Outpatient Facility Coding Alert

Age, stage, and parameters all point you to the best codes.

If you code for facility-based outpatient sleep studies, understanding procedure basics and knowing when certain modifiers apply will boost your coding accuracy – and your bottom line.

“Sleep studies and polysomnography (PSM) refer to a 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,” says Mary Mulholland, MHA, RN, CPC, with the University of Pennsylvania Health System in Philadelphia. These studies help the physician assess whether the patient has sleep disorders and the patient’s response to certain therapies (such as CPAP) initiated to overcome these disorders.

Focus on Stage for Polysomnography

Note that polysomnography tests will usually require the physician to stage sleep with a number of parameters. These can include:

• Frontal, central, and occipital lead electroencephalogram (EEG)
• Left and right electrooculogram (EOG)
• Submental electromyogram (EMG)
• ECG
• Airflow (nasal and/or oral)
• Respiratory effort
• Oxygen saturation (SpO2 — pulse oximetry)
• Extremity muscle activity (bilateral anterior tibialis EMG)
• Body positions.

"Body position is not one of the allowed CPT^® coding parameters of polysomnography,” notes Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver, Co.

You have three coding options for PSG, depending on the number of parameters the physician has opted for to record and stage sleep:

• 95808 (Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist)
• 95810 (Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist)
• 95811 (…4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation…)
• 95782 (Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist)
• 95783 (…4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation…).

“The codes differ based on the number of parameters of sleep that are monitored as well as if the physician initiated either of the obstructive airway treatments,” says Hammer. “Documentation would need to clearly identify the different parameters monitored as well as any therapeutic treatment introduced.”

Example: A 55-year-old male patient presents with complaints of restlessness during sleep, frequent arousal from sleep due to a gasping or choking sensation, and recent episodes of daytime sleepiness. He says one incident almost caused an accident while he was driving. The physician completes a comprehensive evaluation of the patient and suspects obstructive sleep apnea. He schedules a PSG that records EEG, EOG, submental EMG, ECG, nasal airflow, and oxygen saturation for the next day. You’ll report the PSG with 95808, as the physician recorded 3 parameters above the standard parameters (EEG, EOG and submental EMG).

Daytime Sleepiness Assessment Means MSLT or MWT

Sleep studies such as multiple sleep latency test (MSLT) or the maintenance of wakefulness (MWT) testing are generally performed to assess day time sleepiness. MWT involves patient being instructed to remain awake for as long as possible during several 20 or 40 minute sessions while sitting in low-level light. The physician can perform these tests the day after he performs PSG.

“The MSLT objectively assesses the patient’s sleep tendency by measuring the number of minutes it takes for the patient to fall asleep, as well as the premature occurrence of rapid eye movement (REM) sleep,” says Mulholland. “In order to ensure the validity of the MSLT, interpretation should only be made following the PSG performed on the preceding night.”

When your physician performs MSLT or MWT, report 95805 (Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness).

Example: If the physician in the example above also ordered an MSLT or MWT for the patient having polysomnography, you would report 95805 in addition to 95808.

Sometimes sleep studies are performed in a lab and attended by a technologist. In that situation, report 95807 (Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist).

Remember Modifier 52 for Reduced Services

You need a minimum of six hours of interpretable data before you can report a sleep study.

 “CPT^® 95808-95811 procedure codes require six hours of data monitoring,” says Mulholland. “Report them with modifier 52 (Reduced services) for reduced polysomnography or sleep study services if less than 6 hours of recording were obtained.”

“Physicians would also append modifier 52 for less than 7 hours of recording for polysomnography for patients younger than 6 years,” adds Hammer.

Use modifier 52 when less than four nap opportunities occur during MSLT/MWT services. Also, you may be clear on the recording time even though the codes also include interpretation and report creation.

“The documentation will need to include the recording time to support billing the diagnostic study with or without modifier 52,” Hammer notes.