Neurology & Pain Management Coding Alert

Sleep studies and polysomnography help find the causes of potentially life-threatening sleep disorders. Insurers accept few ICD-9 codes as justification of medical necessity for these tests, however, and failure to show the presence of such diagnoses will lead to automatic denials. Also, place and length of service and attendance or nonattendance by a physician affect coding and coverage. Adherence to these guidelines will ensure correct and timely payment and prevent the filing of uncovered claims.

 
According to CPT, "Sleep studies and polysomnography refer to the continuous and simultaneous monitoring and recording of various physiological and pathophysiological parameters of sleep for six or more hours with physician review, interpretation and report." These diagnostic procedures are used to study sleep disorders and their causes or "to evaluate a patient's response to therapies such as nasal continuous positive airway pressure (NCPAP)." Sleep disorders include, but are not limited to, narcolepsy, nocturnal myoclonus, hypersomnolence, insomnia and obstructive sleep apnea. Additional problems might involve daytime somnolence, reports of sleeping/napping during the day, falling asleep at work or when driving, and witnessed apneic episodes. If these signs and symptoms are present, make sure to document them in the patient's medical record. Snoring and nasal obstructive signs and symptoms are not indications for polysomnography, although they may be indications of sleep apnea when other findings are also present. Other causes of sleepiness should be ruled out via a sleepiness scale before performing a sleep study. Also, document these results in the medical record.
 
Acceptable diagnoses for sleep studies and polysomnography may differ from carrier to carrier. For example, Blue Cross/Blue Shield of North Dakota, in its LMRP for Colorado, North Dakota, South Dakota and Wyoming, lists the following as covered:
 
278.01 -- morbid obesity with sleep apnea
 
278.8 --  pickwickian syndrome
 
345.8x -- nocturnal seizures
 
347 -- cataplexy and narcolepsy
 
780.09 -- alteration of consciousness; drowsiness, somnolence
 
780.51 -- insomnia with sleep apnea
 
780.53 -- hypersomnia with sleep apnea
 
780.54 -- other hypersomnia
 
780.55 -- disruptions of 24-hour sleep-wake cycle
 
780.56 -- dysfunctions associated with sleep stages or arousal from sleep
 
780.59 -- other sleep disturbances.

 
Cahaba GBA-Midwest, a Medicare intermediary for Iowa and South Dakota, accepts the above diagnoses plus 780.57, other and unspecified sleep apnea, and 799.0, hypoxia. Contact your carrier for a list of applicable codes.
 
According to Deborah Werner, CPC, neurology reimbursement specialist at Cleveland Clinic Foundation, Cleveland, "The most common and widely accepted diagnosis justifying sleep studies is sleep apnea (780.53), which occurs if the patient stops breathing for 10 seconds or more during sleep." The apnea may be obstructive, meaning a physical obstruction (e.g., the tongue) blocks the upper airway; central, in which the respiratory muscles do not move due to a malfunction of the brain; or mixed. "Generally, one polysomnography is necessary to diagnose apnea," Werner says. "If more than one test is required, make sure that documentation supports the necessity for additional testing." 
 
In limited circumstances, sleep studies may be covered to diagnose impotence of organic (607.84) or psychogenic (302.72) origin. Although impotence is not a sleep disorder, diagnostic testing must occur during sleep. Ordinarily, testing is covered only when necessary to confirm the necessity of surgical, medical or psychotherapeutic treatment. These tests are usually reported using 54250 (nocturnal penile tumescence and/or rigidity test) rather than the sleep study/polysomnography codes listed below.
 
Note: In extraordinary circumstances, the physician may deem diagnostic tests not covered by the carrier to be necessary and in the best interest of the patient. To ensure payment, ask the patient to sign an advance beneficiary notice (ABN) acknowledging that he or she will be responsible for payment. The patient has the option to refuse service by not signing the ABN.
 
If you submit claims with an ABN, append HCPCS modifier -GA (waiver of liability statement on file) to the applicable test code(s).

 
Sleep tests are reported with one of three codes:
 

95805 -- multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness

95806 -- sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, unattended by a technologist
 

95807 -- ... attended by a technologist.

 
Report 95805 for studies on asleep or awake patients. According to the Coders' Desk Reference, "Physiological parameters of a patient asleep in a lab setting are monitored for at least six hours. A physician interprets the results. The code [95805] applies to multiple sleep latency testing during periods of napping to assess sleepiness." This test must be attended.
  
Report a standard sleep study with 95807. These studies are attended by a technologist and include monitoring of the parameters specified in the code descriptor. A physician must interpret and report the results and will generally note the patient's position during sleep, says Larry Seiden, MD, assistant professor of neurology and director of the University of Maryland Center for Sleep Disorders. Sleep studies may also be indicated to evaluate a patient's response to certain therapy. Cahaba GBA-Midwest's policy, for example, notes that monitoring for CPAP, "for snoring when an overnight oximetry indicates desaturation below 90 percent greater than 5 percent of the time," is covered.
 
Most carriers, including Medicare, will not reimburse unattended sleep studies (95806), Seiden says.     

Place of service also affects reimbursement. CareFirst Inc.'s LMRP states, "Medically necessary diagnostic studies for sleep disorders, including polysomnography, sleep staging and sleep latency tests, must be professionally attended," but also notes that such tests must be "performed in an approved sleep center. Portable sleep studies (95806), sleep studies that are performed without professional attendance in the home setting, and sleep studies that only measure and record limited characteristics of the patient's sleep are considered experimental/ investigational" and are therefore not covered. Cahaba GBA-Midwest and Blue Cross/Blue Shield of North Dakota specify similar guidelines.

 
Like sleep studies, polysomnography is reported using one of three codes:
 

95808 -- polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist
 

95810 -- ... with 4 or more additional parameters of sleep, attended by a technologist
 

95811 -- ... with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist.

 
According to CPT,  polysomnography differs from sleep studies by the inclusion of sleep staging, which is defined to include a one- to four-lead electroencephalogram (EEG), an electro-oculogram (EOG), and a submental electromyogram (EMG).

Additional parameters of sleep include:
 

electrocardiogram (ECG)

airflow

ventilation and respiratory effort

gas exchange by oximetry, transcutaneous monitoring or end tidal gas analysis

extremity muscle activity, motor activity-movement

extended EEG monitoring

penile tumescence

gastroesophageal reflux

continuous blood pressure monitoring

snoring

body positions.

 
For a study to be reported as a polysomnogram, sleep must be recorded and staged. Cahaba GBA-Midwest's LMRP notes that polysomnography is covered when performed by a facility in which certain conditions are diagnosed through sleep study and must be under the supervision of a physician. Such places would include an independent diagnostic testing facility for sleep disorders, a sleep laboratory, or hospital. The policy also specifies, "The usefulness of 'portable' polysomnography has not been established in the literature and will be denied in the home setting except when performed with a technician in attendance and when it conforms to all other data and sleep staging criteria for coverage." Carrier guidelines on this issue may differ.
 
All sleep studies, including polysomnography, must last a minimum of six hours. If the test is less than that, the appropriate code must be reported with modifier -52 (reduced services). "Reimbursement is reduced to reflect the diminished time and effort," Werner confirms.

 
Sleep studies and polysomnography are separate diagnostic tests performed at different times to assess various physiological parameters of sleep and, therefore, may be reported separately. Polysomnography involves overnight recording of data. The patient is monitored throughout the night. Multiple sleep latency tests (MSLT) and maintenance of wakefulness tests (95805), however, are performed to assess excessive daytime sleepiness. Generally, polysomnography is performed the night before a sleep study.
 
For example, a polysomnography starts Tuesday night and ends Wednesday morning. A few hours later, the patient begins MSLT. When reporting the tests, the actual date the polysomnography began is the correct date of service (here, Tuesday's date). The MSLT would be reported with a subsequent date of service (i.e., Thursday's date) because this testing began on a different day.
 
Other studies included in polysomnography (e.g., 54250) may not be reported separately. Consult the national Correct Coding Initiative (CCI) edits prior to billing any procedures/services in addition to either polysomnography or sleep study codes.

 
According to Medicare policy, a separate E/M service may not be reported in addition to 95805-95811 unless it is a significant and separately identifiable service (unrelated to the diagnostic testing) clearly documented in the medical record. If a separate E/M service is reported, modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) must be appended.
 
Note: National Medicare guidelines for sleep studies and polysomnography may be found in section 2055 of the Medicare Carriers' Manual, which is available on the CMS Web site, www.hcfa.gov, and LMRPs for Medicare intermediaries may often be found at www.lmrp.net.