the bill is for the technical component of service only," says Mori. In other words, the facility owns the equipment and employs the staff that performed the diagnostic the study and is looking for reimbursement for their resources used in performing the actual diagnostic study. For facilities that are credentialed by Medicare as an Independent Diagnostic Testing Facility (IDTF), submit the claim with POS 49.

Use Same Code, Different POS for Mobile Unit

According to POS descriptors, POS 15 applies to "a facility or unit that  moves from place to place and is equipped to provide preventive, screening, diagnostic, and/or treatment services."

Note: Some payers might have guidelines regarding which sleep study or polysomnography codes you can report for certain POS designations. For example, Trailblazer's Medicare local coverage determination (LCD) for sleep studies states that, "Documentation must show that the polysomnography (95808, 95810, and 95811) was performed in a facility based sleep study laboratory and not in the home or a mobile facility."

Include Other Modifiers as Needed

Other procedural modifiers might come into play when you're finalizing codes, depending on the situation. Consider a few examples from Raphaelson: A sleep study that only lasted three hours; append modifier 52 (Reduced service).

• The physician stops the test because the patient exhibits CPAP intolerance and complains of chest pain. You'll append modifier 53 (Discontinued procedure) to the diagnostic study code.
• The study takes much longer than usual because the patient is a young child or requires a dedicated technician during the entire procedure. You could possibly append modifier 22 (Increased procedural services) to indicate the well documented, substantial additional work.
• The physician might conduct polysomnography and have a follow-up visit with the patient later the same day. If the same physician is involved in both encounters, you can report both the study CPT® code and applicable E/M visit code. Though the established patient E/M codes are not bundled by NCCI edits into the sleep testing CPT® codes some payers may require providers to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to indicate the follow-up visit was separate and distinct from the diagnostic study.