Pulmonology Coding Alert

You can bolster your sleep testing and polysomno-graphy coding success in three sure-fire ways.

Coders reporting their pulmonologist's polysomno-graphy services (95808-95811) must be sure the documentation indicates sleep staging as well as additional parameters used during testing. This information distinguishes the procedure from a standard sleep study (which you would code differently).

You should 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) if the pulmonologist orders a daytime test following polysomnography to measure sleepiness.

During this test, the physician or technologist records the time it takes the patient to fall asleep during a course of four to five 20-minute nap opportunities.

Clarification: During testing as described by 95805, the patient may not necessarily fall asleep. In fact, the MWT (maintenance of wakefulness test) requires the patient try to resist sleep. But this does not affect coding.

Bonus tip: Don't leave your sleep study and polysomnography vulnerable to denials by not documenting where the tests occurred and who attended them, coding experts say.

For instance, tests must take place "in an approved sleep center," as defined by the Medicare Carriers Manual, section 2055. A sleep center may be directly affiliated with a hospital or a freestanding facility under a physician's direction.

Time matters: All sleep studies must last a minimum of six hours, says Susan Turney, MD, FACP, medical director of reimbursement at the Marshfield Clinic in Wisconsin. For tests of less than six hours, you must append modifier 52 (Reduced services) to the appropriate sleep study or polysomnography code. The payer will likely reduce payment for a truncated study.

For a basic sleep study, which includes monitoring of respiratory effort and heart rate, you should use 95807 (Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist). Your physician should interpret and report the results and document the patient's positions while sleeping.

Unattended note: Medicare and many private payers dictate that sleep studies must be "professionally attended" to qualify for reimbursement. Because of this, some coders say you shouldn't bother to bill for unattended sleep study 95806 (Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, unattended by a technologist) with most carriers.

Why: "According to the introduction in the CPT manual, just because a code exists doesn't make it reimbursable," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, CodeRyte Inc. coding analyst and coding review teacher. "CPT was originally designed to track what physicians did, not for billing purposes."

Remember: Because payers will reimburse only for attended studies, you should specifically document physician or technologist attendance when claiming 95805, 95807 or 95808-95811 for polysomnography.

Before reporting polysomnography, note that Medicare requires either the pulmonologist or technologist to stage the patient's sleep and record the results throughout the night.

Sleep staging includes a one- to four-lead electroencephalogram, an electroculogram, and a submental electromyogram. The physician may include other tests, such as nasal and oral airflow, ventilation, and respiratory effort, Turney says.

You can choose from three polysomnography codes, depending on the number of sleep parameters or other tests:

"Additional parameters": When reporting 95808-95811, the pulmonologist must document that he has included one to three (95808) or four or more (95810-95811) "additional parameters of sleep." According to CPT guidelines, these could include:

• 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.

When reporting a physician's component of the service for 95805-95807 or 95808-95811 in a facility setting, you must append modifier 26 (Professional component). The only exception occurs if you are conducting the sleep study/polysomnography in your own approved sleep clinic, and you are supplying the necessary equipment and attending technologist.