Otolaryngology Coding Alert

Otolaryngologists who treat or counsel patients with obstructive sleep apnea (OSA) often order that a sleep test be conducted and either let another physician trained and certified in sleep studies interpret the results or interpret the results themselves.

Report one of the sleep study codes (95806-95811) when the otolaryngologist who ordered the study interprets the results.

Codes 95806 and 95807 represent simpler sleep studies, says Andrew Borden, CPC, CCS-P, CMA, reimbursement manager for the department of otolaryn-gology at the Medical College of Wisconsin in Milwaukee.

Report 95806 when there is no technologist present (i.e., the patient takes the device home, sets it up and sleeps with it turned on).

Medicare and most other carriers do not cover home sleep study tests, citing lack of medical necessity. "Carriers scrutinize claims involving 95806, questioning the validity of a test that relies on the patient using the equipment correctly," Borden says. He notes, however, that these home-based studies can be useful in identifying possible OSA in patients who are facing a long wait for the sleep lab or who, for whatever reason, cannot sleep in their own beds.

Use 95807 when a technologist is present (i.e., the test was performed in a sleep lab). Sleep studies reported as 95807 (such as SNAP tests) do not record as many parameters as the more complex polysomnography tests (95808, 95810 and 95811) and provide the least amount of data for analysis.

Polysomnography tests rely on data collected through "sleep staging," during which diagnostic tools (i.e., electroencephalogram, EEG; electro-oculogram, EOG; and submental electromyogram, EMG) record and measure the various stages of sleep. If less than six hours of sleep is recorded, the appropriate procedure code should be appended with modifier -52 (Reduced services).

Additional parameters of sleep include, among others, airflow, ventilation and respiratory effort, gas exchange by oximetry, transcutaneous monitoring or end tidal gas analysis, extremity muscle activity or motor activity-movement, extended EEG monitoring, penile tumescence, gastroesophageal reflux, continuous blood pressure monitoring, snoring and body positions.

If one to three additional parameters are measured, report 95808. This code is appropriate when the physician wants to select specific parameters for a particular reason.

In most cases involving the patient in the sleep lab, the physician will select four or more parameters for testing, which is reported as 95810. If the study also involves the initiation of continuous positive airway pressure (CPAP) therapy, use 95811 instead.

All the codes mentioned should be appended with modifier -26 (Professional component) when the study is performed in a facility setting. The appropriate "global" code, which includes both the professional and technical components, should not be reported.

Although the otolaryngologist is not required to interpret a study that he or she has ordered, he or she may decide to review the study and any interpretation that a second physician provided and discuss those findings with the patient. When this occurs, says Michelle Logsdon, CPC, CCS-P, a coding and reimbursement specialist in Toms River, N.J., the review of the findings may be counted toward the level of the E/M visit when the results are discussed with the patient.

"If the review of the study is documented, it may boost the medical decision-making [MDM] of the E/M visit," Logsdon says. Its even more likely, she says, that 50 percent or more of the visit will be spent counseling the patient, which means that time becomes the controlling factor, and MDM (as well as history and examination) is not considered at all.

"When a sleep study shows that a patient has mild, moderate or severe OSA, the treating physician must explain to the patient what the options are," Logsdon says. Surgical options (i.e., uvulopalatopharyngoplasty) will be discussed; the patient may also require an explanation of CPAP before determining whether this noninvasive route should be taken. Such discussions can easily take 20 minutes or more.

Note: If the patient cannot tolerate CPAP, surgical options may be in order. However, carriers may require documentation that not only notes that CPAP was attempted but also explains how and why the patient could not tolerate it. In the absence of such documentation, any surgical procedure performed may not be covered.

You should keep in mind that diagnostic testing (i.e., polysomnography) for sleep apnea is covered only when the patient has symptoms of OSA. This is important because only the sleep study can be used to diagnose OSA. If the test returns negative, it may be difficult to obtain payment without clear and accurate notes that describe the symptoms that led to the decision to order the study.

Also, to ensure payment in cases involving home testing or when the carrier will not pay if the diagnosis is negative, patients should be asked to sign an advance beneficiary notice or equivalent waiver written for private payers, which indicates they are aware that they will be asked to pay for the sleep test if the carrier denies the claim.