Neurology & Pain Management Coding Alert

Not all tests during sleep are alike, and an audit might be waiting.

Sleep studies and polysomnography are not one and the same (see box on page 51). Distinguishing between them, and knowing what complaints or symptoms are covered by either a sleep study or polysomnography, will make all the difference if you encounter an audit.

Realize Sleep Studies for Insomnia Are Not Covered

The OIG wants to ensure physicians are not using sleep studies or polysomnography in response to noncovered complaints like insomnia, says Jill M. Young, CPC-ED, CPC-IM, president of Young Medical Consulting LLC in East Lansing, Mich.

Medicare does not cover polysomnography (95808-95811, Polysomnography; sleep staging &) for diagnosis of patients with chronic insomnia because it considers it not reasonable and necessary under §1862(a)(1)(A) of the Act. Evidence at the present time is not convincing that polysomnography in a sleep disorder clinic for chronic insomnia provides definitive diagnostic data or that such information is useful in patient treatment or is associated with improved clinical outcome, according to CMS.

Recognize Other Medicare Noncovered Factors

Many Medicare contractors are not covering several purposes for polysomnography. These include:

 " To preoperatively evaluate a patient for laser-assisted uvulopalatopharyngoplasty without clinical evidence that obstructive sleep apnea is suspected
 " To diagnose chronic lung disease (nocturnal hypoxemia in patients with chronic, obstructive, restrictive, or reactive lung disease is usually adequately evaluated by oximetry; however, if the patients sign/symptoms suggest a diagnosis of obstructive sleep apnea, polysomnography may be considered medically necessary)
 " In cases where seizure disorders have not been ruled out
 " In cases of typical, uncomplicated and non-injurious parasomnias when the diagnosis is clearly delineated
 " For patients with epilepsy who have no specific complaints consistent with a sleep disorder
 " For patients with symptoms suggestive of periodic limb movement disorder or restless leg syndrome unless symptoms are suspected of being related to a covered indication
 " For the diagnosis of insomnia related to depression
 " For the diagnosis of circadian rhythm sleep disorders (for instance rapid time-zone change [jet lag], shift-work sleep disorder, delayed sleep phase syndrome, advanced sleep phase syndrome, and non-24 hour sleep/wake disorder).

Money-clincher: Check with your local carrier for its polysomnography and sleep study policies. What specific ICD-9 codes will be covered for each specific CPT code can vary from carrier to carrier, says Gina Gjorvad, with the American Academy of Neurology Professional Association. And Medicare coverage can vary from area to area.

Realize Polysomnography Does Not = Sleep Study

Because polysomnography and sleep studies are similar in the patients state and the possible outcome, you might incorrectly think theyre the same thing. 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 6 or more hours with physician review, interpretation and report. They are performed to diagnose a variety of sleep disorders including narcolepsy, parasomnias, and sleep apnea.

Check If Study Occurs During Day or Night

Sleep studies and polysomnography represent separate diagnostic studies that are performed at different times of the day.

Sleep studies assess daytime sleepiness. In the Multiple Sleep Latency test (MSLT), the patient is instructed to try to fall asleep during the daytime. During the Maintenance of Wakefulness test (MWT), the patient is instructed to resist sleep during multiple trials throughout the day of low-demand activity.  To report sleep studies, use CPT 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.

Polysomnography is the diagnostic evaluation of an overnight recording of sleep with a trained technician present throughout the entire diagnostic study. Polysomnography is reported with the following codes:

 " 95808 -- Polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist
 " 95810 -- ... sleep staging with 4 or more additional  parameters of sleep, attended by a technologist
 " 95811 -- ... sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist.

Look at Whether Test Involves Parameters

Daytime diagnostic sleep studies typically include EEG, EOG, EMG, and EKG, but do not require sleep staging or the other parameters of sleep as polysomnography requires.

Polysomnography requires the patients sleep to be staged. For sleep staging with one through three parameters, which includes 1-4 lead electroencephalogram (EEG), an electrooculogram (EOG), and a submental electromyogram (EMG), assign 95808. Before assigning 95810 or 95811, look for additional sleep parameters such as:

 " 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.