Neurology & Pain Management Coding Alert

When a patient with a sleep problemusually, falling asleep during the daygoes to a neurologist, the ultimate test is an overnight sleep test, or polysomnography. But at about $2,000 a night, this test draws the scrutiny of payers. Medicare and other payers are very worried that sleep testing will be abused, says Mark Nuwer, MD, PhD, the CPT advisor for the American Academy of Neurology and a professor of neurology at UCLA. Medicare balked at creating the codes in the first place.

One of Medicares concerns, for example, is that neurologists who own their own equipment will go to nursing homes to conduct sleep testing, says Nuwer. So Medicare, and many private payers as well, have a policy of not reimbursing for any sleep testing unless the testing is done at a certified lab.

Although the sleep testing section of CPT lists codes 95805-95962, the only codes that are actually for sleep testing are 95805-95811, Nuwer explains. Code 95805 is for daytime testing, and codes 95806 through 95811 are for overnight testing.

The least likely sleep testing code to get paid is 95806, says Nuwer. Thats because this code is for a sleep test which is unattended by a technologist. Theres a great concern by payers that this code will be abused, because it would allow someone to sleep and be hooked up at home, says Nuwer. The data could be saved electronically, and interpreted by a neurologist. Its unfortunate that this procedure is so hard to get reimbursed, says Nuwer, because there is a legitimate role for 95806. Its much more economical, compared to having a technologist sit in a lab all night, he says. Furthermore, its much more appealing to patients.

The most commonly used sleep testing codes are 95810 and 95811. These are for testing with four or more additional parameters of sleep. Four or more is the best way to do it, says Nuwer of sleep testing. Using only one to three parameters is the quick and cheap way to do it, he says.

Medical Necessity Key to Payment

When is sleep testing used? For excessive daytime sleepiness or nighttime sleep that is disrupted by unusual events, Nuwer explains. Hypersomnia (780.54) is the most commonly used diagnosis, he says. The typical patient is a middle-aged individual who tends to be overweight and who falls asleep in the middle of the day.

But falling asleep during the day, by itself, does not justify sleep testing in the eyes of payers. Margaret Mac, CMM, CPC, for the past five years the practice manager for Tampa Neurology Associates, a four-provider practice in Tampa, FL, explains that first you must establish that the daytime sleepiness is not caused by insomnia or mental depression. The patient could be depressed because he or she is going through a divorce, or having insomnia because of drinking too much coffee at night, says Mac. In addition to 780.54, you could use 347 (narcolepsy) for the diagnosis code to justify sleep testing, she adds.

In addition to 780.54 and 347, payers consider sleep apnea, parasomnias, and impotence (sometimes) as indications that justify sleep testing.

Be careful about which sleep disorder codes you use, says Mac. For sleep apnea, use 780.51 (insomnia with sleep apnea). Do not use nonspecific insomnia codes, as the payer will not cover these. Because apnea is a normal occurrence, you need to demonstrate that it is excessive to justify the sleep studies.For sleep apnea, you need to have five observed apneas per hour of sleep during at least six hours of nocturnal sleep, says Mac. A spouse could stay awake and record the apneas, or the patient could use an at-home apnea monitor, she explains.

For parasomnias, you will need a standard EEG first to rule out a seizure disorder, as well as a clinical history that indicates repeated violent or injurious episodes during sleep, says Mac. The proper diagnosis codes are 307.46 (somnambulism or night terrors) and 307.48 (repetitive intrusions of sleep). Do not use 780.59 (sleep disturbances; other), which is as nonspecific as a code can get.

And in certain cases, impotence justifies a sleep test. See your carriers policy for erectile dysfunction. ICD-9 codes are 302.70-302.72, 607.84, and 607.89.

Note that the pre-test diagnosis may be different from the post-test diagnosis. The neurologist is, in fact, often in the difficult position of making a diagnosis such as narcolepsy before the sleep testing is done, and then sending the patient for the tests to get confirmation.

Nuwer, who does sleep testing, says he usually gets prior authorization first if the payer is private. No such authorization is necessary with Medicare.

Reasons for Sleep Testing Claim Denials There are 10 main reasons for denial of sleep testing claims. They are as follows: 1. use of unallowable insomnia diagnoses (307.40-307.45, 307.49); 2. to preoperatively evaluate a patient undergoing a laser-assisted uvulopalatopharyngoplasty (42145) without clinical evidence that obstructive sleep apnea is suspected; 3. to diagnose chronic lung disease, unless symptoms suggest obstructive sleep apnea; 4. not ruling out seizure disorders; 5. typical, uncomplicated and uninjurious parasomnias; 6. patients with epilepsy who have no complaints consistent with a sleep disorder; 7. patients with symptoms suggestive of periodic limb movement disorder unless there is suspicion of relation to covered indication; 8. for diagnosis of restless legs syndrome; 9. for diagnosis of insomnia related to depression; and 10. for diagnosis of circadian rhythm sleep disorders.

Documentation Requirements

If you are doing sleep testing, dont even think about filing electronically, says Mac. The documentation requirements are too rigid. The following information should be attached to the claim:

evidence that patient was referred to sleep clinic by attending physician;

evidence that patient has signs/symptoms of a covered medical condition (see diagnosis codes above);

evidence that the sleep testing is being performed to diagnose or rule out a condition; and

test results. Its easy to see why filing electronically isnt recommended.