Neurology & Pain Management Coding Alert

Question: Encounter notes indicate that the provider ordered a sleep study with five additional parameters of sleep. A sleep technologist attended. How should I report this encounter?

Illinois Subscriber

Answer: The code you choose depends on the answers to these questions:

• How old was the patient?
• Did the technologist initiate continuous positive airway pressure (CPAP)?
• Did the technologist initiate bi-level ventilation?

Once you get the answers to these three questions, choose from the following codes:

• 95810 (Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist)
• 95811 (Polysomnography; age 6 years or older, 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)
• 95782 (Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist)
• 95783 (Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist).