Sleep Tesing Claiom Denials are Common:
How to Avoid Them
Published on Wed Sep 01, 1999
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 [...]
