Being faced with increased scrutiny from the Office of Inspector General (OIG) regarding polysomnography means you’d better know how to code the procedure – and how to distinguish it from a sleep study. Ages, stages, and correct modifier usage can be your ticket to coding confidence.
Starting point: “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.
Factor 1: Focus on the Polysomnography Stage
Note that polysomnography tests will usually require the physician to stage sleep with a number of parameters. These can include:
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Frontal, central, and occipital lead electroencephalogram (EEG)
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Left and right electrooculogram (EOG)
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Submental electromyogram (EMG)
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ECG
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Airflow (nasal and/or oral)
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Respiratory effort
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Oxygen saturation (SpO2 — pulse oximetry)
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Extremity muscle activity (bilateral anterior tibialis EMG)
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Body positions.
“Though body position may be documented, it isn’t one of the CPT® parameters that can be counted toward the PSM requirements,” notes Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver, Co.
You have five coding options for PSM, depending on the number of parameters the physician has opted for to record and stage sleep:
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95808 (Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist)
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95810 (Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist)
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95811 (…4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation…)
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95782 (Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist)
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95783 (…4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation…).
“The codes differ based on the age of the patient as well as the number of parameters of sleep that are monitored and 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 in the sleep study lab. You’ll report the PSG with 95808, as the physician recorded 3 parameters above the standard parameters (EEG, EOG and submental EMG).
Factor 2: Watch for Daytime Sleepiness Assessment
Standardized 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. You’ll report the codes on different dates of service, however. According to a 2002 CPT® Assistant article, the claim for the polysomnography should be submitted for the date the service started. The claim for the MSLT should be submitted for the date of the MSLT.
Factor 3: Check Whether Modifier 52 Applies
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.”
“For patients younger than 6 years, the minimum recording time is increased. Physicians would need to append modifier 52 for less than 7 hours of polysomnography recording for these pediatric patients,” adds Hammer.
Use modifier 52 when less than four nap opportunities occur during MSLT/MWT services.
“The documentation will need to include the recording time to support billing the diagnostic study with or without modifier 52,” Hammer notes
