Advanced Search

Pulmonology Coding Alert

3 Strategies Improve Your Sleep Studies Reimbursement

Published on Fri Jan 02, 2004

Know which modifiers to use with 95807

To ensure reimbursement for your pulmonologist's sleep-disorder treatments, you should know the difference between sleep studies (95805-95807) and polysomnography (95808-95811) or expect the denials to start rolling in.
 
Although the services are similar, pulmonologists perform sleep studies and polysomnography as separate diagnostic tests, and you can separately report these tests if you prove medical necessity, says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver.
 
Experts offer three strategies to keep your eyes wide- open when reporting sleep studies and polysomnography.

1. Report 95805 for Wakefulness Testing

If you report sleep testing (95805-95807), you should know that your pulmonologist will not stage the study and that the patient could be awake.
 
Typically, you will code sleep studies when the pulmonologist treats conditions such as sleep apnea (780.5x), narcolepsy (347), and acute respiratory failure (518.81). You can choose from three CPT codes:
 

  •  95805 - Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness. A pulmonologist usually performs this test during the day following polysomnography to measure sleepiness. The physician records the time it takes the patient to fall asleep during a course of four to five 20-minute nap opportunities.
     
  •  95806 - Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, unattended by a technologist. Although CPT provides 95806 for unattended tests, don't expect to get paid when you report the code. Medicare carriers, such as National Heritage Insurance Company of Northern California, will not pay for these tests that technologists don't supervise.
     
  •  95807 - ... attended by a technologist. This code represents a standard sleep study, which a technologist or physician attends and includes monitoring of respiratory effort and heart rate. Your physician should interpret and report the results and document the patient's positions while sleeping.

    2. Use 95808-95811 for Staged Studies

    Before you assign polysomnography codes 95808-95811, remember that Medicare insurers require your pulmonologist both to record and stage a patient's sleep. Therefore, the medical documentation should include that the physician staged and recorded the patient's sleep.
     
    Sleep staging includes a one-to-four-lead electroencephalogram, an electroculogram, nasal and oral airflow, ventilation, and respiratory effort. The physician may include other tests, such as a submental electromyogram, says Susan Turney, MD, FACP, medical director of reimbursement at the Marshfield Clinic in Marshfield, Wis.
     
    You can choose from three polysomnography codes, which you use differently depending on the number of parameters and other tests:
     

  •  Typically, your physician supervises the test while a technician performs the base polysomnography service (95808, Polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist). When the pulmonologist performs the testing in his or her laboratory, you may report the global 95808. But if the tests occur at a hospital or hospital-affiliated lab, attach modifier -26 (Professional component) to the code, which indicates that your physician only interpreted the results.
     
  •  You should assign 95810 (... sleep staging with 4 or more additional parameters of sleep, attended by a technologist) and 95811 (... with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist) only when your physician orders them for patients with narcolepsy, sleep apnea or parasomnia (780.57, Other and unspecified sleep apnea).

    3. Document Test Location and Time

    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, insurers will not pay for home-based sleep studies (95806), because a physician or technologist can't supervise them, and insurers don't find them medically necessary. And, if you submit an in-facility code, such as 95807 or 95810, you should attach modifier -26 (Professional component) because the technologist and lab should document physician or technologist attendance.
     
    On the other hand, when you report the global code for services provided in your lab, you must specifically document that a physician or technologist attended.
     
    When you report sleep studies or polysomnographies, make sure they lasted a minimum of six hours, Turney says. If the tests last less than six hours, you should report the code with modifier -52 (Reduced services).

    • Other Articles in this issue of

    Pulmonology Coding Alert

    View All